Allison Shelton, JD

FR-16 General Session 11:00-12:00pm

Open Q & A

Allison Shelton, JD

FR-16 Open Q&A Allison Shelton

Frequently Asked Questions

ALLISON SHELTON, JD BROWN & FORTUNATO, P.C. 40TH ANNUAL TSMSS CONFERENCE

APRIL 21, 2017

Frequently Asked Questions

If we put a practitioner on an FPPE and the practitioner resigns before completion of the FPPE, is it reportable?

FPPE

"A routine, formal peer review process under which a health care entity evaluates, against clearly defined measures, the privilege-specific competence of all practitioners is not considered an investigation for the purposes of reporting to the NPDB. However, if a formal, targeted process is used when issues related to a specific practitioner's professional competence or conduct are identified, this is considered an investigation for the purposes of reporting to the NPDB." NPDB Guidebook, Chapter E.

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FR-16 Open Q&A Allison Shelton

Frequently Asked Questions

If we require a practitioner to have a proctor present before the practitioner may render services, is it reportable? What if the proctor only observes the case?

Proctors

"If, as a result of a professional review action related to professional competence or conduct, a proctor is assigned to a physician or dentist for a period of longer than 30 days, whether the action must be reported to the NPDB depends on the role of the proctor. 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 to the NPDB. However, if the proctor is not required to be present for or approve the procedures (for example, 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." NPDB Guidebook, Chapter E.

See also Q&A 38 regarding routine assignment of proctors for newly granted privileges.

Frequently Asked Questions

Our Medical Staff Bylaws provide that only the Medical Executive Committee has the right to open an investigation. Is such provision permissible under the revised NPDB Guidebook?

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FR-16 Open Q&A Allison Shelton

Investigations

"NPDB interprets the word "investigation" expansively. It may look at a health care entity's bylaws and other documents for assistance in determining whether an investigation has started or is ongoing, but it retains the ultimate authority to determine whether an investigation exists." NPDB Guidebook, Chapter E.

See also AHLA Guidebook Webinar ( on/webcasts/ahlaWebinar.jsp).

Frequently Asked Questions

If we deny a practitioner's request for temporary privileges, is the practitioner entitled to a hearing?

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." NPDB Guidebook, Chapter E.

See also Q&A 39.

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FR-16 Open Q&A Allison Shelton

Frequently Asked Questions

Our Medical Staff Bylaws provide that a practitioner may voluntarily refrain from exercising his or her privileges in lieu of a summary suspension. This allows us to avoid reporting the matter to the NPDB, right?

Reporting

Hospital must report in the event a practitioner surrenders his or her privileges "in return for not conducting . . . an investigation or proceeding." 42 U.S.C. 11133(a).

Frequently Asked Questions

Should psychologists be appointed to the Medical Staff?

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