Flashpoints in the Medical Staff World Horty, Springer & Mattern Making the Medical Staff Meaningful 1
Wrong question: How do we get physicians to participate in the medical staff? ? Better question: What can the medical staff do to bring value to the life/practice of physicians – across the continuum? 2
Collegial environment critical to joy in profession. Picture of joy is not a selfie. (Some speculate that a contributor to the high physician suicide rate is increasing isolation.) 3
American Foundation for Suicide Prevention (2014) 300-400 physicians per year. Major Risk Factors • Depression • Bipolar • Alcohol/substance abuse No evidence that work-related stressors linked to elevated physician rates. 4
• Medical students: 15-30% higher than general population • Male physicians: 70% higher than males in other professions • Female physicians: 250-400% higher than females in other professions Medical staff must create support for its membership in many arenas: Celebrate! Start each meeting with a joyful patient story. You have many. 5
Remember why you do what you do. Why did you choose health care? • To please a parent? • Passion for science? • A doctor you admired? • Money? 6
Formal and Informal Meetings That Matter • Well planned • Substantive • Safe educational programs – starting with orientation: • The Board and what it does • Administration • Support staff • Preceptoring (buddy program) Formal and Informal Meetings That Matter • Expanded role of Wellness Committee • Consultation without stigma • Publicize its role • Facilitate consultations • Communicate in myriad ways • Require members to access available information • Informal, supportive, short get-togethers • Hotlines for news and concerns 7
Formal and Informal Meetings That Matter • Food is love: meet in cafeteria or physician lounge each Tuesday at 6:00 a.m. or 11:00 a.m. for all who can make it • Congressional dining room and the demise of collegiality • Be the go-to source for information, assistance (like the Rapid Response Team that is available to help with EMR) Leadership Development 8
• Recruiting, grooming your successors • Leaders “self-select” (with appropriate encouragement) • True leadership – visionary, quality- driven • Medical Staff [physician leadership] college • Someone told you: • “You’d be great at….” or • “Your skills would really move this project….” or • “You are so well-respected by your peers, you’d make a terrific.…” or • “Please help me out by reviewing these cases and.…” 9
Introduce new leaders with small “wins.” Celebrate/reward good work 10
Thanks. Physicians in Governance 11
No longer required by CMS, but “direct consultation” with “individual responsible for medical staff.” Direct consultation: “a discussion on matters related to the quality of medical care provided to patients periodically (at least twice per year)….” 12
“Governing body (or subcommittee) meets with the medical staff leader(s) either face-to-face or via a telecommunications system permitting immediate, synchronous communication.” Physicians on Boards? • How many? • How chosen? • Conflicts 13
Physicians on Board committees Strategic Advisory Committee 14
Eliminate Litigation • Define Standard of Care • Create Expectations • Education/Compliance/Enforcement • Assessment of high-risk practices − Quality − Risk − Training − Documentation − Practice processes − Environmental hazards 15
But, bad things happen. • Investigate • Disclose • Apologize (Sorry laws) • Remediate What Is Cause of Litigation? • Bad outcome • Injury • Anger • Sense of unfairness • Vengeance • Patient/family wants to know what happened (cases withdrawn at conclusion of discovery) 16
PHTS Experience A. Steps: 1. Prompt reporting of incidents 2. Prompt investigation, including interviews 3. Preserving records 4. Meet with injured party/family 5. Discuss facts openly 6. Offer remuneration commensurate with injury PHTS Experience B. Results: 1. Financial savings – 66% ($8 million from mid-2012 to mid-2014) 2. EVERY SINGLE INCIDENT avoided litigation 3. Average cost of early resolution case: $16,000 4. Average cost of one “progressing to lawsuit status”: $143,000 17
Human benefits, too: • Sterile pack case • Picasso Creative ED Call Solutions 18
DO NOT try to solve one call problem at a time. Multidisciplinary task force designs solutions. 19
Build fair call into all employment contracts. Create and market alternative multi-hour site for non-emergent care; permit immediate triage and transfer. 20
ED directs all patients to hospitalists. ED contract (and bylaws) authorizes ED physician to admit to service of on-call physician. 21
Deferred compensation. Old Is The New Useful 22
“It is time.” Dignity in identifying and communicating with the aging practitioner. 23
The Ultimate Balancing Act • Protect patients • Protect the practitioner • Protect other practitioners • Protect the organization • Comply with accreditation standards • Comply with Age Discrimination in Employment Act (ADEA) • Comply with Americans with Disabilities Act (ADA) Options • Provision in Credentials Policy/Bylaws for “Practitioners Over Age ______” • Late Career Practitioner Policy • Peer Review Policy • Practitioner Health Policy 24
Practitioner Health Policy Medical Staffs should evaluate their unique culture and decide if an age-based rule makes sense in their hospital. 25
Benefits of a Rule (e.g., a Bylaws Provision) • Protect patients • Reduce risk of negligent credentialing claims • Treat all physicians the same (thus reducing risk of discrimination claims) • Depersonalize issue Drawbacks of a Rule • Overly inclusive (affects physicians with no problems) • Controversial and inconvenient • Unnecessary if peer review process is working properly? • Difficulty interpreting test results (especially if no baseline) • Increased risk of discrimination claims 26
Low Risk • Adopt and enforce evidence-based volume requirements for procedures for all physicians • Concurrent chart review of certain number of cases after age “x” • Annual reappointment • Concurrent proctoring of certain number of cases Some Risk • Require physician to have assistant at surgery or back-up immediately available • Comprehensive physical and psychological evaluations 27
Do These Exams Yield Useful Information? • If no baseline to compare to, what do results mean? • Even if decline noted, at what level is it significant? • BUT – exams can be viewed as flagging mechanism for focused review of practice and outcomes High Risk Automatic loss of privileges after a certain age. 28
Age Discrimination in Employment Act (ADEA) • Applies to “employees” (though some courts are interpreting broadly) over 40 • Prohibits employment action based on age • Applies to mandatory retirement, mandatory testing, etc. Can an aging policy treat all physicians the same (e.g., internists and surgeons)? 29
Joint Commission Standard MS 11.01.01 Hospitals must have a process to address: − Education about impairment − Self-referral and referral from others − Confidentiality Joint Commission Standard MS 11.01.01 Hospitals must have a process to address: • Evaluation of credibility of complaint • Monitoring • Reporting when practitioner is providing unsafe treatment • Appropriate action 30
Process • Education • Reporting • Fact-finding • Meeting • Evaluation • Resolution • Follow-up Education 31
Education Policy should address: • Signs and symptoms of impairment • Importance of reporting • Downside of “enabling” Reporting 32
Reporting Policy should: • Emphasize confidentiality • Describe process for reporting by others • Encourage voluntary self-reporting Fact-Finding • Interview staff • Review relevant documents 33
Is there enough evidence to meet with Man Legend? A. Absolutely, YES! B. Absolutely, NO! C. It depends on whether there have been other episodes of confusion. Wrong Question! You don’t need “evidence” or “proof” to meet with a physician. 34
Meeting Plan the Meeting with Care • Don’t shoot from the hip • Have a game plan (and an end plan) • Review your documents – know your own process! • Know your options Meeting Plan the Meeting with Care • Anticipate denial • Emphasize confidentiality 35
Evaluation • Practitioner Health Committee should select evaluating entity • Evaluation is NOT quick visit • Have evaluator complete form that addresses relevant issues Evaluation • Man Legend should sign authorization permitting hospital and evaluating entity to communicate with one another and share information 36
Resolution Conditions of reinstatement should be described in detail. Physician Wellness Committee 37
Policy provides for SAFE reporting. Mentoring, observer, subject matter leader in meetings. 38
Assessments Aging • CME • MOC (whether required by Board or not) 39
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