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Ask the expert: If the medical executive committee decides it needs to investigate a physician's conduct or competence, who should conduct this investigation?

Medical Staff Leader Connection, January 7, 2009

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It is often most practical for the medical executive committee to assign the duty of conducting investigations to an ad hoc investigation committee. This committee should look into the available evidence and make an initial recommendation regarding the need for corrective action. The bylaws should specify how this committee is composed and how members are appointed.

When appointing committee members, fundamental conflict-of-interest policies should be considered, and it is generally wise to avoid assigning partners or associates of the physician under review. Likewise—to the degree feasible when the medical staff is small—physicians who have significant referral relationships or directly compete with the physician under investigation should not be appointed to the investigating body.

However, the federal Health Care Quality Improvement Act and some hospital bylaws do not expressly preclude direct economic competitors from participating in such investigations. The option to not preclude direct economic competitors is in place so there is no second-guessing, should litigation arise, over whether the individuals on the committee were significant economic competitors and therefore placed on the investigating committee in violation of the bylaws.

When composing an investigating committee, it is also prudent to check your state’s peer review laws. A few states have laws outlining the parameters for assigning individuals to an investigation committee.

Joseph D. Cooper, MD, CMSL
Consultant
The Greeley Company

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