5530: Chapter 8


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5530: Chapter 8

  1. 1. Chapter 8Medical Staff 2
  2. 2. Chapter Overview• Overview of medical ethics• Medical staff organization• Credentialing process• Review of pertinent legal cases – where physicians are most vulnerable 3
  3. 3. Principles of Medical Ethics• Code of Medical Ethics• Case: What’s Wrong With This Picture – The Frustrated Patient 4
  4. 4. 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. 5
  5. 5. 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). 6
  6. 6. Blood & Transfusion Committee• Develops blood usage p & p• Monitors transfusion services• Monitors – indications for transfusions – blood ordering practices – each transfusion episode – transfusion reactions 7
  7. 7. 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. 8
  8. 8. Infection Control CommitteeThe infection control committee is generally responsible for the development of policies & procedures for investigating, controlling, & preventing infections. 9
  9. 9. 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. 10
  10. 10. Pharmacy & Therapeutics Committee I• Policies & procedures (e.g., selection, procurement, distribution, hand ling, 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. 11
  11. 11. 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 12
  12. 12. Quality Improvement CouncilFunctions as a patient care assessment & improvement committee. 13
  13. 13. Tissue Committee• Surgical case reviews including – justification & indications for surgical procedures. 14
  14. 14. 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. 15
  15. 15. 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 16
  16. 16. MEDICAL DIRECTORServes as a liaison between medical staff &organizations governing body & management. 17
  17. 17. 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 18
  18. 18. Medical Staff Privileges - II• Delineation of Clinical Privileges• Governing Body & Final Action• Reappointments• Appeal Process• Reappointments 19
  19. 19. Medical Staff Privileges - III Cases• 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 physicians credibility & found many statements to support conclusion that physician intended to misrepresent his board status. No. 04AP-72 (Ohio Ct. App. 2004) 20
  20. 20. Medical Staff Privileges - IV• Limitations on Requested Privileges – Must be accordance with bylaws – Appeal procedures must be followed• Hospital’s Duty to Ensure Competency 21
  21. 21. Physician Supervision & Monitoring• Peer Review• Board responsibility to recognize incompetence• Suspension & termination of privileges 22
  22. 22. Disruptive Physicians• Negative impact on an organizations staff and ultimately affect the quality of patient care.• Physicians ―inability to work with others‖ – sufficient grounds to deny staff privileges• Demonstrated Inability to Work with Others• Failure to Meet Ethical Standards 23
  24. 24. Misdiagnosing Accident Victim – IA police department physician examined anunconscious man who had been struck by anautomobile. The physician concluded that thepatients insensibility was a result of alcoholintoxication, not the accident, & ordered the police toremove him to jail instead of the hospital. Theman, to the physicians knowledge, remainedsemiconscious for several days & finally was taken tothe hospital at the insistence of his family. The patientsubsequently died. An he autopsy revealed massiveskull fractures. Did the physician commit malpractice? 25
  25. 25. Misdiagnosing Accident Victim – II Yes!Although a physician does not ensure the correctnessof the diagnosis or treatment, a patient is entitled tosuch thorough & careful examination as his or hercondition and attending circumstances permit, withsuch diligence and methods of diagnosis as usuallyare approved and practiced by medical people ofordinary or average learning, judgment, and skill inthe community or similar localities. 26
  26. 26. 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 physicians failure to respond. 27
  27. 27. Delay in Treatment• A physician may be liable for failing to respond promptly if it can be established that such inaction caused a patients death, (See text case: Blackmon v. Langley)• Failure to Treat Evolving Emergency 28
  28. 28. 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. 29
  29. 29. 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. 30
  30. 30. 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 patients illness. – The patient suffered injury as a result. 31
  31. 31. Failure to Promptly Review Test Results• A physicians failure to promptly review test results can be the proximate cause of a patients injuries. – See text case: Smith v. U.S. Department of Veterans Affairs 32
  32. 32. 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 33
  33. 33. 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 34
  34. 34. Failure to Obtain Timely Diagnosis• Physician can be liable for reducing a patients chances for survival.• Timely diagnosis of a patients condition is as important as the need to accurately diagnose a patients 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, 35
  35. 35. Failure to Obtain 2 nd 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. 36
  36. 36. 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 patients 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 37
  37. 37. 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 38
  38. 38. 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 39
  39. 39. Misdiagnosis• Mitral Valve Malfunction• Failure to Form a Differential Diagnos• Appendicitis• Diabetic Acidosis 40
  40. 40. 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. 41
  41. 41. 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 42
  42. 42. Medication Errors• Wrong Dosage• Abuse in Prescribing Medications• Wrongful Supply of Medications 43
  43. 43. Failure to Follow: Different Course of ActionFailure 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. 44
  44. 44. Failure to Provide Informed ConsentPhysicians must inform their patients of the known benefits, risks, & alternatives to recommended procedures. 45
  45. 45. 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 46
  46. 46. Improper Performance of a ProcedureImproper performance of a procedure can result in injury to the patient & liability for the physician. 47
  47. 47. 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 patients death 48
  48. 48. Pathologist Misdiagnosis of Breast Cancer• See text case: Anne Arundel Med. Ctr., Inc. v. Condon – Pathologists failure to interpret invasive carcinoma was a departure from standard of care required, & was proximate cause of patient’s injuries. 49
  49. 49. 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. 50
  50. 50. 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 51
  51. 51. 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. 52
  52. 52. 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. 53
  53. 53. Failure to Follow-upFailure to provide follow-up care can result in a lawsuit if such failure results in injury to a patient. 54
  54. 54. Infections• A Case for Best Practices• Infections a Recognized Risk• Preventing Spread of Infection• Poor Infection-Control Technique 55
  55. 55. 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 56
  56. 56. 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 57
  57. 57. Psychiatry - II• Electroshock• Duty to Warn – Exceptions to Duty to Warn – Suicidal Patients• Failure to Provide Appropriate Evaluation – Reimbursement Denied for Inadequate Care 58
  58. 58. 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 59
  59. 59. 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 60
  60. 60. Physician-Patient Relationship - II• Closely monitor patient progress – make adjustments to treatment plan as the patient’s condition warrants – Maintain timely, legible, complete, & accurate records – Do not make erasures. – Do not guarantee treatment outcomes• Provide for cross-coverage during days off 61
  61. 61. 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 62
  62. 62. REVIEW QUESTIONS – I1. Discuss importance of delineating clinicalprivileges.2. Why is it important that the governing bodyapprove the appointment and reappointment ofphysicians to the medical staff?3. What, if any, sanctions should be imposed upon anon-call physician who fails to respond to such callwhen requested? Discuss your answer. 63
  63. 63. REVIEW QUESTIONS – II4. Under what circumstances should a hospital beliable for a physicians negligence?5. Describe what options a hospital has in disciplininga disruptive physician. What effect can a physician’sdisruptive behavior have on patient care?6. When two physicians have opposing views as to apatients medical needs, what course of action shouldthe patients attending physician follow? 64
  64. 64. REVIEW QUESTIONS – III7. Describe malpractice risks for radiologistsand attending physicians.8. Is a poor outcome always an indication of anegligent act? Explain.9. When is a physician considered to haveabandoned his or her patient? 65