A recent Wall Street Journal article (November 1, 2013) reports that hospitals must now report influenza vaccination rates to the CDC and enforce the wearing of masks by healthcare workers who are not vaccinated.
Well, it is time again for my yearly rant. It is unconscionable for healthcare workers to put the at-risk population we care for in jeopardy of acquiring a potentially life threatening illness due to our “right” to refuse immunization. I know I just really annoyed quite a number of folks. But remember, I live and work in New York where a public health law was passed in July requiring mandatory flu shots. So no flu shot, no mask, proceed to jail? Well the state stopped a little short of that. The law actually doesn’t define the penalty. I guess the legislature is made up of a bunch of cowards. It really shouldn’t be left up to the government to create laws to force healthcare workers to do the right thing. We really need to step up and take control. What do you think?
I will be the first to admit that a) I am not a morning person; and b) I am definitely not a Monday-morning person. If you can relate, I hope this new blog installment will help. Every Monday, Credentialing Resource Center will post a tip or best practice related to medical staff services, so you can kick off your week with a new tool in your belt. I consider that a win for Monday morning.
And so, here is this week’s tip, from one of our new books, The Medical Staff’s Guide to Overcoming Competence Assessment Challenges:
Credentials committees often over-analyze credentialing and privileging decisions regarding low- and no-volume practitioners in an attempt to avoid insulting or criticizing a colleague. However, the best course of action is to approach every applicant in a businesslike manner. Rely on your policies and procedures to avoid the appearance of impropriety, and communicate with the low- or no-volume practitioner regarding:
- Established criteria for clinical privileges, including whether your facility requires a minimum number of patient contacts per year
- The practitioner’s plans to grow or narrow his or her practice
- The hospital’s increased focus on determining proficiency for clinical privileges
- Your medical staff’s strategic direction
- Volumes incurred at your facility
Happy Monday morning!
A recent article in the Washington Post titled “D.C. Council chairman to propose bill boosting nursing staffs at hospitals” brings up again the issue of nurse-to-patient ratios. D.C. Council Chairman Phil Mendelson is quoted as saying “I think this bill is today’s version of the eight-hour day — something that we will see business resist but, on the other hand, makes good sense and leads to quality care.”
Wouldn’t it be nice if nurse-to-patient ratios were the key to quality care? The proposed bill includes some ratios, such as intensive care unit patients should have one nurse to every two patients. That sounds good, but some patients require one-on-one nursing due to their complexity, so is the mandate that those patients can’t have one-on-one nursing? Might there be patients in the intensive care units for whom one to three is appropriate? In my experience that answer is absolutely yes!
As far back as when I was in medical school, and that’s a long time ago, when nurses (or physicians) were busy, there was always an outcry for more help. But when things were not as busy, you rarely heard “We have too much help.” The difference is that most folks of my generation went into healthcare to help people. So if more people needed help, we stayed late, came in early, vented our frustrations to each other (not to the media) and just did our jobs. Certainly some places have unsafe ratios and that needs to be addressed – but not with legislation.
Who is in the best position to determine how to care for patients: health care providers or legislators? Should we in healthcare not be the ones to fix this? I for one don’t want to be the person who can’t be admitted to the hospital when sick because I would cause the nurse to have one too many patients. Quality is multi-factorial, and I object when non-clinicians use the word quality as a hot button to stir up the public. I wholeheartedly agree that staffing should be safe, but as with many things in life, there is not a bright line here, but a gray zone. Thoughts?
Public Citizen, a nonprofit organization that advocates for individual rights, says the Texas Medical Board needs to step up its game. The organization asserts that the state medical board has failed to punish many physicians in the state who have received sanctions from healthcare organizations. The Texas Medical Board disagrees, citing Federation of State Medical Boards data that often ranks Texas at the top for disciplining physicians.
According to an article from HealthLeaders Media, Public Citizen analyzed 21 years of NPDB data.The group found that almost 450 Texas physicians who had been sanctioned by a healthcare entity had yet to be disciplined by the Texas Medical Board. Public Citizen sent a letter to Texas Governor Rick Perry urging him to take “immediate action to improve the performance of the Texas Medical Board and thereby protect patients in Texas from physicians who should have been, but were not, disciplined.”
Public Citizen does not blame the medical board; it instead puts the blame on a lack of funding and staffing. In Texas, the money that is collected through physician appointments, reappointments, and fines is placed in the state’s general fund. The medical board than submits a request for funding to perform its functions.
Lee Hopper, spokeswoman for the Texas Medical Board, says the agency is not underfunded or understaffed. “Like anybody, of course we would always like more money. But we haven’t been dealing with a budget crisis so the agency is healthy and it’s effective,” she tells HealthLeaders Media.
In its letter to Perry, Public Citizen recommends letting the medical board keep more—preferably all—of the funds it collects. This raises some interesting questions to think about.
Should the medical board be entitled to all of the money collected through its processes? Should the medical board learn to do more with less, like many other businesses and citizens are currently forced to do? Would more funding lead to more disciplinary action?
The question that really sticks on my mind is, as a healthcare consumer, how important is it that disruptive physicians be disciplined? I know the short answer is very, but at what cost? Do you want your state’s medical board to use all of the money it collects to fund its needs? Or would you like to see some of this money go into the state’s general fund to be used for other public services?
Okay, here are the questions:
- What do you do when the physician requests his privileges be restored after he returns from rehab for his cocaine and sexual addictions?
- What do you do when the 67-year-old internist, who retired five years ago, has just been hired by administration to be your new hospitalist?
- What do you do when your favorite cardiologist returns from a medical leave of absence after suffering a significant stroke?
Of course, these scenarios cause more questions than answers. You suddenly wish you had declined the invitation to be chief of staff of your medical staff. The fact remains that demographics apply to physicians as well as the general public.
Alcohol and substance abuse is 12-14% in the general population and is the same or somewhat higher in the physician population. (P Hughes, Prevalence of Substance Abuse Among US physicians, JAMA, 1992) Sexual addiction, especially cyber addiction to pornography, is present in 6-8% of the general population and one out of five are women. (Carnes, Am J Prev Psychology Neurology, 1991, 3:16-23) Dementia is present in 13.9% of individuals 71 and older and 9.7% of these have Alzheimer’s disease. (Plassman, et al, Neuroepid, 2007) Stroke recovery is possible, but of course, varies widely depending on age, severity of the injury, rehabilitation efforts, and support to name a few. None of us are immune from these possibilities.
Okay, now a few answers. Patients are more important than physicians. Don’t get caught in the trap of treating physicians as “special people.” First and foremost, you should have a concrete policy for dealing with all of the above possibilities. It must be iron clad, fair and equitable, be consistent with HIPPA and the American Disability Act, should be patient-safety focused but also allow for the physician to return to your medical staff. This begins with a viable and credible Physician Health Committee, an engaged credentials committee, OPPE and FPPE plans on steroids, legal advice, and a “Fitness to Work” evaluation from an objective and independent physician.
Want more from Dr. White? R Dean White DDS, MS, of Dean White Consulting, will be speaking about how to create a physician re-entry process at the 15th Annual Credentialing Resource Center Symposium, May 10-11. For more information, click here.
The structure for collecting and trending practitioner data varies from organization to organization. In many, all FPPE and OPPE data is collected, tracked, and trended by medical staff services departments. Incident reports related to patient grievances or other clinical concerns may be tracked and trended through the risk management department while peer review and individual practice deviations may be tracked and trended through the quality review department. In addition to hospital performance, division chiefs may keep division files on any issues that are reported and/or addressed by them.
It is important for organizations to have a clear picture of a practitioner’s performance. Centralizing where practitioner data is tracked will eliminate the possibility that there is performance data missing when conducting performance reviews. Although different departments may handle and/or address different issues related to performance, there should be one central repository for physician data. Departments should then forward all data to this area for safe keeping and filing in the practitioners quality file.
One of the first steps in developing a central repository for practitioner performance data is education. Organizations should spend time educating their division chiefs on how to address concerns that are brought to their attention; when collegial intervention is appropriate and when an issue must be escalated or forwarded to another department and/or a formal medical staff committee. Division chiefs should be educated on how to document performance issues and how to document the steps that they have taken to resolve the concerns. Ensuring that all concerns are well documented helps protect the division chief as well as the organization should an issue arise later which requires further scrutiny or results in due process.
Should an investigation be initiated, having all data centralized saves time and ensures a more thorough review. Having a one-stop shop for all incident reports, collegial interventions, peer review referrals, and all other clinical performance data allows the committee conducting the review to have a full picture of the practitioner’s performance. Organizations should also include all positive feedback in the quality file and should always respond to a practitioner when a review is conducted and the care he or she provided is deemed to have met or exceeded the standard.
Centralization of practitioner performance data not only benefits the committees or division chiefs conducting performance reviews, but also helps protect the organization from claims of negligence should they conduct reviews without all of the information available.
Adverse actions are a serious matter that requires serious attention. From prevention to investigation to reporting, how can you ensure your organization has the best processes in place? In the 90-minute live webcast, “Adverse Actions: Steps to Prevent, Manage and Report,” Joanne Hopkins, JD, and Anne Roberts, CPCS, CPMSM, will discuss how deal with an adverse action from beginning to end. Listeners will learn how to prevent adverse actions through education, how to prepare for an investigation, how to set clear guidelines and expectations for the peer review committee, what types of corrective action can be used, due process obligations, and reporting obligations.
Sponsored by the 15th Annual Credentialing Resource Center Symposium, the webcast will be held on Thursday, Oct. 27 at 1 p.m. EST. Participating in the live webcast or purchasing the CD to listen to at a later date cost just $159.20. For more information, click here.
Most of us may not consider aging to be an impairment, but it can greatly affect a physician’s ability to practice safely. Currently, the aging baby boomer generation of physicians is treating other aging baby boomers who require three to five times the amount of healthcare as younger patients. When you couple this with the fact that more physicians are electing to practice later in life for financial or personal reasons, medical staffs must implement safeguards that ensure aging physicians maintain the competence to practice safely.
Medical staffs cannot refer a physician for evaluation for suspected cognitive decline arbitrarily. A referral is warranted if there are clinical or behavioral aberrations that are difficult to explain, a history of head injury, a history of substance or alcohol abuse, or a known neurologic disease. But before we delve into referrals, a brief explanation of neuropsychological testing is in order.
It’s not uncommon for practitioners to hold privileges at more than one facility. But can a practitioner’s ambitions put patient care in jeopardy? Should medical staffs set a limit on how many different facilities they allow their privileged practitioners to practice at, or set limits on patient case load at each facility?
These are some of the questions raised by the case of Eldridge Pearsall, MD, an OB-GYN who was put on probation by the Medical Board of California after several cases were called into question.
In one instance, a hospital contacted Pearsall to assist with fetal distress in a patient carrying twins, according to a news report. Pearsall responded that he was busy working at another hospital, but would arrive in 45 minutes. When Pearsall eventually arrived, it was later than expected and the twins were already delivered.
In another instance, he forgot about a patient and went home to sleep, ignoring calls about the patient.
The Medical Board cited “patient abandonment” and an “extreme departure from the standard of care,” as some of the reasons for placing him on probation.
Do you think the Pearsall case is an isolated and extreme example or does it contain some learning lessons for all medical staffs about stretching practitioners too thin?
In Schelling v. Humphrey (2009), the Supreme Court of Ohio ruled that a plaintiff can bring a negligent credentialing claim against a hospital without filing a malpractice claim against an individual practitioner.
However, in Plaisance et al., v. Our Lady of Lourdes Regional Medical Center, Inc., et al. (2010), an appeals court in Louisiana ruled that the plaintiffs had to establish a malpractice claim before they could establish that the medical staff knew about the pattern of alleged malpractice behavior and went ahead with its credentialing, thus negligently credentialing the practitioner.
These rulings show that in some states it’s more difficult to prove a negligent credentialing claim if a malpractice claim has to be established first.
The goal for MSPs remains the same: process applications with due diligence to avoid negligent credentialing or even the appearance of it. Ultimately credentialing best practices will help keep the medical staff out of the court room, for malpractice or negligent credentialing cases.