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Board News and Policies > Guidelines for Hospital Reporting, Effective September 9, 2001

Hospitals, health care facilities and other employers of physicians in NH have requested written criteria of which actions under statute (RSA151:6-b) represent disciplinary or adverse action and thus must be reported. A special committee, chaired by Dr. Bruce Friedman of the New Hampshire Medical Board, drafted this report to clarify those actions which require Medical Board notification. Input was reviewed from the New Hampshire Medical Society and various health care facilities. The Medical Board agrees that input from these and other organizations is critical for their ultimate acceptance, and for appropriate future reporting to the Board. The Board unanimously accepted these reporting criteria at its August 7, 2002 meeting.

RSA 151:6-b states "Report of Disciplinary Action. Every facility administrator, or designee, for any health care facility licensed under this chapter shall report to the board of medicine any disciplinary or adverse action, within 30 days after such action is taken, including situations in which allegations of misconduct are settled by voluntary resignation without adverse action, against a person licensed by the board."

Reportable disciplinary or adverse action include reduction, restriction, suspension, revocation, termination or denial of clinical privileges or medical staff appointment or employment, unless the change is voluntary because of the licensee's desire to limit practice, but not as a result of a past clinical quality of care issue. The acceptance of a physician's surrender or restriction of clinical privileges or medical staff appointment while under investigation for possible professional incompetence, or improper professional conduct, or in return for not conducting such an investigation or proceeding, is also reportable.

Suspension of a physician's privileges or disciplinary actions resulting from the following are not reportable:

1. Failure to timely complete medical records unless the suspension is the third within the calendar year for failure to timely complete medical records;

2. Failure to attend meetings;

3. Failure to meet administrative standards, i.e. suspensions for DEA expirations or lapse of malpractice insurance coverage or failure to have PPD testing.

A voluntary corrective action as a formal course, additional training etc. would not be reportable while required or mandated corrective action (course, training) is reportable. Informal action, such as a first time letter of warning by a department head, recommending a physician to the Physician Health Program, or a course is not reportable. However, if an action goes through the credentialing, clinical affairs or executive committee, it should be considered a formal adverse action and it is reportable. Health care facilities feel these distinctions would give them leverage in encouraging physicians to take voluntary corrective steps. The board is very much in support of this type of pro-active corrective action and hopes such criteria would encourage correction without the need for disciplinary actions. Any formal disciplinary action against the physician relating to professional ethics, medical incompetence, moral turpitude or drug or alcohol abuse must be reported.

The Board recognizes that the standards for persons holding trainee licenses should be different to facilitate the education process without being prejudicial to the trainee's future career. Trainees with a recognized problem, remedial plan to assess and help with this problem, verbal or written notice regarding this problem do not need to be reported unless there was gross or repeated negligence which resulted in the harm of a patient. Trainees who fail to meet the goals of the remedial plan, and therefore are put on probation, or are formally suspended from the program, or are dismissed, and/or as a result of any such action are not reappointed shall be reported. Behavior incompatible with the role of a physician including illegal, immoral or unethical behavior shall also be reported to the Board of Medicine.

The Board of Medicine will not take action on every hospital report. The Board will take action when it feels the public is at risk.


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