Resources & Information

Change in Staff Privileges (CISP)

Where do I access the online CISP reporting form on this website?

The CISP reporting form can be accessed in Resources & Information, under Professional Resources - Online Services - Insititutional Services or by clicking here.

What are the possible repercussions for physicians on whom reports are made?

The reports themselves have no direct repercussions. The General Assembly’s requiring of such reports implies that the Board should review them and take whatever action is appropriate under law. The reports and the underlying hospital actions are not reasons under the law for the Board to act against a physician’s license. However, the reports may prompt further inquiry and investigation to determine if grounds exist. Many privilege change reports will not lead to Board actions. Some CISP reports, however, will lead the Board to discover evidence of grounds for the initiation of a case, which may lead to disciplinary action by the Board.

Must hospitals report suspensions for failure to submit a timely request for reappointment?


What does the Board mean by “summary suspension”?

The general reference is to the practice of some entities of suspending a physician’s privileges before a “due process hearing” has been conducted. The Board understands some entities use this procedure in emergencies. The Board has also become aware that some of these emergency situations were not reported to the Board until the full due process called for in the entity’s bylaws had been completed, sometimes months after the emergency had arisen.

How soon must hospitals report privileging actions to the Board?

State law specifies that privilege changes be reported within 30 days of the effective date of the action. However, some healthcare facilties report certain actions, such as summary suspensions, immediately.

Must a hospital report privilege revocations in response to a disciplinary action by the Board?

Yes. The law requires the reporting of “any” privilege change made for cause, except in suspensions or other actions related to delinquent medical records. In such cases, the hospital need only report the privilege change if three offenses occur in the same calendar year.

Must a hospital notify the Board any time a physician seeks an addition or decrease in privileges?

No, only changes that are the result of an adverse action must be reported.

Must a hospital report a privilege suspension imposed for failure to complete medical records?

Only if the suspension is the third for that cause within the calendar year, in which case all three suspensions must be reported.

Is it necessary to notify the Board when a practitioner's status changes from active to courtesy?

Yes, if the change is due to an adverse action or in response to a pending or threatened adverse action.