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Overview Submitting Reports to the NPDB Reporting Medical Malpractice Payments Reporting Adverse Clinical Privileges Actions Reporting Adverse Professional Society Membership Actions Reporting State Licensure and Certification Actions Reporting Federal Licensure and Certification Actions Reporting Peer Review Organization Negative Actions or Findings Reporting Private Accreditation Organization Negative Actions or Findings Reporting Exclusions from Participation in Federal or State Health Care Programs Reporting Federal or State Health Care-Related Criminal Convictions Reporting Health Care-Related Civil Judgments Reporting Other Adjudicated Actions or Decisions

Q&A: Reporting Clinical Privileges Actions

  1. If a physician's initial application for clinical privileges is denied or the privileges granted are more limited than those requested, must this be reported to the NPDB?

  2. A hospital filed a report with the NPDB announcing the revocation of a practitioner's clinical privileges. The reporting hospital had established a system of professional review under its bylaws, and it also had an employment termination procedure. In this case, the hospital used the employment termination procedure, not the professional review process. The practitioner's privileges were revoked by the employment termination process, but no action was taken through the professional review process. The practitioner was not given a choice of which process (system of professional review or employment termination procedure) the hospital would use. Should the hospital have filed the report with the NPDB?

  3. A physician applied for a medical staff appointment at a hospital but then withdrew the application before a final decision was made by the hospital's governing body. The physician was not being specifically investigated by the hospital. Should the hospital report the withdrawal to the NPDB?

  4. A physician member of a hospital medical staff applied for an expansion of clinical privileges. Although the physician met all threshold criteria established by the hospital for the expanded privileges, the physician's department head and the medical staff credentials committee recommended denial of the request for expanded clinical privileges based on their assessment that the physician did not have the clinical competence to perform the additional tests and procedures sought. The hospital's governing body reviewed the case, affirmed the findings and recommendations, and denied the physician's request for reasons relating to professional competence. Does the denial of a request for expanded clinical privileges have to be reported to the NPDB?

  5. A physician who applied for clinical privileges does not meet a health plan's threshold criteria for the privileges and withdraws the application. Is this reportable to the NPDB?

  6. A physician's application for surgical privileges was denied because the physician is not board certified in the clinical specialty and subspecialty for which he applied, as required by the hospital to which he applied for surgical privileges. Must this action be reported to the NPDB?

  7. A physician applied to a hospital for clinical privileges to perform cardiac procedures. The hospital requires that such applications be granted only if the applying physician has performed 50 cardiac procedures in the previous year. The applying physician has performed only 40 such procedures. The hospital denies the application based solely on the physician not having met its 50-procedure requirement. Should this denial be reported to the NPDB?

  8. A physician applying for renewal of his hospital clinical privileges falsified his application by omitting information about an ongoing licensure investigation. The hospital took a professional review action to deny his renewal application, which the MEC considered to be related to the practitioner's professional conduct, even though there was no actual patient harm. Should this be reported to the NPDB?

  9. When a physician surrenders medical staff privileges due to personal reasons, infirmity, or retirement, and such a surrender does not occur in order to avoid an investigation or during an investigation, should it be reported?

  10. A health care entity terminated a physician's contract for causes relating to poor patient care, which in turn resulted in the loss of the practitioner's network participation. Should this be reported to the NPDB using one or two reports?

  11. A preferred provider organization (PPO) investigated a member physician after receiving quality of care complaints from several plan participants. The physician was unaware of the investigation, but, during the investigation, he relinquished his panel membership for personal reasons. Is this reportable?

  12. A hospital automatically revoked a physician's clinical privileges when the physician lost her license. Should this action be reported?

  13. A physician holds clinical privileges at First Hospital and Second Hospital. First Hospital suspends the physician's privileges. Second Hospital's rules provide that a suspension or termination of privileges at another hospital requires suspension or termination at Second Hospital. Consequently, once it learns of First Hospital's suspension of the physician's clinical privileges, Second Hospital also suspends the physician's privileges. Should Second Hospital report its action to the NPDB?

  14. A hospital suspended a physician's clinical privileges for 45 days for failing to complete medical records. Should this action be reported to the NPDB?

  15. A hospital imposed a 30-day suspension of privileges as a result of a professional review action based on a physician's professional competence. Should this be reported to the NPDB?

  16. A physician held clinical privileges at a hospital entitling him to perform specific procedures. The head of the physician's medical department pointed out to the physician that the physician was no longer performing some of the procedures, and the department head suggested that the physician voluntarily relinquish those privileges. The physician agreed. Should this voluntary relinquishment of privileges be reported?

  17. A hospital's chief of surgery summarily suspended a physician's privileges for outbursts of anger and throwing charts and instruments in an operating room. Should this action be reported to the NPDB?

  18. A hospital began an investigation of a physician on staff at the hospital for issues related to professional competence 4 weeks prior to the expiration of the physician's clinical privileges. The physician failed to renew the clinical privileges while the investigation was ongoing. Should this event be reported to the NPDB?

  19. Should investigations be reported if they do not reach a conclusion?

  20. A physician is being investigated by a hospital for issues related to professional competence and resigns her clinical privileges. At the time of her resignation she states that she plans to move to a different state. Should the resignation be reported to the NPDB?

  21. A hospital is investigating a physician who holds clinical privileges at the hospital. Separately from the investigation, colleagues and friends of the physician - who are not hospital officials - caution the physician that he should take time off to resolve personal problems. The physician takes a leave of absence from the hospital for 45 days, and the hospital reports this to the NPDB as a resignation while under investigation. When the physician returns to the hospital and his clinical privileges are reinstated, the hospital's governing body determines that the physician engaged in no professional conduct that adversely affected or could have adversely affected the health or welfare of a patient, and it found no reason to fault the physician's professional competence. What action should the hospital take with respect to the NPDB?

  22. Is an agreement not to exercise privileges during an investigation, without actually surrendering the privileges, a resignation while under investigation that is reportable?

  23. Is a leave of absence while under investigation considered to be a resignation of privileges that is reportable?

  24. When does the review of an application for reappointment become an investigation if the physician resigns before final action is taken on the reappointment application? For example, if a physician discloses on an application for reappointment that she has been a defendant in three malpractice cases during the last 2 years, and the credentials committee requests additional information about the cases, has an ongoing "routine review" become an "investigation?"

  25. Is a resignation while subject to a "quality improvement plan" a resignation while under investigation? A quality improvement plan might include a limit on the number of patients a physician can have in a hospital at a time or a requirement that all surgical cases be discussed with the physician's department chair in advance of surgery.

  26. For the purposes of reporting resignations to the NPDB, when is an investigation considered to be complete?

  27. The hospital where a physician held clinical privileges as a surgeon initiated an investigation and suspended her privileges after receiving a complaint against the surgeon from a patient. Two weeks later, the hospital offered the surgeon the option of returning to work if she agreed to certain restrictions on her privileges. The surgeon chose not to accept the offer and, instead, resigned her clinical privileges. However, after the surgeon resigned, the hospital submitted a report to the NPDB indicating the surgeon resigned while under investigation. The surgeon contended that the investigation was over as evidenced by the hospital's offer to let her return to work. Is the surgeon correct?

  28. After receiving multiple quality of care complaints about a physician, a hospital initiated an investigation. During the investigation, the physician resigned her clinical privileges at the hospital. Since there was no professional review action taken, should a report be submitted to the NPDB?

  29. A physician on staff at a hospital resigned her clinical privileges during a routine review that applied to all practitioners holding clinical privileges. Should this be reported to the NPDB?

  30. After conducting a professional review of a surgeon's competence, a hospital assigned a surgical proctor for 60 days. The surgeon could not perform surgery without being granted approval by the surgical proctor. Is the hospital required to report this action to the NPDB?

  31. Is the requirement that a surgeon operate only with a qualified first assistant a restriction of privileges?

  32. A physician holding courtesy privileges in a hospital applied for and was granted full staff privileges. As a condition of staff privileges, the physician is required to be on-call in the emergency department for one weekend a month. Due to personal reasons, the physician told the hospital he would not be able to fulfill his emergency department commitment. The physician did not miss any on-call duties. The hospital and the physician eventually agreed to change his clinical privileges from full staff to courtesy (with no professional review of this matter). Should this be reported to the NPDB?

  33. A health care entity took a clinical privileges action against a practitioner, but a court issued an injunction against the clinical privileges action before it was implemented. Should the action be reported to the NPDB?

  34. A physician is denied panel membership because a peer review committee determined that the physician had too many malpractice settlements. Is this denial of membership reportable to the NPDB?

  35. A managed care organization's (MCO's) peer review panel restricts a nurse practitioner's panel membership for 31 days because of concerns about his ability to perform certain procedures. May this be reported?

  36. During a hospital's routine chart audit, the hospital discovered that several physicians were "cutting and pasting" notes and/or lab results from one patient's electronic health record (EHR) to another patient's EHR. No patient harm actually occurred, but the hospital viewed these documentation practices as having the potential for patient harm. The hospital took a professional review action against each of the physicians involved, which resulted in the restriction of each of their clinical privileges for 60 days. Should these actions be reported to the NPDB?

  37. An "impaired physician" member of a hospital's medical staff has been repeatedly encouraged to enter a rehabilitation program. The practitioner continues to disregard the hospital's advice and offers of assistance. If an authorized hospital official, such as the CEO or department chair, directs the practitioner to give up clinical privileges and enter a rehabilitation program or face investigation relating to possible professional competence or conduct, and the physician surrenders his privileges, must the surrender of clinical privileges be reported to the NPDB?

  38. If an "impaired practitioner" takes a leave of absence and enters a rehabilitation program, must it be reported?

  39. A physician who holds clinical privileges at a hospital tests positive for a nonprescribed drug. He enters into a treatment plan, but he continues to practice while gradually working to modify his addictive behavior. Is this reportable to the NPDB?

  40. Laws related to drug and alcohol treatment programs have confidentiality provisions. Won't a report concerning a practitioner in a treatment program violate those provisions?

  41. Must a hospital or other health care entity report adverse actions concerning the clinical privileges of medical and dental residents and interns?

  42. A hospital took a professional review action to revoke a nurse practitioner's clinical privileges for reasons related to professional conduct. Should this action be reported to the NPDB?

  43. As a prerequisite for awarding laparoscopic appendectomy clinical privileges, a hospital's standard operating procedures require physicians to perform five procedures within 30 days under the supervision of a proctor. In one situation, a physician successfully completed four procedures, but no additional patients required a laparoscopic appendectomy within the 30-day time period. Consistent with the standard operating procedures, the hospital extended the time period for completing the remaining laparoscopic appendectomy. Should this be reported?

  44. An anesthesiologist is hired by the hospital's anesthesia group and receives temporary privileges while his application for clinical privileges is pending the formal review process. After the hospital receives several quality of care-related complaints about the anesthesiologist, the practitioner agrees to resign the temporary privileges and withdraw his application for full privileges in return for the hospital not investigating the complaints. Is this reportable?

  45. A hospital initiated an investigation related to the professional conduct of a physician who held time-limited, nonrenewable, temporary privileges at the hospital. During the investigation, the physician's temporary privileges expired and the hospital took no further action. Should this be reported?

  46. Is a report required when clinical privileges lapse at the end of a 2-year appointment because there has been a recommendation by the Medical Executive Committee that the physician not be reappointed, but the physician's current 2-year appointment ends before a hearing can be held and final action taken by the hospital's governing body?

  47. A hospital repeatedly reminded a physician to update his medical records in a timely manner. After there was no change in the physician's behavior, the hospital initiated an investigation, which revealed that the physician had more than 300 incomplete medical records. As a result, the hospital took a professional review action to suspend the physician's clinical privileges for 60 days, citing professional misconduct. Because there was no actual patient harm, should this be reported to the NPDB?

  48. A hospital summarily suspended a physician's clinical privileges to allow sufficient time for allegations of gross negligence to be fully investigated. The day after the summary suspension was imposed, the physician requested an educational leave of absence. If the hospital grants the leave of absence, must the summary suspension be reported to the NPDB?

  49. How should a hospital report to the NPDB when an adverse clinical privileges action it took against a practitioner is changed by court order?

Do you have a question about the NPDB Guidebook that you'd like answered?