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Chapter 8 Medical Staff

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Title: Chapter 8 Medical Staff


1
(No Transcript)
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 Whats 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
  • Hospitals 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 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.

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
    patients 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 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

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 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.

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 SurgeryWrong 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 patients
    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.

51
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

52
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.

53
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.

54
Failure to Follow-up
  • Failure to provide follow-up care can result in a
    lawsuit if such failure results in injury to a
    patient.

55
Infections
  • A Case for Best Practices
  • Infections a Recognized Risk
  • Preventing Spread of Infection
  • Poor Infection-Control Technique

56
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

57
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

58
Psychiatry - II
  • Electroshock
  • Duty to Warn
  • Exceptions to Duty to Warn
  • Suicidal Patients
  • Failure to Provide Appropriate Evaluation
  • Reimbursement Denied for Inadequate Care

59
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

60
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

61
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

62
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

63
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.

64
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?

65
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?
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