Physician Privilege Determination at Madison Memorial Hospital

Rexburg, Idaho – December 12, 2016. For the community’s information, Madison Memorial Hospital provides the following information to the public about how the hospital determines which physicians and other healthcare providers practice medicine within the hospital, and the process by which those decisions are made.

Permission to admit patients to the hospital, or to provide treatments or perform procedures, is granted in the form of “privileges.” As this implies, practicing within the hospital is not a right, nor a guarantee, but a privilege, which must be applied for by the practitioner. Practitioners of various specialties are granted permission to provide treatments only within the specific scope of their training, education, and clinical competence, which must be proven prior to the granting of privileges. Applications for privileges are reviewed by a body of physician representatives, who are elected by their peers. After receiving information from physicians within the various departments of the hospital, this body, called the Medical Executive Committee, gives a recommendation regarding the applicant, and the final decision for the granting or denial of privileges is made by the Madison Memorial Hospital Board of Trustees, who are volunteer members of the community.

Once privileges are granted, they must also be maintained through a system of review and renewal which occurs, in our case, every two years. By meeting requirements for licensure and continuing education, demonstrating good outcomes, and following recognized medical protocols and standards of care, physicians prove the ability to keep their hospital privileges. Privileges can be placed in jeopardy when physicians fail to meet these requirements, or when they engage in disruptive behavior in the hospital. In nearly every case, exhaustive efforts are made to improve the level of the practitioner’s care or conduct through educational, rehabilitative, or disciplinary pathways, before the hospital resorts to the removal of hospital privileges.

If the Medical Executive Committee does recommend removal of privileges, the physician is entitled to due process, known as a “fair hearing,” before the Board makes its decision. While not the same, a fair hearing is similar to a court trial, in that the physician and the Medical Executive Committee each call witnesses to testify, introduce evidence, and present arguments. Each party is allowed legal representation. The evidence is heard by a panel of three individuals, typically composed of physicians and legal professionals. Care is taken to ensure that those on the hearing panel are impartial, unbiased, and free of conflicts of interest, such as competitive factors. Once all of the evidence and arguments have been heard, the panel deliberates together at length before issuing its written recommendation to the Board. The panel’s opinion may agree with, disagree with, or completely depart from the recommendation of the Medical Executive Committee. In any case, given this information, the final decision then rests with the Board.

This process is set forth and governed by the hospital’s Medical Staff Bylaws, which we are legally required to follow, and which we do follow. The main intent of the privileging process is to protect the integrity of the practice of medicine in the hospital, and the patients we serve. It also helps to ensure a safe working environment for our staff, who work shoulder to shoulder with our physicians, day in and day out. Care is also taken during the process to ensure that physicians are treated fairly, and safeguarded against the possibility of bullying, anticompetitive campaigns, or “witch hunts.” It is a fair, private, and thorough process that we employ as an effective means of quality control. The details of a fair hearing are confidential under state and federal law. The ability to provide self-governance by the Medical Staff when granting and removing privileges is an essential and integral part of how any hospital functions.