Resolving Problems with Obtaining or Modifying Hospital Privileges

How to Resolve an Obtaining or Modifying Privileges Problem

For Family Physicians Who Are Medical Staff Members

Follow the protocol below if you are faced with a problem in obtaining or modifying hospital privileges, which has been approved by the AAFP Board of Directors.

1. Review the Eligibility Criteria

The hospital should have criteria in place for each privilege you are requesting. Check the medical staff bylaws or credentialing manual to make sure you meet the eligibility criteria before applying for privileges.

If you do not meet the criteria, you will rarely qualify for the appeal and due process remedies of your hospital medical staff bylaws. If you do not qualify for appeal and due process remedies, the subsequent steps in this protocol will not apply to you. Your best recourse may be to work within your local medical staff structure to change the eligibility criteria.

2. Adequate Training and Experience

Review your credentials. You must show that your training and experience qualify you for the privileges you have requested.

3. Assemble All Pertinent Documentation

Make sure the documentation of your training, experience, and current competence is in order.

Collect letters of recommendation from past instructors, preceptors, those who have monitored your clinical work, and colleagues who have worked with you throughout the years. Assemble case reports including data about the number and types of cases, treatment outcomes, etc., and documentation records maintained during your family medicine residency.

Your complete documentation, case reports, and letters of recommendation should be in order at the time you fill out your applications for medical staff membership and privileges. The hospital may only require that you submit a list of references; however, these additional materials should be readily available upon request.

It is important that you make a copy of each document you submit in the event that the original documents are lost or misplaced. Ongoing documentation of your clinical experiences should be maintained.

4. Be Informed of All Hospital Rules and Procedures

Obtain a copy of the current version of the medical staff bylaws (or credentialing manual) and rules and regulations (and department rules and regulations, if available) which apply to privileges.

Assure yourself that the hospital is complying with its own bylaws. Carefully study and comply with your medical staff bylaws, rules, and regulations. Before taking action, fully understand the appeal process as delineated in the bylaws, including any time restrictions.

5. If Your Request for Privileges Has Been Denied, Insist on a Written Explanation

Be sure that specific information regarding the decision is submitted to you in writing and that the letter explicitly states the reason(s) why your privileges have been denied or restricted and under what circumstances these privileges may be obtained.

Identify the real problem. Ask yourself:

  • Have you adequately documented your capabilities?
  • On what reasonable grounds have your privileges been restricted or denied?
  • Are all family physicians denied these privileges at this hospital (unrelated to eligibility criteria) or have you alone been singled out for restriction?
  • Are there other reasons behind those which have been stated in writing?

6. Seek Local Support

In the event of a hospital privilege dispute, your relationships with other physicians may be helpful in influencing your credentialing committee. Their conversations with committee members, other members of the medical staff, and their letters of support may contribute to an early resolution of your problem.

Seek the support of family physicians on the medical staff. If there is an organized department of family medicine, submit your position to it and seek its enthusiastic support. If not, other family physicians/general practitioners on the staff will need to vouch for your abilities. Your local (county or community) AAFP chapter should be informed and may be able to help at this stage.

Seek the support of physicians in other specialties with whom you have a working relationship, especially those with whom you consult and refer patients. Be sure to build alliances with members of other broadly-based specialties at your hospital. They, too, may find themselves with a similar problem in the future, and they may want to seek your support.

Notify your AAFP constituent/state chapter that you have a hospital privilege problem. Some chapters have a committee that deals specifically with privilege problems. They may suggest other actions you could take, write a letter of support, or make a site visit. State your problem to the chapter in writing, and send all pertinent data (copies of letters regarding your privileges, the medical staff bylaws, etc.).

7. Exhaust All Local Avenues of Appeal

Know the appeal process. Familiarize yourself with the section of the hospital medical staff bylaws which describes the appeal process. Especially review the section of your medical staff bylaws that pertains to fair hearings and appellate review mechanisms for medical staff recommendations to deny, curtail, suspend, or revoke hospital privileges.

Note the time frame for requesting an appeal. You must follow your hospital medical staff bylaws explicitly in order to preserve your legal right to appeal.

Take advantage of the hearing process. Since your best opportunity for successfully resolving your privilege problem is at the hearing, you should consider legal counsel. Contact your AAFP constituent chapter, your state or county medical association, or local bar association to obtain the name of an attorney experienced in health care law, and medical staff affairs in particular.

Obtain in writing a list of witnesses expected to testify at the hearing on behalf of the medical staff. Develop your own list of witnesses to testify on your behalf, which may include the chair of the department of family medicine, other physician(s) who are well-informed and respected, and those who can vouch for your current competence.

Bring to the hearing all documents and letters you have compiled that are relevant to your case, as well as the policy statements developed by the AAFP, the AMA, and the Joint Commission on Accreditation of Health Care Organizations. Submit a written statement of your position at the close of the hearing. Be sure you receive the hearing panel's written recommendation, including an explanation of the basis for the recommendation.

In the event of an adverse ruling by the hearing panel, request appellate review. Appellate review is usually conducted before the Board of Trustees. Although a hospital board usually will comply with the hearing recommendation, a ruling in your favor is still possible.

You should prepare a written statement for the board explaining why the hearing recommendation should not be adopted. Find out whether oral presentations will be permitted. Be sure to obtain in writing the Board of Trustees' final decision.

Keep your AAFP constituent chapter informed of the status of your case. Utilize the chapter's advice and assistance on an ongoing basis. Keep the chapter informed of the outcomes of your appeals.

Consider legal action. Whether you actually pursue a lawsuit is a decision to be made between you and your attorney. Talk and listen to physicians who are respected in the community before you decide how far you want to go.

Do not allow yourself to be overly influenced by an attorney's encouragement for you to litigate. In general, courts are hesitant to substitute their judgment for the judgment of hospital boards. Absent a flagrant wrong such as failing to follow medical staff bylaws, courts will usually defer to hospitals as the supreme authority in determining medical staff privileges.

Before making a decision, you should request an opinion letter from your attorney that addresses the merits of your case. The opinion letter should include:

  1. The basis for taking legal action
  2. An opinion on the likelihood of success
  3. Citations to specific statutes and cases that support your position
  4. An estimate of the cost involved to litigate

Neither the AAFP nor its constituent chapters provide individual legal advice, nor are they responsible for financial support for legal expenses. The AAFP may have data available on similar cases, which may be of assistance to you.

8. The Constituent Chapter Determines Whether to Support Your Case

The chapter reviews the information submitted by you to make certain that all steps have been followed, reviews the report of the chapter investigative committee and the opinion of your personal attorney, and then determines whether to support your case.

The chapter may decide to commit funds for your legal expenses (and if so, how much) or whether other measures (e.g., a site visit) are more appropriate. Before deciding to commit financial resources to potentially costly legal action, the chapter should seek the opinion of an attorney, other than your attorney, on the merits of the case.

9. The Constituent Chapter Determines Whether to Seek National Support

If all attempts to resolve your privilege problem at the local and constituent chapter levels have failed, the constituent chapter Board of Directors may wish to seek the support of the AAFP.

The constituent chapter should submit its request for assistance directly to the AAFP Commission on Quality and Practice. The commission will provide advice and assistance to ensure that the protocol requirements have been met and documentation of the case is complete.

The chapter should submit:

  • Complete documentation of your case
  • A written report of the findings of the chapter's investigative committee
  • A detailed list of all steps taken to resolve the case to date
  • Legal opinions from your attorney and the chapter's attorney
  • Specific information about the type of support the chapter would like the national Academy to provide, e.g., a letter of support for your case, a site visit by AAFP officials, financial assistance for a lawsuit, etc.

10. Conditions for AAFP Financial Support

Before the AAFP Board of Directors will consider your request for financial assistance, it must receive an official request from your constituent chapter's Board of Directors and a recommendation from the AAFP Commission on Quality and Practice.

The AAFP Board of Directors has supported such requests only when the constituent chapter has made its own financial commitment in support of its member's case. The AAFP is under no obligation to finance legal expenses incurred before an official request for financial support is approved.

The criteria necessary before the AAFP accepts cases to support financially in the area of hospital privileges include:

  1. Strict following of the protocol outlined in steps 1-9.
  2. Impact on the family medicine movement.
  3. Evidence of discrimination based on physician specialty rather than individual qualifications. In accordance with the legal principle of "inurement," a tax exempt organization may not expend funds for the benefit of an individual.

11. The AAFP Board of Directors Determines Whether to Support the Case

The official request for support then will be considered by the AAFP Board of Directors. The Board Chair or his/her designee will contact the chapter's president immediately following the Board meeting to notify the chapter of the Board's decision. A letter to reiterate this conversation will follow, with a copy of the letter to the member whose case has been considered.

Members who follow the steps outlined in this protocol are not guaranteed that the Academy will automatically support their efforts.

Any questions regarding this protocol should be directed to the AAFP Divison of Practice Advancement. If necessary, staff will consult on members' questions with the AAFP Commission on Quality and Practice.