Change in Staff Privileges (CISP)
Who must report CISP actions to the Board?
State law requires hospitals and other health care organizations to make a report to the Board when they act to limit, suspend, or revoke a licensee’s clinical privileges for cause.
What are the types of actions that healthcare facilities are required to report to the Board?
- A summary revocation, summary suspension, or summary limitation of privileges, regardless of whether the action has been finally determined.
- A revocation, suspension, or limitation of privileges that has been finally determined by the governing body of the institution.
- A privilege revocation in response to a disciplinary action by the Board.
- A resignation from practice or voluntary reduction of privileges if the resignation is made under threat of investigation/disciplinary action or pending investigation/disciplinary action.
How soon must hospitals or health systems report CISP 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 facilities report certain actions, such as summary suspensions, immediately.
What does the term “summary suspension” mean?
Summary suspension means suspending a licensee’s privileges before a “due process hearing” has been conducted. Typically, summary suspensions are emergency actions taken to avoid an imminent threat to the public.
What is the purpose of CISP reports?
State law requires these reports so that the Board can review them and take whatever action is appropriate. The reports and the underlying hospital actions are not, in and of themselves, grounds for the Board to act against a licensee. However, the underlying reason(s) for the change in staff privileges may prompt further inquiry and investigation. Many CISP reports will not result in Board actions. However, some reports may lead the Board to discover evidence of a violation of the Medical Practice Act, which in turn, may lead to disciplinary action by the Board.
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 > Institutional Services or by clicking here.
Must a hospital or health system notify the Board any time a licensee seeks an addition or decrease in privileges or a change in status from active to courtesy?
No, only changes due to an adverse action or in response to a pending or threatened adverse action must be reported.
Must a hospital or health system report a privilege suspension imposed for failure to complete medical records?
No. The NC General Assembly amended state law in 2016 to remove any obligation to report suspensions related to failure to complete medical records in a timely manner.
