In This Presentation:

- What is Disruptive/Impaired Behavior?

- Main Impediments to Addressing Unprofessional Behavior

- Components of Successful Policies

- A Legal Perspective

- Joint Commission and Bylaw Standards

- Data Bank and State Reporting Requirements

- Negligent Credentialing/Malpractice Issues

- Confidentiality Issues

- HR Employment Issues

- After Care Issues

- Responses to Third Party Inquiries

- LEGAL UPDATE: Final Medicare Medical Staff Conditions of Participation: What Should be in your Bylaws

- Areas To Be Covered

- Hospital Governing Board

- Hospital Medical Staff - Membership

- Hospital Medical Staff – Unified Integrated Staff

- Ordering Outpatient Services

- Resource List

- LEGAL UPDATE:Tibbs v. Bunnell

- THE NEW NPDB GUIDEBOOK

- NPDB Background

- Hospital Obligation to Query

- Eligible Entities that Report to and Query the NPDB

- Reporting Requirements and Query Access

- Hospital Obligation to Query

- What if Hospital Fails to Query?

- Centralized Credentialing

- Delegated Credentialing

- Time Frame for Reporting

- Types of Reports

- Narrative Descriptions

- Reporting Adverse Clinical Privileges Actions

- When Are The Actions Reportable?

- Withdrawal of Applications

- Investigations

- Summary Suspensions

- Proctoring/Monitoring/Mandatory Consultations

- Sanctions for Failing to Report

- Excerpt from HR Employment Issues:

- Need to compare “disruptive behavior” and “impaired physician” standards as applied to employed physicians and other hospital employees to those applied to independent medical staff members.

- It is fairly common to see employed physicians held to a higher or different standard then independent physicians.

- Process for dealing with disruptive behavior of employed physician also can be different and remedial measures can be imposed with less process and terminations imposed more quickly.