NICU Privileges Approved Thanks to Hard Fought Privileging Battle in Salinas
By Sumana Reddy, MD

Eleven family physicians found ourselves unexpectedly caught in a privileging battle we had not seen coming. It happened like this…

I practice at two hospitals in Salinas: one is a UCSF residency-affiliated county hospital, Natividad Medical Center, and the other is the district hospital, Salinas Valley Memorial Healthcare System (SVMH). Natividad has had a Level II nursery for some time, while SVM has not. Multiple factors went into the decision to build a new nursery at SVMH. The California Department of Health Services had found SVMH out of compliance with its regulations by providing care such as IV fluids or oxygen to babies in a Level I nursery. The two hospitals are competitive with regard to services provided, with SVMH usually in the lead.

In our area on the central coast of California, there has been a solid primary care base, partly fueled by the existence of the family practice residency program. A significant number of family doctors in both hospitals do obstetrics, and of these, a number perform cesarean sections. We are also accustomed to caring for the newborns we deliver through lower acuity initial illnesses such as hyperbilirubinemia, sepsis workups or temperature instability, and transient tachypnea of the newborn.

In May 2001, the family physicians at SVMH were informed that we would not be able to practice our neonatal privileges in the new Level II nursery or NICU. We were told the reason for this was because of the California Children's Services’ (CCS) stipulation that only Board certified pediatricians and neonatologists may practice in a CCS-accredited NICU. However, our reading of the CCS guidelines was different. The wording states that care must be directed by a CCS empanelled medical director, but does not stipulate who can or cannot work in the nursery under his or her direction. At this point we contacted CAFP for assistance.

With CAFP’s Medical Practice Affairs Director, Laura Johnson Morasch, Executive Director Susan Hogeland and Legislative Advocate Tom Riley involved, we took it to the next level. I spoke personally with Mary Watts of the CCS who stated that while statewide it was not a common occurrence, FPs were not barred from treating non-CCS babies in a CCS NICU. Maridee Gregory, MD, the head of CCS, also sent a letter to CAFP clarifying this.

After this, SVMH chose to take some interesting positions. A letter was sent to the FPs from the CEO stating that this was an action in the interest of “quality care,” although there had never been any specific data or QI review to suggest a problem with FP care of newborns. The newly-hired neonatologist took the position that CCS was an organization within which the political statements coming from the top were unrelated to the auditors' guidelines, and the CCS auditors would never accredit the nursery if FPs worked within it. Meanwhile, in the name of “core privileging” and with a JCAHO survey upcoming, the previous longstanding credentialing application, which clearly allowed FPs to care for sick newborns, was removed. In its place, the form stated only that this higher level of privileges required pediatric board certification, despite the AAFP and other group’s guidelines that privileges should be based on appropriate training and qualifications, not on specialty board certification. This new form was rejected by the family practice department, but somehow seemed to have been swiftly approved by the hospital MEC.

At this point, our group of FPs was unhappy and frustrated, but also largely convinced there were few alternatives left. The hospital called a meeting with its consultant, a Stanford pediatrician, who upheld the hospital's position that it would not receive CCS accreditation with FPs treating newborns in the NICU. Luckily at this meeting, our CAFP representative, Ms. Johnson Morasch, successfully pinned down the medical director and neonatologist. They agreed that if another letter could be obtained from CCS stating affirmatively that FPs treating non-CCS babies would not hinder SVMH’s CCS accreditation application, FPs would be allowed back into the NICU.

In the meantime, at the recommendation of CAFP, we contacted Barbara Hensleigh, an attorney specializing in privileging issues. Her background as a former NICU nurse and her privileging experience made her invaluable. She provided immensely helpful assistance and was sympathetic enough to make her services affordable. She drew up a suit and encouraged the involvement of patients as well as the whole group of physicians. It was most heartening to see how readily the parents of infant patients for whom we had cared expressed their support. In fact, I was spurred on by their eloquence in explaining what a difference it made in their lives to have the doctor they had known all through their prenatal care be their baby’s physician.

Concurrently, the hospital sent us all notices for a mandatory fair hearing regarding our individual privileges. Since such a hearing is stipulated in the Hospital Bylaws as reserved for misconduct or physician practice issues, it did not seem appropriate, but we decided to proceed with it. Each of the 11 physicians (two further supported the suit and four others were in the process of newly applying for privileges and thus could not protest their withdrawal) had a panel of three peers.

After Ms. Hensleigh’s requests for mediation failed, we decided to file suit. It was around this time that CAFP received the clarification it sought from CCS. The hospital's immediate response was to again attempt to change the subject by suggesting that the issues were broader than CCS, and refusing to return our privileges. It appeared that a lawsuit was our only choice.

Just as the lawsuit was to have been filed, the hospital capitulated, calling a meeting and providing a list of conditions that FPs could treat in the nursery, essentially the same conditions we have treated in the past. They require neonatal resuscitation certification and 12 hours of “NICU director-approved” neonatal CME each year.

For the occasional sick baby, are all these hurdles worthwhile? FPs nationally and locally, collectively and individually have been disheartened by the trend of whittling away privileges. Lifestyle considerations and the increasing bureaucratic hurdles of dedicated CME time all add to the hassle. But we felt we had to draw the line when such a large number of active physicians' privileges were arbitrarily and unfairly revoked.

Conversations with CAFP leadership and with our attorney encouraged us to network with other medical staff, to generate publicity, and to build local community support. I would say in retrospect that these are the areas we could have improved upon to have brought this dispute to a swifter resolution. We learned that there’s no substitute for FPs being locally powerful, getting involved in hospital governance and working with the Board and Trustees. It was critical that the family physicians worked in concert. We presented a united front despite varying levels of belief in the strategy and willingness to provide financial support. We also learned that our specialty organization really works for us �" AAFP/CAFP membership proved invaluable. Much more work needs to be done through strong local leadership with assistance from CAFP in order to safeguard privileges from such arbitrary treatment.

Sumana Reddy, MD, a family physician in Salinas, serves on CAFP’s Medical Practice Affairs Committee.