Tip of the week: Define "investigation" in your bylaws

It is important to have a crystal-clear definition of “investigation” in your bylaws, because a failure to do so could have serious implications when reporting to the National Practitioner Data Bank (NPDB). The NPDB requires hospitals to report practitioners who voluntarily surrender membership or clinical privileges while under investigation for possible clinical incompetence or unprofessional conduct. The NPDB also requires hospitals to report physicians who surrender membership or clinical privileges in return for the hospital not conducting an investigation or taking a professional review action.

The NPDB requires a report even when the practitioner is unaware of the investigation. All practitioners who surrender membership or privileges while under investigation must be reported regardless of the practitioner’s stated reason (e.g., personal health concerns, retirement, relocation, and personal circumstances, such as divorce, etc.).

The NPDB guidebook states the following concerning investigations:

• An investigation should be carried out by the healthcare entity and not by an individual on the staff
• The hospital should create contemporaneous evidence of an ongoing investigation (e.g., meeting minutes, an order from a hospital leader initiating an investigation, letters to the practitioner involved, etc.)
• An investigation should address concerns about professional competence or conduct
• An investigation is considered ongoing until a final action is taken or it is formally closed
• An investigation should be a precursor to a professional review action
• A general or routine review of cases is not an investigation
• A general or routine review of a particular practitioner is not an investigation

This week's tip is from The Greeley Guide to Medical Staff Bylaws, Second Edition, by Joseph D. Cooper, MD.