Role and Func,on of Hospital Medical Staff Physician - - PDF document

Role ¡and ¡Func,on ¡of ¡Hospital ¡Medical ¡Staff ¡Physician ¡Well-­‑Being ¡Commi?ees ¡/ ¡Mary ¡Powers ¡Antoine, ¡Esq. ¡

California ¡Public ¡Protec0on ¡& ¡Physician ¡Health ¡(CPPPH) ¡Regional ¡Mee0ng ¡/ ¡January ¡7, ¡2012 ¡/ ¡Sacramento ¡

LEGAL COUNSEL’S OVERVIEW OF THE ROLE AND FUNCTION OF PHYSICIAN WELL-BEING COMMITTEES OF HOSPITAL MEDICAL STAFFS* Sacramento, California January 7, 2012

Mary Powers Antoine, Esq. Nossaman LLP

*This presentation was adapted from one originally given by Kim Ware, of the Ware Law Group.

ROLE & FUNCTION OF PWBC

§ Collegial assistance vs. legal duties § Tension between PWBC and MEC

– MEC as watch dog and disciplinarian: accountable for oversight of medical staff peer review – PWBC as physician helper: must be SEPARATE from disciplinary function

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ROLE & FUNCTION OF PWBC

Hospital licensing requirements – Title 22, CCR 70703(d) (d) The medical staff by-laws, rules, and regulations shall include, but shall not be limited to, provision for the performance of the following functions: executive review, credentialing, medical records, tissue review, utilization review, infection control, pharmacy and therapeutics, and assisting the medical staff members impaired by chemical dependency and/or mental illness to

• btain necessary rehabilitation services. These functions may

be performed by individual committees, or when appropriate, all functions or more than one function may be performed by a single

• committee. Reports of activities and recommendations relating to

these functions shall be made to the executive committee and the governing body as frequently as necessary and at least quarterly.

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Role ¡and ¡Func,on ¡of ¡Hospital ¡Medical ¡Staff ¡Physician ¡Well-­‑Being ¡Commi?ees ¡/ ¡Mary ¡Powers ¡Antoine, ¡Esq. ¡

California ¡Public ¡Protec0on ¡& ¡Physician ¡Health ¡(CPPPH) ¡Regional ¡Mee0ng ¡/ ¡January ¡7, ¡2012 ¡/ ¡Sacramento ¡

ROLE & FUNCTION OF PWBC

§ TJC Standards, MS.11.01.01: “The medical staff implements a process to identify and manage matters of individual health for licensed independent practitioners which is separate from actions taken for disciplinary purposes.”

– Purpose is rehabilitation rather than discipline.

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ROLE & FUNCTION OF PWBC

TJC process design addresses:

1. Education of licensed independent practitioners and other

• rganization staff about illness and impairment recognition issues

specific to licensed independent practitioners (at-risk criteria). 2. Self referral by a licensed independent practitioner. 3. Referral by others and maintaining informant confidentiality. 4. Referral of the licensed independent practitioner to appropriate professional internal or external resources for evaluation, diagnosis, and treatment of the condition or concern. 5. Maintenance of confidentiality of the licensed independent practitioner seeking referral or referred for assistance, except as limited by applicable law, ethical obligation, or when the health and safety of a patient is threatened.

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ROLE & FUNCTION OF PWBC

6. Evaluation of the credibility of a complaint, allegation, or concern. 7. Monitoring the licensed independent practitioner and the safety of patients until the rehabilitation is complete and periodically thereafter, if required. 8. Reporting to the organized medical staff leadership instances in which a licensed independent practitioner is providing unsafe treatment. 9. Initiating appropriate actions when a licensed independent practitioner fails to complete the required rehabilitation program. 10. The medical staff implements its process to identify and manage matters

• f individual health for licensed independent practitioners.

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Role ¡and ¡Func,on ¡of ¡Hospital ¡Medical ¡Staff ¡Physician ¡Well-­‑Being ¡Commi?ees ¡/ ¡Mary ¡Powers ¡Antoine, ¡Esq. ¡

California ¡Public ¡Protec0on ¡& ¡Physician ¡Health ¡(CPPPH) ¡Regional ¡Mee0ng ¡/ ¡January ¡7, ¡2012 ¡/ ¡Sacramento ¡

ROLE & FUNCTION OF PWBC

§ PWBC as physician helper may accept self-referrals and referrals from medical staff committees and leaders. § Disability protection laws (ADA, Unruh Civil Rights Act) must be acknowledged and respected.

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ROLE & FUNCTION OF PWBC

§ PWBC as protector of quality – when to refer matter to the MEC? ** Whenever MD appears to present a danger to patient safety **

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ROLE & FUNCTION OF PWBC

§ Don’t be paralyzed by legal concerns, but be mindful of them

– Review policies and bylaws – Alert the chief of staff – Check with medical staff legal counsel as needed

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Role ¡and ¡Func,on ¡of ¡Hospital ¡Medical ¡Staff ¡Physician ¡Well-­‑Being ¡Commi?ees ¡/ ¡Mary ¡Powers ¡Antoine, ¡Esq. ¡

California ¡Public ¡Protec0on ¡& ¡Physician ¡Health ¡(CPPPH) ¡Regional ¡Mee0ng ¡/ ¡January ¡7, ¡2012 ¡/ ¡Sacramento ¡

INITIAL PWBC INVOLVEMENT

§ In aftermath of abolition of MBC Diversion Program, what to do?

– Assist the physician by providing collegial guidance and external resources for assessment and assistance. – Assist the MEC by serving as a coordinator and conduit between MEC and external private resources that can fill the function of former Diversion Program.

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INITIAL PWBC INVOLVEMENT

§ Monitoring, and referral for disciplinary (or corrective) action (if and when indicated); typical first steps:

– Gather information

• Meeting with chief of staff, other medical staff leaders
• Interview others with pertinent information – nurses, techs,

etc

• Meeting with MD (after other information obtained is best, if

meeting can wait)

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INITIAL PWBC INVOLVEMENT

Initial impressions and assessment of next steps: § Is evaluation warranted? (not always – there must be a threshold of reliable information before formal evaluation should be recommended.) § If “no,” make recommendations for assistance – e.g., stress management classes, counseling, etc. § If “yes,” – can strongly urge evaluation as a condition for the opportunity to continue to work with the PWBC (rather than being referred to the MEC for a formal investigation).

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Role ¡and ¡Func,on ¡of ¡Hospital ¡Medical ¡Staff ¡Physician ¡Well-­‑Being ¡Commi?ees ¡/ ¡Mary ¡Powers ¡Antoine, ¡Esq. ¡

California ¡Public ¡Protec0on ¡& ¡Physician ¡Health ¡(CPPPH) ¡Regional ¡Mee0ng ¡/ ¡January ¡7, ¡2012 ¡/ ¡Sacramento ¡

EXTERNAL EVALUATION ISSUES

Finding the right evaluator § MD’s personal physician vs. the right

• utside expert?

§ Compiling a list of external health evaluators (location, areas of expertise, services they will provide, and fees)

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EXTERNAL EVALUATION ISSUES

What kind(s) of evaluation(s)? § Addiction Medicine § Psychiatric § Psychological § Neuropsychological § Neurological § Internal medicine § Pain management § Other (e.g. for symptoms of visual malfunction or other problems)

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EXTERNAL EVALUATION ISSUES

Who Pays? § Often, the MD – but caution: make sure that you will get the product you need – might be worth having the medical staff pay – depending upon the severity of the concerns and the circumstances of the matter.

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Role ¡and ¡Func,on ¡of ¡Hospital ¡Medical ¡Staff ¡Physician ¡Well-­‑Being ¡Commi?ees ¡/ ¡Mary ¡Powers ¡Antoine, ¡Esq. ¡

California ¡Public ¡Protec0on ¡& ¡Physician ¡Health ¡(CPPPH) ¡Regional ¡Mee0ng ¡/ ¡January ¡7, ¡2012 ¡/ ¡Sacramento ¡

EXTERNAL EVALUATION ISSUES

How to get what you need from the evaluation: § Letter of understanding or agreement with evaluator § Information to be provided to evaluator

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EXTERNAL EVALUATION ISSUES

Generic purpose of evaluation: § E.g., “We are seeking this evaluation due to reliable concerns raised that this practitioner has appeared disoriented and confused and has, on

• ne or more occasions, provided inappropriate

responses to nursing questions, failed to perform daily rounds, rounded in the middle of the night, been unavailable to other members of the healthcare team for consultation as to his patients, and exhibited apparently unwarranted

• utbursts of anger.”

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EXTERNAL EVALUATION ISSUES

More specific information to come. § E.g., “Upon receipt of legally appropriate authorizations, we will provide you with additional information regarding our concerns.” Can then provide any personal health information etc. that might factor into current concerns (e.g. history of head injury, former psychiatric hospitalization, former rehab experience, etc.).

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Role ¡and ¡Func,on ¡of ¡Hospital ¡Medical ¡Staff ¡Physician ¡Well-­‑Being ¡Commi?ees ¡/ ¡Mary ¡Powers ¡Antoine, ¡Esq. ¡

California ¡Public ¡Protec0on ¡& ¡Physician ¡Health ¡(CPPPH) ¡Regional ¡Mee0ng ¡/ ¡January ¡7, ¡2012 ¡/ ¡Sacramento ¡

EXTERNAL EVALUATION ISSUES

Information needed from evaluation – what do you need to know? § Does this MD have an addiction-related impairment or harmful use issue? § Does this MD have any psychiatric or psychological impairment that could interfere with his/her ability, (as a family practitioner, surgeon,

• etc. – to the extent that specialty might be an important factor) to

diagnose and treat patients in the hospital setting? § Is this MD able to communicate and interact with peers, nurses, and

• ther members of the healthcare team effectively and appropriately?

§ E.g., can this neurosurgeon (with known monovision) perform any aspect of neurosurgery without compromising patient safety or quality of care?

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EXTERNAL EVALUATION ISSUES

Is this MD “safe to practice”? § How severe is any identified impairment and what prognosis can be expected? § As to any identified health impairments, what treatment and/or other measures would you recommend in order for this practitioner to be able to practice safely? § Is further health evaluation indicated currently? In the future?

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EXTERNAL EVALUATION ISSUES

§ Requirement for written evaluation and answering of all questions presented. § Deadline for receipt of report. § Additional options:

– Require evaluator’s agreement to refrain from agreeing to become MD’s treating professional. – Require evaluator’s agreement to refrain from being retained, at any time, as an expert witness for or on behalf of MD as any current or future dispute with the medical staff and/or hospital. – Require evaluator to agree to testify at any medical staff hearing that might involve to any extent questions regarding MD’s health issues.

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Role ¡and ¡Func,on ¡of ¡Hospital ¡Medical ¡Staff ¡Physician ¡Well-­‑Being ¡Commi?ees ¡/ ¡Mary ¡Powers ¡Antoine, ¡Esq. ¡

California ¡Public ¡Protec0on ¡& ¡Physician ¡Health ¡(CPPPH) ¡Regional ¡Mee0ng ¡/ ¡January ¡7, ¡2012 ¡/ ¡Sacramento ¡

EXTERNAL EVALUATION ISSUES

§ Confidentiality issues – need for MD to sign appropriate authorizations. ** Make receipt of same in a timely fashion a condition of payment (to the evaluator) and/or a condition of MD compliance with the conditions mandated for continued work with the PWBC (as

• pposed to referral to the MEC).

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PWBC FUNCTIONS AFTER RECEIPT OF EVALUATION

§ Follow-up – recommended self-improvement and/or treatment? § MD – buy-in and commitment § Letter of expectations for working with the PWBC § Provisions might include, among others:

– MD’s acknowledgement of problems and desire to work with PWBC. – Expectations for treatment (including any expected counseling or therapy). – Agreement for alcohol and drug testing (as appropriate). – Agreement to refrain from use of addictive substances –e.g. drug/alcohol. – Expectations of attendance at support group meetings. – Agreement to undergo further evaluation or continue treatment in the manner determined reasonable and necessary by the PWBC. – Agreement to execute further authorizations for full and free 2-way sharing of all health information.

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PWBC FUNCTIONS AFTER RECEIPT OF EVALUATION

PWBC must not drop the ball § Important to follow-up diligently. § Make sure to communicate with any treating providers to ensure that the individual is compliant and doing well. § Important to meet with the MD on a periodic basis to “check in”. § Can adjust requirements as appropriate. § Must report on all PWBC activities to MEC and Board at least 1x per quarter (TJC Standards).

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Role ¡and ¡Func,on ¡of ¡Hospital ¡Medical ¡Staff ¡Physician ¡Well-­‑Being ¡Commi?ees ¡/ ¡Mary ¡Powers ¡Antoine, ¡Esq. ¡

California ¡Public ¡Protec0on ¡& ¡Physician ¡Health ¡(CPPPH) ¡Regional ¡Mee0ng ¡/ ¡January ¡7, ¡2012 ¡/ ¡Sacramento ¡

PWBC FUNCTIONS AFTER RECEIPT OF EVALUATION

§ Remember patient safety is primary! *** Report to chief or MEC if MD is non- compliant and/or if corrective action is needed, for any reason, to ensure patient safety. ***

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Questions?

Mary Powers Antoine Nossaman LLP 915 L Street, Suite 1000 Sacramento, CA 95814 (916) 442-8888 mantoine@nossaman.com

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