Medical Staff & Privileged Health Care Providers
Surviving the Storm: Preparing, Navigating, and Forging Ahead
The Challenge
Disasters come in all shapes and sizes and give rise to many unexpected problems. In addition to traditional staffing-related challenges posed by pandemics and natural disasters, other types of disasters now, unfortunately, occur with more frequent regularity, creating the potential for internal chaos and devastating consequences if hospitals or health care facilities and their medical staffs are not prepared to deal with such situations. For example, what would you do if any of the following scenarios occurred?
- Your hospital/medical staff databases are hacked or held for ransom, and there is no access to the credentialing/privileging database, including medical staff credentials files and delineations of privileges, or to the electronic health record or computerized order entry system, etc.
- Physician contract negotiations break down at the eleventh hour, and your hospital must provide interim physician or advanced practice clinician staffing in a matter of days in order to keep the emergency department functioning.
- Your hospital and medical staff are today’s negative headline: A physician is accused of harming patients or other inappropriate conduct, and the national media spotlight focuses on your hospital’s credentialing and privileging practices and the medical staff’s oversight of the quality of care provided by privileged practitioners and advanced practice clinicians at the hospital.
- Privileged providers are confronted with an active shooter situation in the midst of patient care.
Don’t wait! A "disaster” situation is not the time to learn that the medical staff is unprepared.
The Solution
Epstein Becker Green, with its team of health care lawyers experienced in addressing all types of disasters that involve medical staffs and privileged health care providers, assists medical staff leaders and medical staff office professionals in proactively planning for disaster situations. We provide counsel during the crisis and address “next steps” after the disaster resolves. Depending upon the type and stage of disaster, the solution may include (but not be limited to):
- a proactive review/assessment of medical staff governing documents (e.g., the medical staff bylaws, policies, and rules and regulations) to ensure that applicable provisions and procedures are included and available for use in the event of a disaster;
- guidance regarding:
- the applicable Medicare hospital or critical access hospital conditions of participation;
- the applicable accreditation standards (e.g., TJC, ACHC, DNV);
- credentialing verification standards (e.g., NCQA, TJC, ACHC, DNV, etc.);
- negligent credentialing;
- medical staff appointment and privileging procedures;
- types of clinical privileges, requirements, and applicability to different scenarios;
- state professional licensure;
- state scope of practice;
- return-to-practice considerations;
- the use of telehealth/telemedicine and credentialing by proxy;
- medical staff procedures for privileged provider conduct and impairment matters;
- formal corrective action and summary suspension procedures; and
- reporting requirements; and
- an assessment of clinical competency (e.g., the use of peer review and professional practice evaluation—Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE)); and
- the preparation of corresponding materials (e.g., letters, resolutions, etc.) with respect to the medical staff processes/procedures noted above.