Adverse Privileging Action Summary
Is the military investigating you for some allegation of alleged wrongdoing in connection with professional services rendered to patients?
Have you received notice of an abeyance? Is the military investigating you for some allegation of alleged wrongdoing in connection with professional services rendered to patients? If so, this information paper should provide you a detailed overview of what to expect during the subsequent investigations and meetings to follow. Paying close attention to this process, and your rights, could be the difference between surviving an investigation into your conduct versus having the allegations reported to your home licensing state.
Introduction: In order to provide medical treatment of any kind in the United States, a health care provider must be licensed in the state[s] they plan to practice in; this includes pediatricians, chiropractors, dentists, psychologists, nurses, pharmacists, social workers, and other occupations in a similar realm. For those who seek employment in a military treatment facility (MTF), proper credentials are necessary. In order to obtain professional credentials, a practitioner must provide a litany of information, including various degrees and proof of license in one or more states. The ability of a properly licensed provider to practice in the military is known as a “privilege” of medical practice. The “quality assurance and licensing program,” a military program, assures the validity of licensing for providers of medical treatment, and adheres to the guidelines outlined in the Department of Defense Manual 6025.13, issued October 29th, 2013. The services of the program available in each MTF are responsible for ensuring the compliance of medical providers with the quality assurance policy. Each service maintains its own implementing regulation. This program is designed to guarantee safe and effective care for patients by competent providers, as well as to ensure action is taken if the policy is violated via the occurrence of an adverse event.
Although the DoD Manual presents guidelines as to how the credentials board, which manages clinical privileges for health care providers, is meant to be conducted, there can be wide variance in the way the board is conducted. The board may consult Army Regulation 15-6 for guidance, but much will depend on decisions of the Board President and advice of the non-voting legal advisor.
This white paper will explain the step-by-step process of provider credential revocation/suspension as a result of an adverse event that allegedly threatened the safety of a patient[s]. We hope that this article offers helpful guidance on the whole process.
Step One – An incident prompts investigation into clinical privileges of a provider.
Actions against a provider’s privileges are taken when it is suspected or evidenced that the provider has not acted in the best interest of patient care. Such actions, as outlined by AR 40-68, include an incident of gross negligence, patterns of substandard care or inappropriate prescribing, acts of incompetence that cause bodily harm or death, abuse of legal and illegal drugs and alcohol, and significant, unprofessional misconduct. As with many areas of military law, the regulation offers little concrete guidance on what constitutes misconduct. This creates significant risk that commands can use this subjective standard for retaliatory reasons that have nothing to do with patient care. Be sure to share any such suspicions and facts with your attorney for careful evaluation.
Actions against one’s clinical privileges can include an abeyance, a summary suspension, a period of reduced privileges and monitoring and evaluation [M&E], or revocation. The process of investigating the privileges of a provider and ultimately deciding on an action is referred to as “an adverse clinical privileging action.” This process can only be introduced when “reasonable cause” is introduced to believe the provider is lacking competence to practice in the best interest of patient health.
Step Two – Quality Assurance [QA] investigation
The first step in an adverse privileging action is a notification of abeyance of privileges delivered to the provider. This abeyance marks the beginning of a quality assurance investigation, in which a QA investigator—a designated, impartial investigating officer [IO] of similar clinical background as the provider—is appointed to investigate. The provider notification should include the allegations and any restrictions placed on the provider during the investigation. An abeyance can last for up to 30 calendar days. If the government needs more time it automatically converts to a summary suspension. Keep in mind that neither the abeyance nor the summary suspension is reportable to licensing agencies. The QA IO may request a provider interview. Although there is no right to counsel during the interview itself, the provider should seek legal advice in advance of the interview. Counsel can help prepare the provider for the interview and what to expect. Be sure to treat the QA IO with courtesy and respect since he or she can testify at subsequent hearings.
Step Three – The Credentials Committee reviews the investigation and recommendation(s)
Next, the Credentials Committee (CC) of the Medical Treatment Facility (MTF) will review the case file before making recommendations to the MTF Commander. To encourage fair decision-making, one member of the CC is required to be of similar clinical profession to the provider. The IO will often testify before the CC, answer questions, and provide additional insight into the investigation. Though the provider may provide a written statement and written materials for consideration, they do not have the right to be present during the CC review.
After the review, the CC will recommend a course of action. Possibilities include full reinstatement of privileges and no further action, formal peer review, administrative, personnel, civil, or legal action, or a period of Monitoring and Evaluation (M&E). Interestingly, the M&E option is not listed in the Army Regulation but is available in the DoD Manual. An M&E plan, if recommended, establishes clear guidelines and expectations for the provider, as well as mandates periodic reviews of the provider for the duration of the evaluation. M&E, along with abeyance and summary suspension, is not reportable to any regulatory agencies and does not constitute an adverse action.
Step Four – Peer Review Panel
A peer review panel is exactly what its name implies – a group of the provider’s peers that evaluate the allegations and review the provider’s conduct. Its members must include only members with a similar clinical background to the provider in question. After provider notification (similar fashion to the notice of abeyance/summary suspension), they are encouraged to meet in person with the peer review counsel and provide written and verbal statements, answer and ask questions, and provide additional materials for consideration. However, the provider is not permitted to attend the official Peer Review proceedings. Considering all materials provided, including the QA Investigation, materials provided by the provider, and any additional information, the Peer Review panel will forward its recommendation to the CC. The CC will evaluate the case evidence and forward its recommendation to the MTF Commander. This recommendation may include: Full reinstatement of privileges, M&E, suspension (which in this context is considered an adverse privileging action, and is reported to regulatory agencies), restriction of privileges, reduction of privileges, complete revocation of privileges, or denial of reinstation.
Thank you for reading about the first four steps of the Adverse Clinical Privileging process. Stay tuned for information about Steps 5-8 (part two of this series) and Steps 9-12 (the final part of this series). As always, for more information about this topic or others on this website, please contact us at 913-827-3729.