March 27, 2023

Volume XIII, Number 86


March 24, 2023

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Title 22 is Governing Law in California – Think Twice Before Adopting a Three-Year Practitioner Reappointment Cycle

In November 2022, when The Joint Commission (“TJC”) announced its decision to update its accreditation standards to permit practitioner recredentialing every three years instead of two, many California hospitals and their medical staff questioned whether they could extend their reappointment cycles.[1] In particular, health care facilities were curious whether TJC’s new reappointment cycle would align with their obligations under Title 22, which requires that the medical staff establish controls to reevaluate the ability of all practitioners to competently perform surgical and other procedures at least every two years.[2] Although state law has not changed, the California Department of Public Health (“CDPH”) may grant program flexibility from regulatory requirements to a facility that qualifies. Facilities should evaluate the challenges and risks of adopting an extended reappointment cycle before taking action.

TJC’s Decision to Update the Reappointment Cycle

Currently, many California health entities perform dual credentialing functions by operating two reappointment tracks; one track operates every two years for purposes of medical staff credentialing, and the other track operates every three years for purposes of provider enrollment. Changing to a three-year reappointment cycle for clinical privileges and membership would align the two reappointment tracks and potentially reduce the administrative burden on medical staff offices, eliminate redundancies and in turn ease costs on facilities.

Title 22 Has Not Changed but Hospitals May Seek Program Flexibility

California has not changed the Title 22 requirement, and the CDPH has not indicated they will advocate for a change in the regulation. However, in some situations, the CDPH has the authority to grant program flexibility from regulatory requirements, which could be an option for some facilities looking to make the change. Applications for program flexibility must include justification for the request and adequate supporting documentation that the proposed alternative does not compromise patient care.[3]

Additional Issues to Consider Before Requesting Program Flexibility

There are practical considerations before a California facility decides to apply for program flexibility. While a three-year reappointment cycle may bring about certain administrative benefits, extending the reappointment cycle may prolong the length of time before potential problem practitioners are addressed. Failure to conduct thorough, frequent assessments may lead to claims of medical malpractice or negligent credentialing. There are also implementation challenges, such as medical staff establishing a comprehensive and, potentially years long, transition procedure to ensure that all practitioners are appropriately processed.[4]


California health care facilities must weigh the practical risks and implementation challenges of switching to a three-year reappointment cycle. Facilities should consult legal counsel to thoughtfully evaluate the legal risks, as well as the logistical challenges.

[2] 22 CCR Section 70701(a)(7).

[4] For an in-depth analysis on issues to consider, please read the feature article “A Practical Review:
Risks and Challenges of The Joint Commission’s New Three-Year Reappointment Cycle” By Erik A. Martin & Rebecca Hoyes, Med-Staff Newsletter, February 2023│Vol. 11 (

© Polsinelli PC, Polsinelli LLP in CaliforniaNational Law Review, Volume XIII, Number 37

About this Author

Rebecca Hoyes Healthcare Attorney Polsinelli San Francisco

Rebecca Hoyes has an extensive background in the healthcare sector on various legal issues, including the representation of hospitals and their medical staffs in peer review investigations, corrective action, hearings and appeals. She counsels clients on privileging and credentialing of AHPs and physicians; bylaws, rules and policies; compliance with accreditation, licensure and regulatory requirements; practitioner disruptive behavior, disability and impairment; responding to subpoenas by state agencies requesting peer review or health information; and medical staff...


Tish Pickett is an associate in the Health Care Litigation and Disputes practice group. She is committed to providing practical legal advice in the constantly evolving health care industry. Tish’s practice focuses on providing strategic counsel on issues related to the Federal Anti-Kickback Statute and the False Claims Act, state fraud and abuse laws, and HIPAA and state privacy laws.

Prior to joining Polsinelli, Tish served as in-house counsel for a health care technology company in which she provided advice on such matters as consumer protection and patient privacy laws impacting...

Erik Martin Healthcare Lawyer Polsinelli Law Firm

Erik Martin is dedicated to providing practical legal solutions to health care clients’ real world problems. His practice focuses on medical staff, clinical research, and health care operations, and regulatory compliance matters. 

Erik partners with hospitals and health systems to advise them in areas of medical staff governance, including credentialing and privileging, bylaws and medical staff documents, and governing body relationships.

Erik also works closely with academic medical centers and health care providers to advise them in areas of research and clinical trials. He...