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Clinical Privileges Reporting Scenarios Webinar

The Clinical Privileges Reporting Scenarios Webinar was held on September 20, 2022.

Watch the recording for the Clinical Privileges Reporting Scenarios Webinar exit icon (video - 1:31:03).

Event Materials:

Q&As

  1. How soon does an adverse clinical privileges action need to be reported to the NPDB?
    Adverse actions must be reported to the NPDB within 30 days of the action taken.

  2. How is a denial of privileges that occurs during the application process addressed?
    If the denial is related to the candidate's professional competency or professional conduct and the denial is a result of a professional review action, then it would be reportable to the NPDB. This includes denials of initial applications for clinical privileges.

  3. A physician held clinical privileges at a hospital to perform specific procedures. The head of the medical department pointed out that the physician no longer performed some of the procedures and suggested the physician voluntarily relinquish those privileges. The physician agreed. Should this voluntary relinquishment of privileges be reported?
    No. If the physician was not under investigation when the privileges were voluntarily relinquished, then this is not reportable.

  4. Is an agreement not to exercise privileges during an investigation (without actually surrendering the privileges) reportable?
    Yes. The agreement not to exercise privileges is reportable if other reportability conditions are met. NPDB regulations state that "acceptance of the surrender of clinical privileges or any restriction of such privileges . . .while under investigation" is reportable. An agreement not to exercise privileges is a restriction of privileges. Any restriction of privileges while under investigation, temporary or otherwise, is considered a resignation and must be reported.

  5. When is the imposition of a proctor reportable to the NPDB?
    If, as a result of a professional review action related to professional competence or conduct, a proctor is required in order for a physician or dentist to proceed in freely exercising clinical privileges, and the period lasts longer than 30 days, the action must be reported to the NPDB. In other words, if, for a period lasting more than 30 days, the physician or dentist cannot perform certain procedures without proctor approval or without the proctor being present and watching the physician or dentist, the action constitutes a restriction of clinical privileges and must be reported. However, if the proctor is not required to be present for or approve the procedures (for example, if the proctoring consists of the proctor reviewing the physician's or dentist's records or procedures after they occur), the action is not considered a restriction of clinical privileges and should not be reported to the NPDB.

  6. If a hospital governing board places a physician on a clinical privileges restriction lasting more than 30 days and the physician appeals the restriction of privileges, is this action still reportable, or does the appeal pause the process?
    Yes. The action is reportable even if there is an appeal. An appeal of the governing board's decision does not affect the reportability of an adverse clinical privileges action. If an appeal is successful and the original action is overturned, the hospital may be required to submit a Void Report.

  7. A hospital summarily suspended a practitioner for patient safety concerns. The practitioner resigned shortly thereafter. Did the practitioner resign while under investigation?
    If a practitioner surrenders his or her clinical privileges during a summary suspension, regardless of whether the suspension has been confirmed by a hospital review body, that action must be reported to the NPDB. The action is reportable because the practitioner is surrendering the privileges either while under investigation concerning professional conduct or professional competence that did or could affect the health or welfare of a patient, or in return for not conducting an investigation concerning the same.

  8. If the hospital places a physician on a for-cause focused review for a six-month period, so that all post-operative complications can be reviewed due to a trend of safety concerns being identified, is the action reportable?
    If the for-cause review of the particular physician does not require another health care practitioner to be present for or approve procedures in advance, then the action is not considered a restriction of clinical privileges and should not be reported to the NPDB. If the for-cause review is the result of a professional review action related to professional competence or conduct, and another health care practitioner (e.g., a proctor) is required in order for a physician to proceed in exercising clinical privileges, and the period lasts longer than 30 days, the action must be reported to the NPDB. Additionally, if the for-cause review is considered an investigation for NPDB reporting purposes, and the practitioner resigns while under the for-cause review, the resignation would be reportable as a resignation while under investigation.

  9. Does the NPDB make a distinction in its reporting requirements for temporary privileges?
    For the purpose of reporting to the NPDB, no distinction is made between temporary clinical privileges (including but not limited to emergency and disaster clinical privileges) and clinical privileges. However, if temporary privileges are awarded to a physician or dentist for a specific amount of time, with no opportunity for renewal - and both the physician or dentist and the privileging party agree that the privileges are temporary - and the temporary privileges expire while the practitioner is under investigation, a report should not be submitted to the NPDB. In this scenario, there is no opportunity to renew the temporary clinical privileges, so the expiration of the temporary privileges while under investigation cannot be considered a nonrenewal or surrender of clinical privileges while under investigation.

  10. Is it reportable when a physician resigns and requests that a hospital revoke their privileges?
    If a physician resigns, for any reason, while under investigation for issues related to professional competence or professional conduct, the resignation is reportable to the NPDB. The NPDB considers an investigation to run from the start of an inquiry until a final decision on a clinical privileges action is reached. For reporting purposes, the NPDB definition of an investigation is not limited to a health care entity's gathering of facts or limited to the manner in which the term "investigation" is defined in an organization's by-laws or policy. The NPDB defines the start of an investigation to occur as soon as the health care entity begins an inquiry. However, it would not be reportable if the physician were not under investigation.