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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. 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.

    Imposition of a quality improvement plan raises two issues with respect to reportability. First, a quality improvement plan may restrict a practitioner's clinical privileges. If so, and if the restriction is the result of a professional review action, concerns the practitioner's professional competence or conduct, and is in place longer than 30 days, the plan may be reportable.

    Second, if the quality improvement plan does not meet these requirements, it nonetheless may be considered an investigation so long as it meets the other requirements for an investigation. The reporting entity needs to determine whether the quality improvement plan is focused on one practitioner for competency concerns and whether such plans typically lead to a professional review action. When making this determination, the entity should consider the language of the plan: Does it describe future disciplinary measures that may follow if the elements of the plan are not met? The entity also may consult its bylaws and policies, as well as standard practices, to decide whether the plan is the type of inquiry that leads to a professional review action. If the quality improvement plan meets the requirements of an investigation, then a resignation while under the plan would be reportable.

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