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 > Institutional Services or by clicking here.

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 physician’s license. 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.

What does the term “summary suspension” mean?

Summary suspension means suspending a physician’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.

How soon must hospitals 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.

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

Yes. The law requires the reporting of “any” privilege change made for cause, except suspensions or other actions related to delinquent medical records.

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?

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.

Is it necessary to notify the Board when a practitioner's status changes 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.