Resources & Information

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.

• 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.

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.

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.

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.

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

No, only changes due to an adverse action or in response to a pending or threatened adverse action must be reported.

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.