Chapter 8 Medical Staff

2. Chapter 8Medical Staff

3. Chapter Overview • Overview of medical ethics • Medical staff organization • Credentialing process • Review of pertinent legal cases • where physicians are most vulnerable

4. Principles of Medical Ethics • Code of Medical Ethics • Case: What’s Wrong With This Picture • The Frustrated Patient

5. 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. Peer review. Fair hearing process. Review & act on reports of medical staff departmental chairpersons & medical staff committees.

6. 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).

7. Blood & Transfusion Committee Develops blood usage p & p Monitors transfusion services Monitors indications for transfusions blood ordering practices each transfusion episode transfusion reactions

8. 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.

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

10. Medical Records Committee Develops policies & procedures, including 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.

11. Pharmacy & Therapeutics Committee I 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.

12. Pharmacy & Therapeutics Committee II 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

13. Quality Improvement Council Functions as a patient care assessment & improvement committee.

14. Tissue Committee Surgical case reviews including justification & indications for surgical procedures.

15. 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.

16. 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

17. MEDICAL DIRECTOR Serves as a liaison between medical staff & organization's governing body & management.

18. Medical Staff Privileges - I 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

19. Medical Staff Privileges - II Delineation of Clinical Privileges Governing Body & Final Action Reappointments Appeal Process Reappointments

20. Medical Staff Privileges - IIICases • Screening for Competency • Misrepresentation of Credentials • Evidence submitted supported physician falsely indicated that he had American Board of Internal Medicine certification. • Board contended hearing examiner addressed physician's credibility & found many statements to support conclusion that physician intended to misrepresent his board status. No. 04AP-72 (Ohio Ct. App. 2004)

21. Medical Staff Privileges - IV • Limitations on Requested Privileges • Must be accordance with bylaws • Appeal procedures must be followed • Hospital’s Duty to Ensure Competency

22. Physician Supervision & Monitoring Peer Review Board responsibility to recognize incompetence Suspension & termination of privileges

23. Disruptive Physicians Negative impact on an organization's staff and ultimately affect the quality of patient care. Physician's “inability to work with others” sufficient grounds to deny staff privileges Demonstrated Inability to Work with Others Failure to Meet Ethical Standards

24. PHYSICIAN NEGLIGENCE CASES

25. 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. 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?

26. Misdiagnosing Accident Victim – IIYes! 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.

27. Failure to Respond: Emergency Calls Physicians on call in emergency dept expected to respond to requests for emergency assistance when such is considered necessary. Failure to respond is grounds for negligence should a patient suffer injury as a result of a physician's failure to respond.

28. Delay in Treatment A physician may be liable for failing to respond promptly if it can be established that such inaction caused a patient's death, (See text case: Blackmon v. Langley) Failure to Treat Evolving Emergency

29. Inadequate History & Physical Failure to obtain an adequate family history & perform adequate physical violates a standard of care owed to the patient. (See text case: Foley v. Bishop Clarkson Memorial Hospital) Failure to Document H & P See text case: Solomon v. Ct. Med. Exam. Bd.

30. Choice of Treatment:Two Schools of Thought Under this doctrine, a physician will not be 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 even though due care was followed.

31. Failure to Order Diagnostic Tests A plaintiff who claims that a physician failed to order proper diagnostic tests must show: It is standard practice to use a certain diagnostic test under the circumstances of the case. The physician failed to use the test & therefore failed to diagnose patient's illness. The patient suffered injury as a result.

32. Failure to Promptly Review Test Results A physician's failure to promptly review test results can be the proximate cause of a patient's injuries. See text case: Smith v. U.S. Department of Veterans Affairs

33. Efficacy of Test Questioned Physicians should be sure that the tests they order are a valuable tool in diagnosing a patient’s ailments. Not all tests are equal some can leave false impressions e.g., blood occult test

34. Imaging Studies/Radiology Failure to Order Appropriate Imaging Studies Image Misinterpretation Leads to Death Failure to Consult with a Radiologist Failure to Read Images Delay in Conveying Imaging Results Failure to Communicate X-Ray Results

35. Failure to Obtain Timely Diagnosis Physician can be liable for reducing a patient's chances for survival. Timely diagnosis of a patient's condition is as important as the need to accurately diagnose a patient's injury or disease. Failure to do so can constitute malpractice if a patient suffers injury as a result of such failure. See text case: Powell v. Margileth,

36. Failure to Obtain 2nd Opinion Physicians must seek 2nd opinions when required. See text case: Goodwich v. Sinai Hospital In this case, the record was replete with documentation of questionable patient management & continual failure to comply with 2nd-opinion agreements.

37. Failure to Refer A physician has a duty to refer his or her patient whom he or she knows or should know needs referral to a physician familiar with and clinically capable of treating the patient's ailments. To recover damages, the plaintiff must show that the physician deviated from the standard of care and that the failure to refer resulted in injury. See text case: Doan v. Griffith

38. Practicing Outside Field of Competence Physicians should practice discretion when treating patients outside their field of expertise. Standard of care required in a malpractice case will be that of the specialty in which a physician is treating, whether or not he or she has been credentialed in that specialty. See text case: Carrasco v. Bankoff

39. Timely Diagnosis • Liability for reducing a patient’s chances for survival • Timely diagnosis as important as the need to accurately diagnose • Failure timely diagnose can result in a malpractice suit • if a patient suffers injury as a result of such failure • Wronguful Death

40. Misdiagnosis Mitral Valve Malfunction Failure to Form a Differential Diagnos Appendicitis Diabetic Acidosis

41. Failure to Read Nursing Notes A physician can breach his or her duty of care by failing to read nursing notes. See text case: Todd v. Sauls.

42. Failure to Use Patient Data Gathered • Assume Nothing • Critical information often gets lost in the record • Information critical to patient care must be readily available • Failure to Use Critical information • Patient allergic to Latex has a Latex catheter inserted • Leads to chronic bladder disorder

43. Medication Errors Wrong Dosage Abuse in Prescribing Medications Wrongful Supply of Medications

44. Failure to Follow:Different Course of Action Failure of an attending physician to recognize recommendations by consulting physicians—who determine a different diagnosis & recommend a different course of treatment in a particular case—can result in liability for damages suffered by the patient.

45. Failure to Provide Informed Consent Physicians must inform their patients of the known benefits, risks, & alternatives to recommended procedures.

46. Surgery The Phantom Surgeon Wrong Surgical Procedure Correct Surgery–Wrong Site Wrong Site Surgery: Fraud Foreign Objects Left In Patients Needle Fragment Left in Patient

47. Improper Performance of a Procedure Improper performance of a procedure can result in injury to the patient & liability for the physician.

48. Failure to Maintain Adequate Airway See text case: Ward v. Epting Anesthesiologist failed to conform to the standard of care. Deviation from the standard was the proximate cause of the patient's death

49. PathologistMisdiagnosis of Breast Cancer See text case: Anne Arundel Med. Ctr., Inc. v. Condon Pathologist's failure to interpret invasive carcinoma was a departure from standard of care required, & was proximate cause of patient’s injuries.

50. Aggravation of A Pre-Existing Condition See text Case: Nguyen v. County of Los Angeles Aggravation of a preexisting condition through negligence may cause a physician to be liable for malpractice. If the original injury is aggravated, liability will be imposed only for the aggravation, rather than for both the original injury & its aggravation.