Chapter 8 Medical Staff

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Chapter 8Medical Staff
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Chapter Overview

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

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Principles of Medical Ethics

• Code of Medical Ethics
• Case Whats Wrong With This Picture
• The Frustrated Patient

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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.

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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).

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Blood Transfusion Committee

• Develops blood usage p p
• Monitors transfusion services
• Monitors
• indications for transfusions
• blood ordering practices
• each transfusion episode
• transfusion reactions

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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.

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Infection Control Committee

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

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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.

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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.

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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

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Quality Improvement Council

• Functions as a patient care assessment
  improvement committee.

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Tissue Committee

• Surgical case reviews including
• justification indications for surgical
  procedures.

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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.

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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

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MEDICAL DIRECTOR

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

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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

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Medical Staff Privileges - II

• Delineation of Clinical Privileges
• Governing Body Final Action
• Reappointments
• Appeal Process
• Reappointments

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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)

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Medical Staff Privileges - IV

• Limitations on Requested Privileges
• Must be accordance with bylaws
• Appeal procedures must be followed
• Hospitals Duty to Ensure Competency

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Physician Supervision Monitoring

• Peer Review
• Board responsibility to recognize incompetence
• Suspension termination of privileges

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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

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• PHYSICIAN NEGLIGENCE
• CASES

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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?

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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.

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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.

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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

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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.

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Choice of TreatmentTwo 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.

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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.

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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

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Efficacy of Test Questioned

• Physicians should be sure that the tests they
  order are a valuable tool in diagnosing a
  patients ailments.
• Not all tests are equal
• some can leave false impressions
• e.g., blood occult test

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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

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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,

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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.

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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

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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

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Timely Diagnosis

• Liability for reducing a patients 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

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Misdiagnosis

• Mitral Valve Malfunction
• Failure to Form a Differential Diagnos
• Appendicitis
• Diabetic Acidosis

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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.

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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

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Medication Errors

• Wrong Dosage
• Abuse in Prescribing Medications
• Wrongful Supply of Medications

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Failure to FollowDifferent Course of Action

• Failure of an attending physician to recognize
  recommendations by consulting physicianswho
  determine a different diagnosis recommend a
  different course of treatment in a particular
  casecan result in liability for damages suffered
  by the patient.

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Failure to Provide Informed Consent

• Physicians must inform their patients of the
  known benefits, risks, alternatives to
  recommended procedures.

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Surgery

• The Phantom Surgeon
• Wrong Surgical Procedure
• Correct SurgeryWrong Site
• Wrong Site Surgery Fraud
• Foreign Objects Left In Patients
• Needle Fragment Left in Patient

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Improper Performance of a Procedure

• Improper performance of a procedure can result in
  injury to the patient liability for the
  physician.

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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

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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 patients
  injuries.

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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.

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Loss of Chance to Survive

• A loss of chance to survive can result in
  malpractice.
• See text cases
• Boudoin v. Nicholson, Baehr, Calhoun Lanasa
• Downey v. University Internists of St. Louis,
  Inc .
• Possibility of Survival Destroyed
• Griffett v. Ryan

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Lack of Documentation

• Value of maintaining records of treatment.
• Important for patients 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.

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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.

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Failure to Follow-up

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

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Infections

• A Case for Best Practices
• Infections a Recognized Risk
• Preventing Spread of Infection
• Poor Infection-Control Technique

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Obstetrics

• C-Section Delay Causes Injury
• Failure to Perform Cesarean Section
• Failure to Attend Delivery Fetus Decapitated
• Failure to Perform Timely C-Section
• Wrongful Death of Unborn Fetus

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Psychiatry - I

• Commitment
• Involuntary commitment
• Involuntary commitment ordered
• Continuation of Commitment
• Involuntary Commitment Invalid
• Commitment by spouse
• Commitment by parent
• Patient due process rights
• Release denied
• Recommended Discharge Denied

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Psychiatry - II

• Electroshock
• Duty to Warn
• Exceptions to Duty to Warn
• Suicidal Patients
• Failure to Provide Appropriate Evaluation
• Reimbursement Denied for Inadequate Care

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Abandonment

• Elements Necessary to Recover Damages
• Medical care unreasonably discontinued
• Discontinuance against patients will
• Failure to assure follow-up care for patient
• Foresight - failure could result in patient
  injury
• Actual harm was suffered by patient

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Physician-Patient Relationship - I

• Personalize treatment
• Conduct a thorough Assessment
• Develop a problems list comprehensive treatment
  plan
• Provide sufficient time and care to each patient
• Request consultations when indicated refer if
  necessary

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Physician-Patient Relationship - II

• Closely monitor patient progress
• make adjustments to treatment plan as the
  patients condition warrants
• Maintain timely, legible, complete, accurate
  records
• Do not make erasures.
• Do not guarantee treatment outcomes
• Provide for cross-coverage during days off

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Physician-Patient Relationship - III

• Do not over-extend your practice
• Avoid prescribing over the telephone
• Do not become careless because you know the
  patient
• Seek advice of counsel should you suspect the
  possibility of a legal action

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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.

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REVIEW QUESTIONS II

• 4. Under what circumstances should a hospital be
  liable for a physician's negligence?
• 5. Describe what options a hospital has in
  disciplining a disruptive physician. What effect
  can a physicians disruptive behavior have on
  patient care?
• 6. When two physicians have opposing views as to
  a patient's medical needs, what course of action
  should the patient's attending physician follow?

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REVIEW QUESTIONS III

• 7. Describe malpractice risks for radiologists
  and attending physicians.
• 8. Is a poor outcome always an indication of a
  negligent act? Explain.
• 9. When is a physician considered to have
  abandoned his or her patient?