Inactivating Practitioners’ Credential Files and Privileges

Question about when to maintain files and privileges for departing practitioners:
When a practitioner declares that he or she is leaving a health care facility, is it a requirement to “inactivate” the credential file and privileges? I have always felt that, if the file and privileges are not inactivated, the MSP is required to maintain the file. So it only stands to (my) reason that the file and privileges need to be inactivated. What are the CoPs or Standards in regards to the subject? Or is it best just to allow the file to expire and not offer a reappointment packet?

Your guidance will be greatly appreciated.

Susan Swanz, Indian Health Service, Billings, Montana

Hello, Susan. This question comes up more often now than at any time in the past. I can easily see that it may be a frequent occurrence at an Indian Health Service Facility.

While physicians do not change practice locations with the same frequency as the general population, they are becoming more mobile as they receive offers from other locations or simply seek a new environment. Additionally, many baby boomer physicians are beginning “partial” retirement. That is, they are leaving practice but are maintaining medical staff membership as long as possible, just in case something changes and they wish to go back into practice. These physicians do occasionally physically leave town and relocate in other areas of the country. When these things happen, you are left with a file, but no physician. He or she has neither resigned nor been terminated, and reappointment does not roll around until sometime in the distant future. Both medical staff membership and privileges are still intact. There are no requirements that you “inactivate the file.” You should follow your bylaws, but unfortunately, most bylaws and polices do not address this issue. They do address leaves of absence; however, it does not seem from your letter that this policy would apply in this case.

You have a number of options:

  1. Perhaps the best is simply to wait until reappointment and then take one of two actions:
    • Discuss the situation with the credentials chair and, if circumstances warrant, send the practitioner a letter asking for a clarification of his or her intentions. You night use the intended practice plan mechanism for this request. If the practitioner submits a satisfactory intended practice plan, you would then send a reapplication. If he or she has been out of practice for some time, the credentials committee would find it tough to recommend re-granting of clinical privileges.
    • Discuss the situation with the credentials chair and do not send out a reapplication, but do send a letter informing the practitioner that “due to your recent relocation, your membership on the staff has expired. In the event your circumstances change in the future, you should feel free to contact us about obtaining a new application.”
  2. As soon as the practitioner makes his or her intentions clear, the appropriate medical staff leader might make contact to determine his or her intentions. During this conversation or within the letters sent to these practitioners, the leader should make it clear that they either may or may not maintain membership and privileges if they have no intention of assisting the staff and hospitals with their patient care needs. (This will depend upon the policy of the MEC and hospital.) After such a contact, the Medical Staff Director should take that action necessary to support the medical staff leader.
  3. Your suggestion is perfectly fine. Your chief or president of the staff or CEO could send a letter advising the practitioner that his or her membership and privileges will be inactivated pending receipt of information clarifying future plans. Should circumstances necessitate reactivation of both membership and privileges, you will be glad to forward appropriate forms and material to the practitioner for completion.

Regardless of the action you take, Credentialing Principle #1 should guide the staff’s actions. This, coupled with the competency equation, will provide excellent guidance if this person chooses to return to your community to practice. (Competency equation-recent relevant clinical performance plus evidence that such performance was of high quality is required in order to make a determination that a practitioner currently is clinically competent.)

On a more practical note, medical staffs have for too long maintained physicians on staff who have no functional connection to the community or staff. This gives rise to confusion at the time of reappointment due to the fact that we routinely send reapplication to all physicians, regardless of their location or situation. MSPs have asked if they are required to send reapplication to physicians serving time, who have relocated oversees, or who have taken full-time positions in other facilities a great distance from the community. It might be time for the staff and board to consider a simple policy: “Physicians who do not in any way assist the medical staff or hospitals with their various missions will no longer qualify for medical staff appointment.” Assistance can be defined as admissions, referrals, procedures, education, medical staff/hospital committee work, etc. Implementing such a policy is not difficult; simply use the intended practice plan process to determine the intentions of a seemingly inactive physician.

Thanks for the question.



Inactivating Practitioners’ Credential Files and Privileges — 3 Comments

  1. could you put an electronic copy on the CheckMedic book on the website for readers to download and read?

  2. Thats a great idea, Hugh. We will work on getting a copy online and make it available for people to download.

  3. Are there any policy samples of disrutpive behavior regarding members of the medical staff that include behaviours that undermine a culture of safety? I am not quite sure what TJC expects for MS 08.01.01. Thaks for any quidance you may have.
    Marion Morrison

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