Medical Staff Matters: Why bother with reappointment?
Many medical staff members grouse that reappointment is another bureaucratic activity foisted on them by hospital management. They dismiss the importance of the paperwork and the deadlines by which it needs to be submitted. They think, “If the hospital has 20-plus years of quality data to confirm that I’m clinically competent, what difference does it make if I send in the required paperwork?”
This of course, causes medical staff services professionals much frustration—when e-mail reminders, letters, and phone calls don’t catch physicians’ attention, they may feel they have to climb on top of a hill to send out smoke signals or invest in a fog horn.
But the truth of the matter is that both federal law and accrediting agency requirements require regular reappointment periods. The Centers for Medicare & Medicaid Services’ (CMS) 2008 Conditions of Participation (CoP), state under §482.22 CoP: Medical Staff:
(1) The medical staff must periodically conduct appraisals of its members (A-0340)
(2) The medical staff must examine credentials of candidates for medical staff membership and make recommendations to the governing body on the appointment of the candidates (A-0341)
The Joint Commission’s 2009 standards are even more specific:
MS. 06.01.09: Decisions to grant, deny, or limit an initially requested privilege or existing privilege petitioned for renewal are communicated using the specified process and within the specified time frames to the requesting practitioner.
MS.06.01.07: Each requesting practitioner’s current licensure status, training, experience, current competence, and ability to perform a requested privilege are reviewed and analyzed. Any privileging criteria are consistently applied by the organized medical staff as defined and in a timely manner, with the governing body or delegated governing body committee having final authority for denying privileges or granting/renewing privileges for a period not to exceed two years.
Thus, everyone on the organized medical staff who is credentialed and privileged must undergo reassessment following a standardized process, and that process must be completed within two years.
In most states, the medical staff bylaws constitute a legally binding contract between individual members of the medical staff and the governing board. Typical language in contemporary bylaws state:
Criteria for reappointment
It is the policy of the hospital to approve for reappointment and/or renewal of privileges only those practitioners who meet the criteria for initial appointment. The medical executive committee (MEC) must also determine that the practitioner provides effective care that is consistent with the hospital’s standards of ongoing quality and performance improvement program. The practitioner must provide the information as required to fulfill the criteria for credentialing and privileging. All reappointments and renewals of clinical privileges are for a period not to exceed twenty-four (24) months.
What do these laws, regulatory requirements, and bylaws have in common?
1. There is a common process and procedure to follow to evaluate each practitioner based on pre-existing criteria for both membership and privileges.
For those who believe in a system based on fairness and consistency, this makes sense. After all, would you want to be treated differently than another practitioner based on political, economic, or personal criteria that have nothing to do with your clinical competency and professional conduct?
Also, uniformity and standardization creates a “due process” approach to assessing practitioners for appointment and reappointment, which is needed to fulfill Joint Commission standard MS.06.01.05: Objective, evidence-based criteria and decisions are used to grant or deny a privilege(s) and/or renew an existing privilege(s).
Most would agree that attempts to reduce personal or professional bias are preferable when making professional decisions. Objective measures, though potentially flawed, are still a significant improvement over innuendo, rumor, and worse—the mere absence of negative information.
2. All reappointment and renewals of clinical privileges are for a period not to exceed twenty-four (24) months.
According to regulatory requirements, membership and privileges must lapse after a period not to exceed 24 months. Why create an arbitrary time limit? Privileges should ideally be based on current competency criteria, so it only makes sense that there should be a time limit to ensure that skills are maintained on an ongoing basis. Twenty four months is an arbitrary time period; however, most would agree that if you haven’t done anything clinically in the past 24 months, someone should raise the competency question.
Furthermore, by regulatory standards, neither the board nor the MEC/credentials committee may extend the period of appointment beyond 24 months.
Thus, federal law, accreditation standards, and bylaws require that credentialing and privileging be performed in a consistent and standardized approach within specified time frames to protect patients, healthcare organizations, and the due process rights of physicians. Perceived bureaucracy may be a challenge; however, a biased, inconsistent, arbitrary, and capricious process may be much worse!
And so next time you see that paper work for reappointment come your way, think of all the alternatives!
Jonathan Burroughs, MD, MBA, CMSL, is a senior consultant with The Greeley Company, a division of HCPro, Inc. in Marblehead, MA.