Decision-rights atlas · eight systems · five slots each · California and federal authorities verified
Who Actually Decides
Eight systems hold a physician’s working life, and they do not answer to one another
Hospital privileges, the licence, medical necessity, the formulary, a training position, continuing certification, scope of practice, employment. Each mapped the same way: who initiates, what standard applies, who decides, who reviews, and what record travels. Where the authority is statutory the statute is linked; where it is a contract or a private standard, the page says so — and that distinction decides what a physician can actually do about it.
Policy analysis by Kanwar Partap Singh Gill, MD · primary authorities verified · educational analysis, not legal advice.
The question
A physician who has just been told that something has been decided about them asks a natural question and usually the wrong one: is that legal? The more useful question, and the one that determines what can actually be done, is narrower.
Who held the authority to make this decision, under what instrument, on what standard, and who reviews it?
Health care in the United States is administered through overlapping systems that each hold a piece of a physician’s working life. A hospital medical staff decides what a physician may do inside the building. A state licensing agency decides whether they may practise at all. A payer decides whether a proposed treatment will be funded. A pharmacy benefit manager decides which drug is reachable. A certifying board decides whether a credential stays current. An employer decides what the day looks like. A residency programme decides who enters the profession in the first place.
These bodies do not answer to one another. They apply different standards, keep different records, move on different timetables, and give different amounts of process — and in several cases the most consequential decision in a physician’s year is made by the body furthest from any statute. This page maps those decision rights: not what each system is supposed to achieve, but where the authority to decide actually sits.
This is the first published output of item 021 in the research program. Its companion, the regulatory cascade, maps where consequence goes once a decision has been made. It is a map, not a dataset. Where a decision right rests on a statute the statute is cited and linked; where it rests on a contract, a bylaw or a private standard, the page says so, because that distinction is the single most useful thing a physician can learn about their own situation.
Why “what does the law say” comes second
Legal analysis of health care tends to start with statutes because statutes are searchable. But a great deal of the authority exercised over physicians is not statutory at all, and treating it as though it were produces two opposite errors.
Error one
Assuming a statute governs when a contract does
A physician reads the licensing statutes, finds nothing that permits an employer to end a clinical assignment on thirty days’ notice, and concludes the employer cannot do it. The employer’s authority is contractual. The statutes were the wrong place to look.
Error two
Assuming a contract governs when a statute does
A physician is offered a resolution described as an internal matter that will stay inside the institution. Whether it stays inside is not a matter for the parties: B&P Code §805 attaches filing duties to defined events on a 15-day clock, and the parties’ characterisation of what they did is not one of its elements.
So the map has to record the instrument alongside the decider. Four instruments do nearly all the work, and they behave very differently when challenged.
| Instrument | What it is | What review typically looks like |
|---|---|---|
| Statute | Legislated text of general application. | Interpretation is a legal question. Compliance is measurable against the words. Non-compliance is a defect that survives everyone’s good intentions. |
| Regulation and agency adjudication | Rules made under delegated authority, and the decisions of agencies applying them. | Internal administrative process first, then judicial review on the record — in California, ordinarily administrative mandamus under Code of Civil Procedure §1094.5. |
| Private governance instrument | Medical-staff bylaws, certifying-board policy, accreditation standards. | Process is whatever the instrument provides, plus whatever statute requires on top. California is unusual in legislating the floor for hospital peer review; most private governance has no such floor. |
| Contract | Employment agreements, payer participation agreements, management services agreements. | Whatever the parties agreed, read by a court if it comes to that. Notice periods, termination triggers and dispute clauses are the operative law of the relationship. |
The instrument determines the remedy. A physician who identifies the wrong instrument spends their energy in the wrong forum.
The anatomy of a decision right
Every decision right in the maps below is recorded in the same five slots. The slots are the point: a decision right described only by its outcome tells a physician nothing about where it can be contested.
Slot one
Who initiates
A decision that can be triggered by anyone, anonymously, behaves very differently from one that requires a named complainant or an institutional referral. Initiation controls exposure.
Slot two
What standard applies
Preponderance, clear and convincing, reasonable belief, medical necessity, or a purely discretionary judgement with no stated standard at all. The absence of a standard is itself a finding.
Slot three
Who decides
A committee of peers, a hearing officer, an agency panel, a reviewer employed by an interested party, an algorithm, or a single administrator.
Slot four
Who reviews
An internal appellate step, an agency, a court on the record, an arbitrator, or nobody.
Slot five
What travels
Whether the decision creates a record that follows the physician into other systems. This is the slot physicians discount most and regret most.
Slot five is what makes the map more than an organisational chart. A decision can be small in its immediate effect and permanent in its consequence, because the systems that hold physician records query one another by design. Section 805.5 obliges institutions to ask the licensing board for §805 information before granting or renewing privileges, and the federal National Practitioner Data Bank exists precisely so that a decision in one place is visible in the next. Recredentialing runs on a cycle, so the question is asked again and again.
Map: hospital clinical privileges
The best-documented decision right in this map, and the one where California has legislated most explicitly.
What a physician may do inside a hospital
Instrument: medical-staff bylaws, operating on a statutory floor set by the B&P Code §809 article. This combination is unusual — most private governance over physicians has no legislated floor at all.
Initiates
A medical staff officer, a department chair, the medical executive committee, a peer report, a patient complaint, an occurrence screen, or an institutional referral. Practice varies by bylaw; the bylaws define who may initiate and are the first document to read.
Standard
For a final proposed action reportable under §805, §809.3(b)(3) places the burden on the peer review body to persuade the trier of fact, by a preponderance of the evidence, that its action or recommendation is reasonable and warranted — except for initial applicants. The substantive concept is medical disciplinary cause or reason, defined by §805(a)(6) as that aspect of competence or professional conduct reasonably likely to be detrimental to patient safety or to the delivery of patient care.
Decides
An arbitrator or a panel meeting the §809.2 composition requirements: unbiased, no direct financial benefit from the outcome, not having acted as accuser, investigator, factfinder or initial decisionmaker in the matter, and including a same-specialty practitioner where feasible. A hearing officer may preside but does not vote.
Reviews
An internal appellate step under §809.4, then judicial review, which §809.8 preserves. In California that review is ordinarily record-based, which is why the internal hearing is where the case is actually won or lost.
Travels
A §805 report to the licensing agency within 15 days of a qualifying event; a separate federal analysis under the NPDB clinical-privileges criteria; and, on any future application, the §805.5 inquiry and an NPDB query.
Three features of this map are worth stating plainly because they are so often described the other way round.
First
The label on the privilege does not decide anything
§805(a)(4) defines staff privileges as any arrangement under which a licentiate is allowed to practise in or provide care for patients in a health facility, and lists limited, temporary, courtesy, provisional and auxiliary privileges, locum tenens arrangements and contractual arrangements including outpatient services. A narrow privilege is inside the framework.
Second
The physician is not the applicant
Except for initial applicants, the institution carries the burden. A physician who approaches the hearing as though they must prove their fitness has conceded the structural advantage the statute gave them.
Third
Speed has its own gate
The summary route under §809.5 requires that failure to act may result in an imminent danger to the health of any individual, and a summary suspension left running more than 14 days carries its own report. Urgency is a finding, not a mood.
Deeper analysis on this site: the structure of the peer review body, bylaws as a source of rights, the hearing rights, summary suspension, the taxonomy of adverse actions, and the teaching case at viral off-duty conduct and visiting privileges.
Map: the licence
The decision right with the widest consequence and the most formal process.
Whether a physician may practise medicine in the state
Instrument: statute and regulation, adjudicated through the state administrative process.
Initiates
A complaint from any source — patient, family, colleague, employer, insurer, another agency, an anonymous submission — or a mandatory report. Several reporting channels run into the agency independently of any complaint: §805 institutional reports; a physician’s own duty under §802.1 to report a felony indictment or information and any felony or misdemeanor conviction within 30 days; and the clerk of the court’s transmission of a certified record of conviction within 48 hours under §803.5(b).
Standard
Statutory grounds for discipline, applied through the administrative process. This site treats the standard of proof separately because it is the most consequential single variable in the system — see standards of proof.
Decides
An administrative law judge hears the matter and issues a proposed decision; the board decides whether to adopt it. Those are two distinct decision rights, and the gap between them is a research question in its own right — item 006 of the program.
Reviews
Judicial review on the administrative record, ordinarily by administrative mandamus under Code of Civil Procedure §1094.5.
Travels
Everywhere. A licence action is the most portable record in the system: it reaches other states, the federal data bank, payers, employers, certifying bodies and immigration processes.
Two propositions about this map are commonly overstated, and the overstatement causes real harm to physicians making decisions under pressure.
A report is not a finding, and a charge is not a conviction. A §805 report produces a record and frequently an inquiry; it does not produce discipline by operation of law. A pending criminal charge is an allegation; a physician’s self-report duty under §802.1 attaches to a felony indictment or information and to any conviction, not to the pendency of a misdemeanor charge. Compressing these steps is how a survivable event becomes a panic. A complaint is not a finding sets this out at length.
Related: how the hearings work, the proposed decision, investigation against public accusation, how peer review reaches licensing systems, and the codebook at the discipline observatory.
Map: medical necessity
Here the map changes character. The decision is clinical in subject and contractual in authority, and the asymmetry between those two things is the whole problem.
Whether a proposed treatment will be paid for
Instrument: the payer’s participation agreement and its own clinical policy documents. Insurance regulation and, for public programmes, programme rules constrain the process; the criteria themselves are usually the payer’s own published policy rather than legislated text.
Initiates
The treating physician, by requesting authorisation. Note the inversion: the physician initiates a proceeding in which they bear the burden and hold none of the decision rights.
Standard
Medical necessity as the payer’s policy defines it. Definitions are not uniform between payers, and two payers can reach opposite conclusions on identical facts without either being wrong under its own criteria.
Decides
A reviewer engaged by the payer. Whether that reviewer practises the same specialty, how much time they have, and what record they see are institutional facts rather than statutory guarantees.
Reviews
Internal appeal, then external review where the applicable regulatory regime provides it. The appeal ladder is real and is used far less than it could be.
Travels
Not into the physician’s professional record — and that is the point most often missed. What travels is the patient’s outcome: the delay, the substitution, the abandonment of the plan.
The structural observation this map produces is not that payers deny care. It is narrower and harder to argue with: the decision right over the treatment plan and the accountability for the clinical outcome sit in different institutions. The physician who is answerable for the result does not hold the authority over the input; the body holding the authority is not answerable to the licensing system that governs clinical judgement.
Clinical accountability without clinical authority is the defining structural condition of contemporary practice. Every reform proposal on this site is, in some form, an attempt to close that gap.
Related: the prior authorisation dossier and the reform proposal on duration and algorithmic denial.
Map: the formulary
A decision right exercised at scale, on populations rather than patients, and visible to the physician only as a rejection at the pharmacy counter.
Which medicine is reachable
Instrument: benefit design and pharmacy benefit contracts. Layered: plan sponsor, insurer, pharmacy benefit manager, and in public programmes the programme’s own rules.
Initiates
Nobody the patient can identify. Formulary placement is a periodic commercial and clinical decision, not a response to a request.
Standard
A mix of clinical evidence review and negotiated commercial terms. The two inputs are not separately disclosed, which means the clinical reasoning cannot be examined independently of the commercial reasoning.
Decides
A pharmacy and therapeutics function within the plan or the benefit manager.
Reviews
Exception and appeal processes at the level of the individual prescription. The placement decision itself is generally not reviewable by the prescriber at all.
Travels
Into the prescribing pattern. A physician’s own record of what they prescribe is shaped by a decision they did not participate in and cannot see the reasoning for.
Formulary is the clearest illustration of a general truth in this map: the further a decision moves from an individual patient, the less process attaches to it, and the more people it affects. An individual denial has an appeal ladder. The tier change that generated ten thousand denials has none.
Map: a training position
The decision right that determines who becomes a physician in the United States, exercised almost entirely through private institutional discretion.
Who enters graduate medical education
Instrument: programme policy, institutional policy, accreditation standards and immigration status. Very little of it is statutory, and almost none of it is individually reviewable.
Initiates
The applicant, by applying.
Standard
Programme-defined eligibility and selection criteria: examination thresholds, years since graduation, visa sponsorship, clinical experience requirements, and unstated preferences. Many criteria operate as filters before any human reads the application.
Decides
The programme, through a selection committee, subject to institutional constraints it does not control.
Reviews
Nobody. There is no appeal from not being interviewed, and no obligation to state a reason.
Travels
The absence of a position travels. An unmatched year is itself a screening criterion in the following cycle, which is how a single decision compounds.
The reason the program puts four pipeline datasets in an early tranche is visible in the review slot. Where a decision right has no review mechanism, the only available correction is disclosure — publishing what the filters actually are, so that applicants stop spending money on applications that an unpublished rule already excluded. That is a transparency project, not a litigation project, and it is one of the few places where publishing a dataset is itself the remedy.
Related: the IMG institute and its pages on physician visas and research positions.
Map: continuing certification
A private decision right with quasi-regulatory force, because other institutions have chosen to condition their own decisions on it.
Whether a specialty credential stays current
Instrument: the certifying board’s own policy. Not statute, not regulation, not contract with the physician in the ordinary sense.
Initiates
The board’s cycle.
Standard
Board policy, revised by the board.
Decides
The board.
Reviews
Internal processes as the board provides them.
Travels
Into hospital privileging, payer participation and employment eligibility — because those institutions incorporate the credential into their own criteria. This is how a private standard acquires the practical force of a rule.
The mechanism is worth naming precisely, because it recurs throughout health care: a private body’s decision becomes binding not through legal authority but through incorporation by third parties. The board does not need power over the physician if the hospital, the payer and the employer have all agreed to treat its decision as dispositive.
Map: scope of practice
The one decision right in this map that genuinely sits with a legislature — and the one where the loudest public argument happens for that exact reason.
What each profession may lawfully do
Instrument: statute, implemented through professional regulation.
Initiates
Legislation, and the organised advocacy that precedes it.
Standard
Legislative judgement. Not an evidentiary standard, and not required to be one.
Decides
The legislature, then the relevant regulatory boards in implementation.
Reviews
The political process, and litigation over interpretation.
Travels
Into every institutional decision downstream: privileging, payer credentialing, employment, supervision structures.
Because the decision right is legislative, the productive question is not what the correct scope is but what evidence was before the body that decided, and whether the implementing regulation matches the statute it implements. Related: nurse practitioner independent practice.
Map: the employed physician
The decision right that touches a physician most often, carries the least process, and is the least studied.
What the working day contains
Instrument: contract, plus employer policy incorporated by reference.
Initiates
The employer, at will within the contract’s terms.
Standard
Business judgement. Productivity targets, panel size, template length, schedule density and coverage obligations are managerial decisions, not clinical ones, even when their clinical effects are direct.
Decides
Management.
Reviews
Whatever the contract provides. Frequently nothing, or arbitration.
Travels
Rarely as a record, often as a consequence: a departure requires explanation, a non-renewal invites a question, and a contract term can restrict where the physician practises next.
This map is the reason the corpus treats corporate structure as a clinical-governance subject rather than a business subject. When the instrument governing the conditions of clinical work is a contract, the protections a physician assumes from licensing law are simply in the wrong body of rules. Related: the corporate practice dossier and the reform proposal on corporate control of clinical judgement.
Six patterns across the maps
Read together, the eight maps show regularities that none of them shows alone. These are the findings this article actually offers.
Pattern one
Process is inversely proportional to reach
The decision affecting one patient has an appeal ladder. The decision affecting a hundred thousand — a formulary tier, a selection filter, a policy revision — usually has none. Process attaches to individual adjudication, not to rulemaking by private bodies.
Pattern two
The most consequential decisions carry the least process
A licence action is heavily proceduralised and rare. Not being interviewed for a training position is unreviewable and determines a career. Physicians prepare for the first and are blindsided by the second.
Pattern three
Private decisions become binding by incorporation
A certifying board, an accreditor and a benefit manager each acquire practical authority because hospitals, payers and employers write their outputs into their own criteria. No statute confers that power, and no process constrains it.
Pattern four
Records travel further than decisions
The immediate effect of a decision may be small and reversible. The record it creates is queried by other systems for years, which is why the reporting analysis has to be done before a resolution is agreed rather than after.
Pattern five
Clinical accountability and clinical authority are separated
The physician answers for the outcome; other bodies decide the inputs. Every reform proposal on this site is an attempt to narrow that gap somewhere.
Pattern six
The absence of a stated standard is the strongest position a decider can hold
Where no standard is articulated, no departure from it can be shown. Several of the maps above have an empty standard slot, and that emptiness is not an oversight.
Where decision rights fail
A decision right fails in a small number of recognisable ways. Naming them is more useful than a general complaint about power, because each failure mode has a different remedy.
| Failure mode | What it looks like | Remedy that fits |
|---|---|---|
| Unlocated authority | Nobody involved can say which document confers the power being exercised. | Ask, in writing, for the instrument. A decider who cannot name it is frequently exceeding it. |
| Role collapse | The same person or body accuses, investigates, decides and hears the appeal. | Structural separation. In California hospital peer review the §809.2 composition rules address this directly; most other systems in this map have no equivalent. |
| Standardless discretion | A decision is made on no stated criterion. | Disclosure of criteria, which is a transparency remedy rather than a due-process one. |
| Undisclosed record | The decision rests on material the affected physician has not seen. | Documentary access. §809.2 provides it in the peer-review setting, with a 30-day rule that makes late production good cause for a continuance. |
| Consequence without proportionality | The sanction bears no stated relationship to the risk established. | A proportionality finding on the record, which is what makes judicial review possible at all. |
| Invisible propagation | A record reaches other systems without the physician knowing it was created. | Reportability analysed before the resolution is signed. When a privileges dispute becomes reportable works through the counting. |
Finding out who decides in your own matter
The map is general. This is the procedure for making it specific, and it is deliberately short enough to use on the day the letter arrives.
Name the instrument
Which document confers the authority being exercised — statute, regulation, bylaw, board policy or contract? Get it in writing. Everything else follows from the answer.
Find the standard
What must be established, by whom, to what level of proof? If the instrument states no standard, record that; it changes the strategy entirely.
Identify the decider, and their role history
Has this person or body already acted as accuser, investigator or initial decisionmaker in the same matter? In the peer-review setting that question has statutory bite.
Locate the review step, and its deadline
Internal appeal, agency, arbitration or court — and the date by which it must be invoked. Missed internal steps are usually unavailable later.
Ask what will be created
What record does each possible outcome generate, and which systems will query it? Ask before agreeing to anything, including anything described as voluntary.
Ask whether an investigation is open
In writing. A step taken after notice of a pending investigation is a different regulatory object from the same step taken before it — see resignation during investigation.
Six questions, asked in writing, at the beginning. Most of the damage this site documents happens in the days before anyone thinks to ask them.
What this maps and what it does not
The honest boundaries of this page, stated on its face rather than discovered by a reader.
No decision counted, no outcome measured, no frequency claimed. Frequencies belong to the program items that collect records.
The statutory content is Californian and federal. The structural patterns generalise; the citations do not.
Bylaws, contracts and payer policies differ between institutions. Where this page describes practice rather than law, it says so, and the reader’s own instrument governs.
A map of decision rights is not an assessment of anyone’s matter.
Authorities marked as verified were read at source on the date given. Others are carried from the corpus’s earlier verification and are noted as such in the authorities list.
Several decision rights that belong in this map — correctional care, device clearance, guideline authorship, accreditation — are program items rather than sections here, because each needs its own primary-source pass.
Primary authorities
Where a decision right rests on statute, the statute is linked. Where it rests on a contract, a bylaw or a private standard, no citation is offered, because none exists — and that absence is one of this page’s findings rather than a gap in its research.
Definitions of peer review body, staff privileges and medical disciplinary cause or reason; 15-day filing duties and the events that trigger them. Verified at source 2 September 2026.
The separate report following formal investigation into four enumerated categories. Verified 2 September 2026.
The duty to request 805 information before granting or renewing staff privileges, including at ambulatory surgical centers and accredited outpatient settings. Verified 2 September 2026.
Physician self-reporting: felony indictment or information, and any felony or misdemeanor conviction, within 30 days. Verified 2 September 2026.
Prosecutorial notification of felony filings, and the clerk’s 48-hour transmission of a certified record of conviction. Verified 2 September 2026.
Legislative findings and the peer-review framework implemented through medical-staff bylaws.
Notice of a proposed final action and the right to request a hearing.
Panel and hearing-officer composition; voir dire; documentary access and the 30-day rule; commencement within 60 days. Verified 2 September 2026.
Hearing rights, and the peer review body’s burden of persuasion by a preponderance that its action is reasonable and warranted. Verified 2 September 2026.
Findings and the internal review or appellate step.
Immediate suspension or restriction on imminent danger to the health of any individual. Verified 2 September 2026.
Preservation of judicial review.
Protection of qualifying committee proceedings and records from civil discovery. Carried from the corpus’s earlier verification.
Code of Civil Procedure §1094.5
Administrative mandamus: the record-based review through which agency and peer-review decisions are tested. Carried.
HCQIA standards for a protected professional-review action, and the rebuttable presumption. Cited to Cornell LII rather than an official federal source.
Federal reporting duties of health care entities. Cited to Cornell LII.
NPDB Guidebook — adverse clinical privileges actions
The more-than-30-day professional-review action; surrender or restriction while under investigation; the label-is-not-controlling principle.
The federal query and report architecture through which a decision in one system becomes visible in the next.
Related analysis on this site: anonymous allegations · professionalism as a standard · administrative harm · the regulatory cascade · hospital peer-review structure · bylaws as a source of rights · fair hearing rights · summary suspension · adverse privileges actions · the 805 report · what gets reported to the NPDB · when a dispute becomes reportable · resignation during investigation · how peer review reaches licensing systems · administrative hearings · the proposed decision · standards of proof · a complaint is not a finding · economic versus patient-safety credentialing · recredentialing and continuous monitoring · discovery in disciplinary proceedings · the peer-review teaching case · the credentialing dossier · the prior authorisation dossier · the corporate practice dossier · the research program · the discipline observatory codebook · the due-process proposal