Health care law and legislation assignment week 3

Chapter 9

Medical Staff Organization

and Physician Liability

LEARNING OBJECTIVES

• Describe medical staff organization and committee structure.

• Describe the credentialing and privileging process.

• Discuss the purpose of physician supervision and monitoring.

• List and discuss common medical errors.

• Explain how the physician–patient relationship can be improved.

Medical Staff Committees Executive Committee

• Recommends medical staff structure.

• Develops a process for reviewing credentials.

• Recommends appointments to the medical staff.

• Develops processes for delineating clinical privileges.

• Performance improvement activities.

• Conducts peer review.

• Review & act on reports of medical staff departmental chairpersons & medical staff committees.

Bylaws Committee

• Organization of the medical staff is described in its bylaws, rules, & regulations.

• Bylaws must be approved by the governing body.

• Bylaws must be kept current & the governing body must approve recommended changes.

• Bylaws describe various membership categories of the medical staff (e.g., active, courtesy, consultative).

Blood & Transfusion Committee

• Develops blood usage p & p

• Monitors transfusion services

• Monitors

– indications for transfusions

– blood ordering practices

– each transfusion episode

– transfusion reactions

Credentials Committee

• Oversees application process for medical staff applicants, requests for clinical privileges, & reappointments to the medical staff.

• Makes its recommendations to the medical executive committee.

Infection Control Committee

 The infection control committee is generally responsible for the development of policies & procedures for investigating, controlling, & preventing infections.

Medical Records Committee Develops Policies & Procedures

• Release, security, & storage

• Determining the format of medical records

• Monitoring records for accuracy

• Completeness, legibility, & timely completion & clinical pertinence

• Ensures records reflect condition & progress of the patient, including results of all tests & therapy given & makes recommendations for disciplinary action as necessary.

Pharmacy & Therapeutics Committee

• Policies & procedures (e.g., selection, procurement, distribution, handling, use, & safe administration of drugs, biologicals, & diagnostic testing material).

• Oversees development & maintenance of formulary.

• Evaluates & approves protocols for the use of investigational or experimental drugs.

Pharmacy & Therapeutics Committee Oversees

• tracking of medication errors

• adverse drug reactions

• management, control, effective & safe use of medications through monitoring & evaluation

• monitoring of problem-prone, high-risk, & high-volume medications

Tissue Committee

• Surgical case reviews including

– justification & indications for surgical procedures

Utilization Review Committee – I

• Monitors & evaluates utilization issues such as medical necessity and appropriateness of admission & continued stay, as well as delay in the provision of diagnostic, therapeutic, & supportive services.

• Ensures each patient is treated at appropriate level of care.

Utilization Review Committee – II

• Objectives of the committee include:

– transfer of patients requiring alternate levels of care

– promotion of efficient & effective use of resources

– adherence to quality utilization standards of third- party payers

– maintenance of high-quality, cost-effective care

– identification of opportunities for improvement

MEDICAL DIRECTOR

• Serves as a liaison between medical staff & organization's governing body & management.

Medical Staff Privileges – Screening Process

• Application

• Medial Staff Bylaws

• Physical & Mental Status

• Consent for Release of Information

• Certificate of Insurance

• State Licensure

• National Practitioner Data Bank

• References

• Interview Process

Medical Staff Privileges – II

• Delineation of Clinical Privileges

• Governing Body & Final Action

• Appeal Process

• Reappointments

Medical Staff Privileges – III

• Screening for Competency

• Physician Supervision and Monitoring

• Practicing Outside Field Of Competence

• Misrepresentation of Credentials

Disruptive Physicians

• Negative impact on an organization's staff and ultimately affect the quality of patient care.

• Physician's inability to work with other members org staff can be sufficient grounds to deny staff privileges

Disruptive Physicians Rage in the O.R.

• Experts say that doctor’s bad behavior is not merely unpleasant; it also has a corrosive effect on morale And poses a significant threat to patient safety. —Sandra G. Boodman, The Washington Post, March 5, 2013

Emergency Calls – Failure to Respond

• Physicians on call expected to respond to requests for emergency assistance.

• Failure to respond is grounds for negligence should a patient suffer injury.

Emergency Calls – II

• Gynecologist’s Refusal to Treat

– Patient’s Death

• Dillon v. Silver

Misdiagnosing Accident Victim – I

• A police department physician examined an unconscious man who had been struck by an automobile.

• The physician concluded that the patient's insensibility was a result of alcohol intoxication, not the accident, & ordered the police to remove him to jail instead of the hospital.

Misdiagnosing Accident Victim – I

• The man, to the physician's knowledge, remained semiconscious for several days & finally was taken to the hospital at the insistence of his family.

• The patient subsequently died. • An he autopsy revealed massive skull

fractures. • Did the physician commit malpractice?

YES!

• Although a physician does not ensure the correctness of the diagnosis or treatment, a patient is entitled to such thorough & careful examination as his or her condition and attending circumstances permit, with such diligence and methods of diagnosis as usually are approved and practiced by medical people of ordinary or average learning, judgment, and skill in the community or similar localities.

HISTORY & PHYSICAL

• Inadequate H & P Exam

– Failure to obtain an adequate family history & perform an adequate H & P violates a standard of care owed to the patient.

• Cursory Exam Fails to Reveal Head Injury

DELAY IN TREATMENT

• Lung Cancer

– Plaintiff/Patient awarded damages

– Blackmon v. Langley

– failure of the examining physician to inform patient in a timely manner that a chest X- ray showed a lesion in his lung.

MEDICAL RECORD – I Tool for Communications

• Patients Records

– tool for gathering patient information

– means of communication between caregivers

• Critical information lost in the record

MEDICAL RECORD – II

• Failure to Use Information

• Failure to read the record can lead to an action in malpractice

– Patient Allergy Communication Breakdown

– Physician Fails to Read Nursing Notes

MEDICAL RECORD - III Lack of Documentation

• Value of maintaining records of treatment.

– Important for patient’s on-going care

– Important for family member care

– It may be many years after a patient has been treated before litigation is initiated.

• Jury could consider failure to document as sufficient evidence for finding a physician guilty of negligence.

DIAGNOSTIC TESTS – I

• Failure to Order

– Standard practice to order specific diagnostic tests based on H & P

– Physician failed to use the test

• failed to diagnose patient's illness.

– Patient suffered injury

DIAGNOSTIC TESTS – II

• Failure to Order Appropriate X-Rays

• CT Misinterpretation Leads to Death

• Failure to Review Lab Tests

• Surgeon Fails to Read X-ray Report

• Failure to Consult with a Radiologist

DIAGNOSTIC TESTS – III

• Delay in Reporting Critical Tests

• Failure to Communicate X-Ray Results

• Failure to Timely Diagnose

• Patient’s Failure to Follow-up

CONSULTATIONS – I 2nd Opinions

• Physicians should practice discretion when treating patients outside their area of expertise

• Standard of care required

– specialty in which a physician is practicing

– whether or not the physician has been credentialed in that specialty

CONSULTATIONS – II 2nd Opinions

• Failure to Refer

• Untimely Referral

• Failure to Advise Patient’s Need for a Specialist

• Discounting Consulting Physicians’ Advice

DIAGNOSIS – I

• Failure to Diagnose

– Physician can be liable for reducing patient's chances for survival

• Timely diagnosis

– important as the need to accurately diagnose a patient's injury or disease

– failure to do so can result in malpractice

DIAGNOSIS – II

• Most frequently cited injury.

• Misdiagnosis will not in and of itself impose liability.

– unless there is a departure from the standard of care & injury results.

DIAGNOSIS – III

• Pathologist Misdiagnoses Cancer

• Radiologist: Loss of Chance to Survive

• Physician Fails to Follow-Up: Lost Chance to Survive

• Possibility of Survival Destroyed

• Failure to Form a Differential Diagnosis

DIAGNOSIS – IV

• Choice of Treatment: Differing Opinions

– Two Schools of Thought Doctrine

• Physician not liable for medical malpractice if he or she follows a course of treatment supported by reputable, respected, & reasonable medical experts.

• Use of unprecedented procedures that create an untoward result may cause a physician to be found negligent.

MEDICATION ERRORS

• Wrong Dosage

• Abuse in Prescribing Medications

• Excessive Drug Dosage Leads to Death

INFORMED CONSENT

• Physicians must inform patients of known benefits, risks, & alternatives to procedures.

• Case: Failure to Advise Patient of Treatment Alternatives

INVASIVE PROCEDURES – I Surgery Mix-Ups Surprisingly Common

• Unthinkable errors by doctors and surgeons—such as amputating the wrong leg or removing organs from the wrong patient—occur more frequently than previously believed, a new study suggests.

• Over a period of 6.5 years, doctors in Colorado alone operated on the wrong patient at least 25 times and on the wrong part of the body in another 107 patients, according to the study, which appears in the Archives of Surgery.

—Amanda Gardner, Health.com, 2011

INVASIVE PROCEDURES – II

• Wrong Surgical Procedure

• Catheter Fractured

• Wrong Patient

• Wrong Site: Colon

• Wrong Site: Herniated Disk

• Wrong Site Cover-up: Kidney

• Foreign Objects Left In Patients

– Needle fragment

• Improper Performance of a Procedure

ANESTHESIA – I

• Longview Regional, Surgeon Part of $1.9 million Civil Lawsuit Verdict

• Evidence before the jury showed a breathing tube was not inserted when Ross was put under anesthesia.

• When Ross began to retch during the procedure, his anesthetized body could not prevent the stomach contents from spilling into his lungs.

—Glenn Evans, newa-journal.com, November 9, 2012

ANESTHESIA – II

• Untimely Insertion of Breathing Tube

• Failure to Maintain Adequate Airway

• Improper Positioning of Arm

AGGRAVATION OF PRE-EXISTING CONDITION

• May cause a physician to be liable for malpractice.

– if original injury is aggravated, liability will be imposed for the aggravation

– rather than for both the original injury & its aggravation

PREMATURE DISCHARGE

• Premature discharge of a patient is risky business.

• Intent of discharging patients more expeditiously is often due a need to reduce costs.

• Dr. Nelson, an obstetrician & board member of the American Medical Association

• Discharge "should be based on medical factors & ought not be relegated to bean counters.“

– Anita Manning, AMA Calls Drive-Thru Birth Risky, USA TODAY, June 21, 1995, at 1.

FAILURE TO FOLLOW-UP

• Failure to provide follow-up care can result in a lawsuit if such failure results in injury to a patient.

INFECTIONS

• Leading cause of injury

• 2 Million patients annually get infections.

• Infections a Recognized Risk

• Preventing Spread of Infection

• Poor Infection-Control Technique

DENTISTRY

• Practicing Outside the Scope of Practice 2

• Drill Bit Left in Tooth Preventing Spread of Infection

• Anesthesia Abuse and CEO Dilemma

OBSTETRICS

• C-Section Delay Causes Injury

• Failure to Perform C-Section

• Failure to Attend Delivery

– Fetus Decapitated

• Failure to Perform Timely C-Section

• Wrongful Death of Unborn Fetus

PSYCHIATRY

• Commitment

– Commitment Upheld

• Duty to Warn

– Exceptions to Duty to Warn

• Suicidal Patients

• Failure to Provide Appropriate Evaluation

ABANDONMENT

• Elements Necessary to Recover Damages

– Medical care unreasonably discontinued

– Discontinuance against patient’s will

– Failure to assure follow-up care for patient

– Foresight - failure could result in patient injury

– Actual harm was suffered by patient

Physician-Patient Relationship - I

• Personalize treatment

• Conduct thorough assessment

• Develop comprehensive treatment plan

• Take time to get to know your patient

• Request consultations when needed

• Closely Monitor your patient’s progress

• Maintain complete, legible, & accurate records

Physician-Patient Relationship - II

• Do not guarantee treatment outcomes

• Provide coverage when off-duty

• Do not overextend your practice

• Limit telephone orders

• Do not become careless because you know the patient

• Seek advice of counsel should you suspect a legal action

REVIEW QUESTIONS – I

1. Discuss importance of delineating clinical privileges.

2. Why is it important that the governing body approve the appointment and reappointment of physicians to the medical staff?

3. What, if any, sanctions should be imposed upon an on-call physician who fails to respond to such call when requested? Discuss your answer.

4. Describe what options a hospital has in disciplining a disruptive physician. What effect can a physician’s behavior have on patient care?

REVIEW QUESTIONS – II

5. When two physicians have opposing views as to care, what course of action should the patient's attending physician follow?

6. Describe malpractice risks for radiologists and attending physicians.

7. Is a poor outcome always an indication of a negligent act? Explain.

8. When is a physician considered to have abandoned his or her patient?