DEI at the Hospital - Addressing Bias in Medical Staff Credentialing and Peer Review

Diversity, equity, and inclusion are often included as goals in hospital mission statements. Failure to address DEI in medical staff documents creates a disconnect.

Medical staff policies and procedures that do not correct biases create bigger problems than bad optics. Bad faith credentialing loses opportunities for hospitals, harms overall staff morale, and jeopardizes both physicians' reputations and patient care. Prejudiced peer review means huge damages in court.

This webinar will review basic medical staff processes that need to be corrected to comply with state and federal law and regulation and Joint Commission accreditation standards.

Hospital Medical Staff are required by state law and nationwide accreditation to review physicians and other clinicians without bias.

Register Now,
https://conferencepanel.com/conference/dei-at-the-hospital-addressing-bias-in-medical-staff-credentialing-and-peer-review

1. DEI at the Hospital
Addressing Bias in Medical Staff
Credentialing & Peer Review
Elizabeth ”Libby” Snelson
[email protected]

2. Physician Peer Review Defined
(1) Medicalpeerreviewis an organized effort to evaluate and analyze medical care services delivered to patients and to assure the quality
and appropriatenessof these services.Peerreviewshould exist to maintain and improve the quality of medical care.
(2) Medicalpeerreviewshould be a local process.
(3) Physicians should be ultimately responsible for allpeerreviewof medical care.
(4) Physicians involved inpeerreviewshould be representatives of the medical community; participation should be structured tomaximize the
involvement of the medical community. Anypeerreviewprocess should provide for consideration of the views of individual physiciansor
groups of physicians or institutions underreview..
(5)Peerreviewevaluations should be based on appropriateness, medical necessity and efficiency of services to assure quality medical care.
(6) Any system of medicalpeerreviewshould have established procedures.
(7)Peerreviewof medical practice and the patterns of medical practice of individual physicians, groups of physicians, and physicians within
institutions should be an ongoing process of assessment and evaluation.
(8)Peerreviewshould be an educational process for physicians to assure quality medical services.
(9) Anypeerreviewprocess should protect the confidentialityof medical information obtained and used in conductingpeerreview.
AMA Policy # H-375.997
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3. PEER REVIEWIS A GOOD THING*
➢Improving quality
➢Physicians reviewing physicians
➢Physician-determined standards
➢Keep accountants and attorneys
out of medical decision-making
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*when it works

4. PEER REVIEW IS PROTECTED *
➢Protected by state & federal
statutes
➢Protected under professional
liability insurance policies
➢Protected by medical staff bylaws
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*when it’s compliant

5. Balancing Interests
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Patient care
quality
Potential
liability for
hospitals and
medical staff
leadership
Physicians’
reputation
Conflicting Interests
Competition Profit Power

6. The Many Components of
Peer Review
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7. HOSPITAL MEDICAL STAFF
PEER REVIEW PROCESSES
✓Application Process
✓Credentialing & Privileging
✓Ongoing Professional Performance Evaluation
✓Focused Professional Performance Evaluation
✓Physician Wellness
✓External Peer Review
✓Investigation
✓Corrective Action
✓Hearing Rights
✓Appeal Rights
✓Reporting to state and federal governments
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8. Targeting A Professional
because…
Patient Advocate
Discrimination
Higher Standards
New Approach
Professional Envy
Harassment
Bigotry
Profit
Whistleblower
&&&&&&&& 8

9. “Limitation on damages for professional review actions”
If a professional review action (as defined in section 11151(9) of this title) of a professional review body
meets all the standards specified in section 11112(a) of this title, except as provided in subsection (b) of
this section -
(A) the professional review body,
(B) any person acting as a member or staff to the body,
(C) any person under a contract or other formal agreement with the body, and
(D) any person who participates with or assists the body with respect to the action,
shall not be liable in damages under any law of the United States or of any State (or political subdivision
thereof) with respect to the action.
The preceding sentence shall not apply to damages under any law of the United States or any
State relating to the civil rights of any person or persons, including the Civil Rights Act of 1964,
42U.S.C.2000e, et seq. and the Civil Rights Acts, 42U.S.C.1981, et seq.
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The Health Care Quality Improvement Act of 1986, as amended 42 USC Sec. 11101

10. Under the federal Health Care
Quality Improvement Act of 1986:
Adequate Notice & Hearing
The physician is given written notice of the
proposed action, stating
➢That a professional review action has
been proposed to be taken against the
physician;
➢The reasons for the proposed action;
➢That the physician has the right to
request a hearing on the proposed
action;
➢Any time limit (of not less than 30 days)
within which to request such a hearing;
➢A summary of rights in the hearing.
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11. Medical Staff Documents
➢Should at least meet
HCQIA & state laws
➢Should protect
physicians
•Notice & Transparency
•Confidentiality
•Access to All Information,
Including Favorable
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12. Target Targeted Peer Review

Where to Look
❑Medical Staff Bylaws
❑Medical Staff/Department Rules and
Regulations
❑Medical Staff Code of Conduct (in or separate
from Medical Staff Bylaws)
❑Medical Staff “Disruptive Behavior” Policy
❑Medical Staff Sexual Harassment Policy
If these policies do not exist and the medical
staff bylaws fail to prohibit harassment and
protect medical staff members, the medical
staff should amend its bylaws.
❑Hospital Code of Conduct
❑Hospital Compliance Code
Hospital policies might apply to medical staff
members or only to those it employs.
What to Look For
❑Harassment Banned
❑Description/Discussion of Physical Harassment
❑Description/Discussion of Verbal Harassment
❑Description/Discussion of Illustration/Photographic Harassment
❑Harassment Reported to Medical Staff Leadership
❑Harassment Reporters Protected from Retaliation
❑Harassment Prevention Measures
❑Advocacy Protected
❑Medical Staff Education
❑Leadership Diversity Training
❑Leadership Diversity Goals
❑Leadership Diversity Planning
❑Peer Review Participants (Proctors & Reviewers) Diversity Planning
❑Medical Staff Diversity Committee/Medical Staff Diversity Officer
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13. Elizabeth A. Snelson
Legal Counsel for the
Medical Staff PLLC
[email protected]
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