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  • 1. Who’s Who in Healthcare
    • Katharine C. Rathbun, MD, MPH
    • Strategic Management of Health Care Organizations
    • Spring 2005
    • LSU MPA Program
    • Course Page:
      • http://biotech.law.lsu.edu/Courses/mpa/index.htm
  • 2. Physician-Patient Relationship
    • the basic relationship in healthcare
    • between two people
    • requires consent of both parties to establish
    • unilateral termination
  • 3. Establishing the Relationship
    • sign a contract
    • hang out a shingle
    • make an appointment
    • accept payment
  • 4. Group Practice
    • May create multiple relationships without prior interaction with a given physician
    • System may assign patients
    • difficult to “fire” a patient from one doctor
  • 5. Hospital Practice
    • contracts can create a physician-patient relationship
    • all the rules apply
    • cannot pick and choose patients
  • 6. Emergency Room Coverage
    • staff privileges specify the duty to take ER call and provide care for patients in specific situations
    • privileges at multiple hospitals can cause problems
    • “I’m not on call” isn’t the right answer
  • 7. Mandatory Consultation
    • Cardiologists reading all EKGs
    • Pathologist supervising lab
    • this is a physician-patient relationship
  • 8. Hospital Practice
    • hospitalist groups becoming common
    • contracts between doctors as well as the other relationships
    • hospital administration may be involved as well
  • 9. Medical Specialties
    • voluntary associations
    • AMA or AOA recognized boards
    • residency training or grandfathering
    • medical licenses are general not specific
  • 10. Historical Specialization
    • most boards were set up in the 1940’s
    • all doctors did GP training
    • some went on to residencies to specialize
    • some would just start doing a specialty practice
    • most boards accepted both residency and experience
    • board certification was for a lifetime
  • 11. Current Specialization
    • everyone does at least 1 year of residency
    • this is specialty training
    • specialists are no longer GP’s first
    • most boards have closed to grandfathering
    • most boards now require recertification
  • 12. Legal Status of Specialization
    • many states now accept a board exam in lieu of a repeat licensing exam
    • hospitals require certification for privileges
    • federal programs require certification for certain systems
    • insurers require certification for payment
  • 13. Certified vs Eligible
    • most boards will not recognize a status of “board eligible”
    • you have passed the exam or you haven’t
  • 14. Schools of Practice
    • Allopath - what most think of as a real doctor
    • Osteopath - also real doctors - scientific training with some physical therapy added
    • These are the only two schools of scientific medical practice
    • Share the same licenses
  • 15. Osteopathy vs Allopathy
    • Historically had separate hospitals and practice groups
    • Osteopaths were the less respected - still some stigma
    • Becoming integrated
    • Often share residencies
    • Many osteopaths take AMA boards
  • 16. Physician Extenders
    • many doctors use physician extenders
    • state specific rules
    • physician is responsible for what they do
  • 17. Rules About Supervision
    • how many can you have
    • how close do they have to be
    • how do you authorize care
  • 18. Extenders in Hospitals
    • these extenders should be credentialed individually
    • staff bylaws should deal with extenders specifically
  • 19. Students
    • don’t call them doctor or nurse
    • they are there to learn not serve
    • they take time to supervise
  • 20. Residents
    • doctors in training
    • may or may not be licensed
    • working on an institutional license
    • there to learn although they may give some service
    • DON’T charge for their services
  • 21. Team Care
    • doctor - captain of the ship
    • modern practice is more complicated
    • hospital has responsibility and liability
  • 22. Lesser Levels of Training
    • basic rule is you cannot hand off care or responsibility to someone less qualified than yourself
    • you also cannot supervise someone doing something you don’t know how to do
    • both these rules are violated all the time
      • side of the road
      • in the clinic/hospital
  • 23. Nurses
    • Registered Nurses - real nurses
    • LPN - licensed practical nurses
    • Nurse Practitioners
    • non-licensed caregivers
  • 24. Nurse-Patient Relationship
    • Nurses are independently licensed
    • Nurses have an independent duty to their patients
    • Nurses exercise independent judgement
  • 25. Nurse-Physician Relationship
    • Mostly nurses are absolutely subservient to doctors
    • If they do not agree with physician orders, they can refuse to participate but they cannot change orders.
    • They may be protected by the practice acts or the rules of the hospital
  • 26. Independent Nurse Practice
    • Nurses may open an office and do wound care and nutrition advise
    • Nurses may not open an office and practice medicine even if they are nurse practitioners
    • Nurses may not be hired by a hospital and set up a medical practice either
  • 27. Nurses in Institutions
    • Nurses in hospitals and clinics are generally employees of the institution
    • The institution is generally liable for what they do.
    • If the physician hires them, they are generally functioning as a physician extender.
  • 28. Other Providers
    • There are many other licensed or certified health care professionals
      • x-ray, laboratory, pharmacy
    • Legally and administratively these are similar to nurses
  • 29. Nurse Extenders
    • lower level care providers - certified
    • medical assistants, OR technicians, lab technicians
    • on the job training vs certification
  • 30. Nurse Extenders in Institutions
    • need to be carefully screened
    • need to be carefully supervised
    • cannot rely on the license or certification
    • institution has all the responsibility
  • 31. Licenses
    • the license belongs to an individual
    • it is a privilege to get a license
    • you have a right to keep it
    • general not specialty license
  • 32. Other Licensees
    • many other licensed professions in medical practice
    • may have separate licensing boards or be under the board of medical examiners
    • often work in hospitals or other institutions
  • 33. Unlicensed Practitioners
    • unlicensed physicians
    • faith healers
    • alternative medicine
  • 34. Administrators
    • great responsibility - little authority when it comes to patient care
    • laws forbid corporate practice of medicine
    • need good contracts and institutional rules to allow them to control what goes on
  • 35. Duties to Treat
    • statutory - cord blood serologies
    • contractual - orthopedist in the ER
    • ethical - patient is there
    • continuing care
  • 36. Abandonment
    • stopping care to a patient without providing sufficient notice and opportunity for the patient to find substitute care
    • illegal
    • unethical
    • hospitals may be the perpetrators or the victims
  • 37. Fiduciary Duty
    • a physician is a fiduciary
    • the fiduciary has a duty to put the interests of the client above their own interests and do what is best for the client
    • this does not mean break the law, violate ethics or work for free
  • 38. Terminating the Relationship - Patients
    • patients may terminate the provider-patient relationship at will as long as they are legally able to consent
    • patients don’t always do what is good for them
    • patients can’t force a physician or hospital to provide certain types of care - their legal choice is shut up or go away
  • 39. Terminating the Relationship - Providers
    • The physician-patient relationship is 24/7.
    • It must be formally terminated by the physician.
    • The physician must provide alternatives to the patient or a lot of time during which they continue to provide care.
    • Alternative care must be realistically available.
  • 40. Referral/Consultation
    • REFERRAL shifts the care of a patient to another provider and is an acceptable way to terminate a relationship
    • CONSULTATION brings another provider into the relationship but does not terminate the original relationship
    • either may be done by both physicians or hospitals
  • 41. Referrals
    • usually done because the physician or hospital is not able to provide the necessary services
    • may be done for religious or ethical reasons
    • may be done for personality reasons
    • may not be done for prohibited reasons
      • protected classes of people
      • emergency wallet biopsies
  • 42. Consultations
    • Bringing in the expert or the specialist
    • hospitals often require these for certain services
      • ICU admissions, obstetrics, reading EKGs
    • in-house second opinions
    • curb-side consults - illegal under HIPPA
  • 43. Consent to Care
    • you have to have permission from a consenting adult to do anything to them
    • violating this is battery
    • the patient may pick and choose with some exceptions
    • the patient may terminate the relationship by refusing consent
  • 44. Substitute Consent
    • not everyone is a consenting adult
    • know who has the authority to consent and talk only to them
    • parents have limited authority over the care of their children
    • spouses have no authority over each other
  • 45. Questions of Ability to Consent
    • you either have someone with the legal ability to consent or you don’t
    • questionable situations have to be addressed by a judge
    • big city hospitals often have the judge’s phone number posted in the ER
  • 46. Informed Consent
    • more detailed than simple consent
    • many states have statutes on this
    • this is about not loosing a law suit
  • 47. Exceptions to Consent
    • emergency exception
      • expectation that anyone would want preservation of life and limb
      • may apply if the patient is medically or legally incompetent
    • statutory exceptions
      • public health law
      • mental health law
    • court ordered care