How to Implement Late-practice Evaluation

The appropriate medical staff bylaws must be followed if findings lead to recommendation for action on a practitioner's medical staff membership and/or clinical privileges.

A version of this article was first published November 9, 2020, by HCPro's Credentialing Resource Center, a sibling publication to HealthLeaders.

Increasingly, organizations are implementing policies for evaluating older members of the medical staff—often for practitioners at age 70, or earlier if self-referral occurs. The policy may contain steps such as the following:

1. An anonymous evaluation by selected references.

• Peers and staff who work closely with the practitioner.
• Assessment of the six competencies (patient care, medical/clinical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice).

2. Increased ongoing review.
3. Focused review.
4. Health evaluation.

• The practitioner may use his or her own annual or employment physical.
• The practitioner attests that he or she has had an annual physical and no health conditions that would prevent safe practice were found.

5. Annual, rather than biennial, reappointment.
6. A comprehensive fitness-to-work evaluation in the case of ongoing illness. If the practitioner can safely practice hospital medicine, reasonable accommodations will be made whenever possible in accordance with the Americans with Disabilities Act.

The results of any evaluation are reviewed and discussed with the affected practitioner and the appropriate clinical service line chief, the credentials committee chair, and the medical staff president, or their designees.

If findings do not identify potential patient care concerns, the results are filed in the practitioner’s peer review file as a matter of routine and the reappointment is processed in the usual manner.

However, if the results reveal a cause for concern, the information will be discussed with the affected practitioner and MEC, and action will be taken and protection afforded the practitioner in accordance with your hospital’s medical staff bylaws.

The appropriate medical staff bylaws must be followed if findings lead to recommendation for action on a practitioner’s medical staff membership and/or clinical privileges.

The same peer review process applies to employed and contracted practitioners.

However, administration must be notified and involved when any action is considered on these practitioners’ medical staff membership and/or clinical privileges, as the disciplinary process for these practitioners may differ.

Source: The Medical Staff Office Manual: Tools and Techniques for Success, Second Edition by Marna Sorensen, CPMSM