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I.        PURPOSE

To set policy and to delineate procedures to ensure the timely notification to the State of allegations or disciplinary actions arising out of professional misconduct by practitioners.

This policy is intended to implement Title IV of Public Law 99­660, the Health Care Quality Improvement Act of 1986, and the Professional Medical Conduct Reform Act of 1989 ("Act") and the regulations promulgated thereto.

Under the President and the Senior Vice President for Academic Affairs, the Deans of NJMS, RWJMS, SOM, NJDS, and SHRP, the Vice President and Chief Executive Officer for University Hospital, and the Vice President and Chief Executive Officer for Mental Health Services are accountable for ensuring compliance with this policy.

The Deans, Vice Presidents or designees of the individual health care facilities, the Medical Director and Associate Dean for Clinical Affairs ­ University Hospital, and the Director of Risk and Claims Management shall implement this policy.

Both federal and state laws apply to "practitioners" employed by or affiliated with University health care facilities. Under the federal law, the Health Care Quality Improvement Act of 1986, practitioners include physicians, dentists, podiatrists, interns and residents. Under the state law, the Professional Medical Conduct Reform Act of 1989, practitioners include physicians, podiatrists, and medical interns and residents.

Health care facilities of UMDNJ include University Hospital, Community Mental Health Centers, University Physician Associates ­ New Jersey Medical School, Faculty Practice ­ Robert Wood Johnson Medical School, Faculty Practice ­ School of Osteopathic Medicine, Intramural Faculty Practice and Oral & Maxillofacial Surgery Faculty Practice Service ­ New Jersey Dental School, Nurse Midwifery, Nursing Faculty Practice, Department of Developmental and Rehabilitative Sciences ­ School of Health Related Professions, etc.

The intent of Public Law 99­660 is to improve the quality of medical care by encouraging physicians, dentists and other health care practitioners to identify and discipline those who engage in unprofessional behavior and to restrict the ability of incompetent practitioners to move from state to state without disclosure or discovery of the practitioners' previous damaging or incompetent performance. The law has two separate and distinct areas: 1) provision for immunity from civil damages suits for health care entities and medical staff members providing information to peer review bodies, and for actions taken as part of the peer review process; and 2) requirement for reporting of malpractice claims, settlements and judgments paid on behalf of practitioners and reporting of certain professional review actions taken by health care facilities and State Boards which license practitioners.

Title IV of the Public Law 99­660, the Health Care Quality Improvement Act of 1986, also established the National Practitioner Data Bank (NPDB), an information clearinghouse to collect and release certain information related to the professional competence and conduct of physicians, dentists and other health care practitioners.

In an effort to enhance the protection of the public and to close loopholes in existing practitioner reporting laws, the New Jersey Legislature enacted the Professional Medical Conduct Reform Act of 1989 ("Act"). The Act creates a Medical Practitioner Review Panel ("Review Panel") to serve as the repository for notices from health care facilities, health maintenance organizations and medical malpractice insurers regarding practitioner misconduct and disciplinary actions arising therefrom. The Review Panel serves in an advisory role to the Board of Medical Examiners ("Board") and is empowered to recommend disciplinary actions to the Board.

The Act also requires physicians, podiatrists, and medical interns and residents to notify the Board of any information which reasonably indicates that another practitioner has demonstrated an impairment, gross incompetence or unprofessional conduct which would present imminent danger to the patient or the public's health, safety and welfare, except when such information is obtained during the course of treatment of the affected practitioner.

A.    Requirements:

       1.    Practitioners employed by or affiliated with University health care facilities
              shall become knowledgeable about the quality assurance procedures of
              their clinical department to ensure individual awareness and advance
              notification of potential patient care quality issues before they develop into
              reportable actions.

       2.    As required by both federal and state law, all disciplinary actions shall be
              reported to the NPDB and the Review Panel through the appropriate State
              licensing board in a timely manner, in full compliance with the timeframes
              set forth in each.

      3.     Matters not related to professional competence or professional conduct
              shall not be reported to the State or the NPDB.

      4.    Notification to the NPDB of an adverse action taken against a practitioner
             shall be made if the action taken against the employed or affiliated
             practitioner will reduce, suspend, revoke or deny clinical privileges for a
             period of thirty (30) days or longer. No such time limit exists for reporting
             adverse actions to the State. Adverse actions against a practitioner shall be
             reportable under the State law without exception for time restraints placed
             on the clinical privileges. (Refer to Exhibit A to determine what actions are
             reportable to the State and the NPDB.)

    5.     Malpractice information including any settlement, judgment or arbitration
            award, regardless of dollar amount, must be reported in accordance with
            both the State and Federal laws.

            The amount of payment reported includes only the amount paid by the
            insurer for the benefit of a practitioner to the plaintiff in settlements on
            satisfaction of a written claim or judgment. A waiver of debt is not
            considered a payment and should not be reported.

   6.     Requests for NPDB information must be made each time a physician or
          dentist or other health care practitioner applies for medical staff membership
          or clinical privileges.

All subsequent requests for NPDB information must be made every two (2) years thereafter or at the time of reappointment to the medical staff.

   7.    A practitioner shall notify the Board of information which reasonably indicates
          that another practitioner has demonstrated an impairment, gross
          incompetence or unprofessional conduct which would present an imminent
         danger to a patient or to the public health, safety or welfare, except when such
         information is obtained by virtue of a physician/patient relationship with the
         affected practitioner. Failure to notify the Board will subject the practitioner to
         disciplinary action and civil penalties.

  8.   Actions Reportable to the State and to NPDB:

        In instances where the report contains information that must be reported under
        both the State Law and the Federal Law, the reporting entity should send the
        Medical Practitioner Review Panel the entire Adverse Action Report Form
        (See Exhibit B for a list of official forms and their availability) with all copies
        attached with the exception of the entity's own gold copy. The Review Panel
        will retain a copy and forward the white copy to the Data Bank and maintain
        the pink copy for use by the Department of Health. A copy of the Adverse
        Action Report will be provided to the Board Office and another copy will be
        mailed by the board to the practitioner involved.

  9.  Action Reportable to the State Only:

       In those instances where a reporting entity believes that the action taken is not
       reportable under Federal Regulations, but is reportable under New Jersey Law,
       the Adverse Action Report must still be utilized. The entity should forward the
       reporting form to the Review Panel but should remove the top white copy. This
       will indicate to the Review Panel that the reporting entity does not believe the
       reported action is covered by the Federal requirements. The licensing Board
       will notify the practitioner involved that a report has been sent to the Review
       Panel as mandated by State Law.

       a.     Leave of Absence

              There is some question about the reporting requirements of the Data Bank
              relative to Leaves of Absence. There is no question, however, that a Leave
              of Absence is reportable under New Jersey Law. When reporting a Leave
              of Absence, use the method described in # 9 above.

      b.     Malpractice

              Under the Data Bank regulations, a health care facility, unless it makes a
              payment on behalf of a physician in a malpractice suit, is not required to
              report a malpractice action. Under New Jersey Law, the facility is required
              to report the physician who is named in a malpractice suit in which the
              facility is a party and for which any settlement is made for judgment or
              arbitration award entered.

             When completing the Adverse Action Report, as much information as is
             available in the relatively short time allotted for reporting to the Board, is to
             be provided. The reporting entity, in completing Section C, item 31, may
             include only that information as it deems appropriate for the Data Bank but
             should attach a thorough description, with whatever appropriate
             documentation is available, for use by the State Board of Medical
              Examiners.

              The Board will be reviewing the Adverse Action Report; and in, those
               instances where sufficient information has not been supplied concerning the
               incident, the Board will send the health care facility a request for
               Supplemental Report Form. This form requests detailed information and
               documentation relating to the reported action. The facility will have 30
               days from the date of the request in which to return the supplemental form
               and the required documents.

               The Supplemental Report Form will be used by the New Jersey Board of
               Medical Examiners only. If you submit information that is to be transmitted
               to the NPDB and you decide that you must revise or void that report, you
               must use the Adverse Action Report Form to make those changes.

B.      Responsibilities:

1.     The Dean or Vice President for each health care facility is
        responsible for:

        a.    designating an individual authorized to report the adverse
               action to the Medical Practitioner Review Panel and the
               NPDB only after he/she is satisfied that all quality assurance
               and due process provisions of the health care facility's
               Medical/Professional Staff Bylaws have been met.

       b.     creating a mechanism to query NPDB for adverse actions
               each time a practitioner applies for medical staff
               appointment, membership or clinical privileges.

       c.     forwarding copies of all adverse action reports to the Office
              of the Medical Director and Associate Dean for Clinical
              Affairs ­ University Hospital.

2.     The Medical Director and Associate Dean for Clinical Affairs ­
        University Hospital is responsible for:

        a.     consulting with the Medical/Professional Staff leadership to
                facilitate implementation of the policy provisions.

        b.     furnishing the requesting health care facility the official forms
                outlined in Exhibit B to comply with the policy's reporting
                requirements.

        c.     maintaining a file containing adverse action reports generated
                by all UMDNJ health care facilities on a centralized basis.

 3.     The Director of Risk and Claims Management is responsible for:

a.     notifying the Review Panel of all medical malpractice
        settlements, judgments and arbitration awards,
        regardless of dollar value.

b.     notifying the Review Panel of any termination, denial
        of coverage of any practitioner or surcharge
        assessed against a practitioner because of medical
        malpractice claims history.

c.     notifying the named practitioner that a settlement has
        been reported to the Review Panel.

d.     making claims records available to the Review Panel,
        upon request.

  4.     Practitioners employed by or affiliated with University health
          care facilities are responsible for:

a.     following the quality assurance procedures of their
        clinical department and due process provisions of
        the health care facility's Medical/ Professional Staff
        Bylaws.

b.     notifying the Board, as appropriate, of instances of
        impairment, gross incompetence or professional
        misconduct among fellow practitioners in
        conformance with this policy.

The procedure described below is intended to provide guidance only and, does not
replace the internal quality assurance, due process policies and procedures as described in the Medical/Professional Staff Bylaws of each health care facility.

A.    Notification to the Review Panel and the NPDB

 

Performed by:	Action Taken:
Dean, Vice President or Designee	1. Receives information from the responsible Department Chairman/Director that an action is contemplated or necessary to reduce the likelihood of immediate injury or damage to the health or safety of any patient. 2. Initiates an inquiry and if warranted, refers the matter to the appropriate Medical/ Professional Staff Committee and Dean or Vice President for review and appropriate action.   3. Notifies the Review Panel of any disciplinary action taken or contemplated to be taken against a practitioner which would result in the revocation, restriction, limitation, resignation, reduction or termination of any clinical privileges. 4. Sets forth the facts and transmits the report, in writing, utilizing the Adverse Action Report Form (see Exhibit B) within seven (7) days of the action to the Review Panel for appropriate action. Report must include practitioner's name, status at UMDNJ and reason for report. A copy of this report is also sent to the Office of the Medical Director and Associate Dean for Clinical Affairs ­ University Hospital for central file maintenance.
Director of Risk and Claims Management	5. Notifies the Review Panel of  all medical malpractice settlements, judgments and arbitration awards, regardless of dollar amount. Reports must be in writing utilizing the Medical Malpractice Payment Report Form and transmitted within seven (7) days of the action. 6. Notifies the Review Panel of any termination, denial of coverage, of a practitioner or surcharge assessed against a practitioner because of medical malpractice claims history. 7. Notifies the named practitioner that a settlement has been reported to the Review Panel. 8. Makes available records of claims to the Review Panel upon request.

 B.    Requesting Information from the National Practitioner Data Bank
 
 

Performed by:	Action Taken:
Dean, Vice President or Designee	1. Requests adverse action reports and malpractice payment information from the Data Bank each time a practitioner applies for medical staff membership or clinical privileges. Utilizes the Request for Information Disclosure Form for this purpose. 2. Requests subsequent information at least every two (2) years thereafter for licensed individuals holding clinical privileges.

C.     Notification to the Board of Medical Examiners (Board)
 
 

Performed by:

Action Taken:

Practitioners (physicians, podiatrists, medical he/she possesses information which interns and residents)

1. As appropriate, notifies the Board if he/she possesses information which reasonably indicates that another practitioner has demonstrated an impairment, gross incompetence or unprofessional conduct which would present an imminent danger to a patient or to the public health, safety or welfare. Such notification must include the name and address of all practice locations and the name of any other licensee directly associated with the practice.

  A.    Reportable Actions Checklist.
  B.    Forms for the State and NPDB Reporting

By Direction of the President:

__________________________________
Vice President for Academic Affairs

FORMS FOR THE STATE AND NPDB REPORTING

 All UMDNJ health care facilities must use specific forms to fulfill reporting requirements under this policy. The following forms may be obtained from the Office of the Medical Director and Associate Dean for Clinical Affairs - University Hospital (UHD215A, NEWARK).

 

FORM	Purpose
Adverse Action Report	to notify to the State and the NPDB reportable adverse actions taken against a practitioner.
Supplemental Report	to provide detailed information and documentation relating to the reported action to the State Board of Medical Examiners.

 

_________________________________
Senior Vice President for Academic Affairs   

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