Adverse Clinical Privileging Actions in the Army

September 27, 2026

Adverse clinical privileging actions in the Army are governed by AR 40-68, available for download at this link. Any privileged provider or other professional concerned about adverse actions should read this webpage.

Adverse clinical privileging actions in the Army may be warranted based on performance suspected or deemed not to be in the best interest of quality patient care. Actions may include:

holding privileges in abeyance
denying privileges
suspending privileges
restricting privileges
reducing privileges
revoking privileges

A Commander only needs "reasonable cause" to hold privileges in abeyance, deny them, or to suspend them. "Reasonable cause" includes:

A single incident of gross negligence
A pattern of inappropriate prescribing
A pattern of substandard care
An act of incompetence or negligence causing death or serious bodily injury
Abuse of legal or illegal drugs or diagnosis of alcohol dependence
Documented alcohol or other drug impairment and the individual refuses/fail rehab or a psychiatric disorder that is not responsive to treatment
Significant unprofessional conduct

All adverse clinical privileging actions in the Army must follow a specific process before being implemented.

Adverse Clinical Privileging Actions in the Army: Abeyance or Summary Suspension

An abeyance action is taken by the appropriate authority when an evaluation of performance appears warranted, but information is insufficient to suspend privileges or the potential hazard to patient care is not well defined. During a period of abeyance, the provider is assigned to nonclinical duties until an investigation is completed. An abeyance is valid for 15 calendar days and may be extended by the Command, if required, provided the total period of abeyance does not exceed 30 calendar days. If the abeyance is not closed on the 31st day, the action automatically becomes a summary suspension of clinical privileges.

A summary suspension of clinical privileges is a temporary removal that is used to limit a provider's/professional's practice while an investigation and due process procedures are conducted or while performance reevaluation, targeted training, or rehab is completed.

If a provider's/professional's privileges are put in abeyance or summarily suspended, notice must be provided within 14 calendar days. The notice must state the basis for the abeyance/summary suspension, the duration of the action, that a quality assurance investigation (QAI) will be conducted, and that the results of the process will be reviewed by the credentials committee.

Adverse Clinical Privileging Actions in the Army: Quality Insurance Investigation (QAI)

A QAI investigation is an "immediate and rigorous investigation" designed to collect the relevant facts and information. A disinterested and unbiased investigating Officer will be appointed. A QAI may include voluntary consultation with the individual in question, review of any relevant documents, or discussions with other individuals having knowledge of the situation. After the completion of a QAI, the investigating Officer will present factual findings with appropriate justification or details and may include recommendations.

Adverse Clinical Privileging Actions in the Army: Credentials Committee Action

After a QAI, the credentials committee will review and carefully consider the investigating Officer's report. The credentials committee may recommend the following actions to the Commander:

that no further action by taken and that privileges be fully reinstated;
that the abeyance/suspension be continued pending a formal peer review;
that a peer review panel be convened to evaluate available information and to determine if the standard of care was met; and/or
Other actions (administrative, personnel, civil, or criminal) be taken

Adverse Clinical Privileging Actions in the Army: Peer Review Process

A peer review panel is convened to evaluate a provider's performance, conduct, or condition to determine the extent of a problem and to make recommendations through the credentials committee to the Commander. The provider in question does not have the right to be present during the proceedings; however, he/she shall have the opportunity to provide a written statement regarding the events under review, to appear before the committee and make a verbal statement, to clarify issues in the case as needed, to ask questions, and to respond to questions from the committee. Consultation with a lawyer is recommended.

After consideration of all information, the peer review panel may make the following recommendations to the Commander: reinstatement, suspension, restriction, reduction, revocation, or denial. Within 7-days of completing the peer review process, the panel's recommendations, along with the case evidence, will be forwarded to the credentials committee. The credentials committee will include its recommendations, and the entire case file, with recommendations, will be forwarded to the Commander.

Adverse Clinical Privileging Actions in the Army: Commander Action

The Commander has 14 calendar days from receipt of the recommendations to review and decide what privileging action to take based on the facts provided. The Commander is not bound by the recommendations of the credentials committee or the peer review panel. The Commander will provide written notification to the provider of the privileging action to be taken and the justification for this action. If the proposed action is to deny, suspend, restrict, reduce, or revoke the provider's privileges, the Commander must advise the provider in writing of his/her her hearing and appeals rights.

Adverse Clinical Privileging Actions in the Army: Hearing

If a provider wishes to request a hearing, he/she will have 10 duty days to request one. Prior to the hearing, the provider will have access to all information that will be presented for consideration at the hearing.

These hearings are administrative in nature; the rules of evidence do not apply. The committee will be fully informed of the facts to allow an intelligent, reasonable, good faith judgment. The committee may question witnesses and examine documents, as necessary, to collect pertinent information. AR 15-6 may be consulted, but its provisions do not have to be followed.

At the hearing, the provider in question can submit evidence, question witnesses called, and to call witnesses on his/her own behalf. Lawyers may be retained to provide advice prior to and during the hearing; however, participation is limited to advising the provider only. Lawyers will not be permitted to ask questions, respond to questions on behalf of the provider, call or question witnesses, or seek to enter material into the record. Article 31 of the UCMJ does apply and a DA Form 3881 should be used, if applicable.

Following the presentation of evidence and relevant information, the provider being examined will be excused, and the hearing board will determine its findings and recommendations. Each finding must be supported by a preponderance of the evidence. Decisions are made by majority vote.

Post Hearing

The findings and recommendations are advisory in nature. After undergoing a legal review, the Commander in question will review the findings and recommendations, along with the complete record, and make a decision. If the decision includes denial, suspension, restriction, reduction, or revocation of privileges, a provider may appeal. An appeal may be submitted within 10 duty days.

The Surgeon General is the final appellate authority for denying, suspending, restricting, reducing, or revoking clinical privileges.

Other Considerations

Often, actions relating to clinical privileges overlap with other types of investigation (15-6, CID, or MPI) and adverse actions (Article 15s, GOMORs, Referred/Relief for Cause OERs, etc.). Furthermore, adverse privileging decision can result in the initiation of elimination.

Legal Representation

Any provider facing an adverse clinical privileging action the Army should immediately consult an experienced Military Lawyer. While Trial Defense/Legal Assistance Attorneys may be available to assist, they are often inexperienced in this area, over-worked, and unwilling or unable to provide the appropriate amount of time and attention needed, which is ill-advised with so much at stake. A civilian Military Lawyer can be retained, which allows a provider to be represented by a proven lawyer with good former client reviews.

A lawyer can provide advice during the investigative process, ensuring the right decisions are made by the provider in question. Furthermore, during a hearing, a lawyer can prepare the provider's hearing plan, advise on what evidence to present, provide questions to ask of each witness, and attend the hearing in question and provide legal advice. Finally, a lawyer can collect evidence and draft written appeals during the process.

This Article was written by Attorney Matthew Barry. Attorney Barry is highly rated by former clients and has a proven track record of success. He as extensive experience adverse clinical privileging actions in the Army and all associated adverse actions.

The Law Office of Matthew Barry represents Servicemembers worldwide. He has offices on the East Coast, West Coast, and in the Central U.S.