The Gray Zones: Ambiguities in What do all these stories Hospital - - PDF document

The Gray Zones: Ambiguities in Hospital and Physician Relationships What do all these stories have in common? Neither the problem nor the solution is clear. Can you wait? Must you act now? Goal: Give each physician best chance to be successful.

Steps to determine problem, solution: Triage Collegial Intervention Health Conduct Quality Two or more?

Bylaws/Credentials Policy Authorizes: a) To guide those who intervene b) To assure it’s “peer review”

What?

a) If health issue → Health Policy b) If behavior → Code of Conduct c) If quality → PPE d) If serious/urgent → Bylaws/ Credentials Policy

How?

a) Do homework; know issues b) Interview those who have reported/observed c) Meet with physician, if necessary

Collegial Approach First

• Meet with the physician
• Have a script
• Don’t let physician change

subject/ control meeting

• Counsel?

Don’t let lawyers knock you off course.

Physician Health Issues

An impaired physician is unable to practice medicine because of physical or mental illness. An impaired physician is unable to practice medicine because of physical or mental illness.

AMA AMA Impairment Can Be Caused By: Impairment Can Be Caused By:

• Age
• Physical limitation
• Disease
• Substance abuse
• Age
• Physical limitation
• Disease
• Substance abuse

“Physicians who have been in practice longer may be at risk for providing lower-quality care. Therefore, this subgroup of physicians may need quality improvement interventions.” — Annals of Internal Medicine, 2005; 142:260-273.

Possible Causes Stemming from the Effects of Aging

• Deterioration of cognitive skills or

physical dexterity

• Memory loss
• Decreased reaction time
• Increased difficulty in staying focused
• n task in highly stressful situations
• Hearing loss and visual impairment

“For surgeons older than 60 years … significant differences in mortality rates were largely restricted to those with low procedure volumes... Among high- volume surgeons, however, there were no significant differences in mortality rates ….

— Annals of Surgery, 2006; 244(3):353-622

Age Discrimination in Employment Act (ADEA)

ADEA

• Federal civil rights statute designed

to protect individuals 40 years of age and older

• Only applicable in an employment

setting

• (Unless you are in CT, NY or VT)

ADEA

• Makes it unlawful “to discriminate

against any individual with respect to his compensation, terms, conditions, or privileges of employment because of such individual’s age.”

Exception: “Bona fide occupational qualification” or BFOQ

• Age limit is “reasonably necessary” for

the operation of the business, and, either:

• “all or substantially all” of the disqualified

members are unable to perform duties, or

• the unfitness of at least some members of

the class, plus the infeasibility of making individual determinations

Narrow Exception

• Age has successfully been established as

a BFOQ primarily in occupations where public safety is at stake:

• Airline pilots
• Bus drivers
• Law enforcement officers
• Firefighters

Physicians or Other Practitioners?

• A hospital could use age in credentialing

employed physicians if it could show that:

• the use of age in credentialing actually

effectuated its goal (e.g., public safety), and

• that there was no acceptable alternative

which would equally advance the goal with less discriminatory impact

Solutions to Address Concerns About the Older Physician

Establish a Rule

• Increased uniformity and

consistency

• Ability to depersonalize an
• therwise very personal issue
• Greater ability to protect patients

Minimal Level of Risk

• Reduce the Focus on Age
• Substantially improve existing peer

review processes

• Require comprehensive examinations

for all physicians at initial appointment and reappointment

Higher Level of Risk

• FPPE, including concurrent review
• f a stated number of cases
• Annual reappointment at a certain

age

• Additional CME for older

physicians

• Comprehensive physical and

psychological evaluations

Also Consider

• Informal discussions
• Special staff category

Follow your Physician Health Policy First and Last Question:

What is in the best interest

• f the patients?

Is it different if the physician is an employee? Leadership Drives Behavior Leadership Drives Behavior Who is the Disruptive Practitioner? Who is the Disruptive Practitioner? Identification Identification

• Always Right
• Others — Especially Those in

Authority Are Fools, or Worse

• Writing Incoherent
• Charismatic
• Always Right
• Others — Especially Those in

Authority Are Fools, or Worse

• Writing Incoherent
• Charismatic

Identification (cont.) Identification (cont.)

• Doesn’t understand
• rganization or authority
• No rules apply to him or her
• Attacks immediately if

criticized or crossed

• Actively enjoys suing and

threatening suit

• Doesn’t understand
• rganization or authority
• No rules apply to him or her
• Attacks immediately if

criticized or crossed

• Actively enjoys suing and

threatening suit

Board Policies Board Policies

• Report
• Interview
• Action
• Follow-Up
• Report
• Interview
• Action
• Follow-Up

Interviews Interviews

• Those who observed
• Assure confidentiality
• Listen
• Prepare summary
• Those who observed
• Assure confidentiality
• Listen
• Prepare summary

Collegial Approach First Collegial Approach First Put it in bylaws. Put it in bylaws. Documentation is Critical Documentation is Critical

111

Define Precisely Required Behavior Define Precisely Required Behavior “In The Box”

Content Content

• Bylaws/Policy requirement
• Long history, previous warnings
• List of incidents
• Detailed do’s and don’ts
• Or else… specific consequences
• Bylaws/Policy requirement
• Long history, previous warnings
• List of incidents
• Detailed do’s and don’ts
• Or else… specific consequences

“In The Box” Letter

Multiple Purposes Multiple Purposes

“In The Box” Letter

• Save the doctor
• Alert counsel
• Head off injunction
• Alert successor
• Solidify legal position
• Save the doctor
• Alert counsel
• Head off injunction
• Alert successor
• Solidify legal position

Progressive Discipline Progressive Discipline

Discipline (medical staff bylaws/credentials policy) Specific requirement

• r else

Discuss with physician Clarify expectations

Progressive Steps

Take Home Tips for When Your Are Working in the “Gray Zone” Take Home Tips for When Your Are Working in the “Gray Zone” Training/Education

• Identifying/recognizing

problems early

• Practice in intervention/“script”

preparation

• Awareness of evasive tactics

Your Tools:

• Health Policy
• Code of Conduct
• Triage/Collegial Intervention (in

Credentials Policy)

• PPEP
• Assurance of Legal Protection and

Organization Support

• Leaders Who Are Willing to Act