Medical Staff

A Summer Slow-down in Healthcare - Not this Year!

Medical Staff Affairs Monthly, August 29, 2007

Dear Colleagues,

Summer is often a time when the pace of life slows down-especially if you are trying to travel anywhere by airplane. In healthcare, however, there has been no slowdown in the flow of news and events as growing public scrutiny continues to hone in on our dysfunctional delivery system.

For those tempted to take an occasional shortcut in our ever more complex credentialing processes, the recent news from Puerto Rico should be sobering. This month, federal agents arrested dozens of doctors accused of obtaining medical licenses through fraud and bribery. A federal grand jury indicted 88 practicing physicians, many of whom had failed the licensing exam multiple times or had presented fake medical degrees. I should note that at least five states recognize Puerto Rican medical licenses (Arizona, Florida, New York, Texas, and Virginia). Is Puerto Rico just an exceptional outlier? Possibly, but there are hundreds of negligent credentialing lawsuits being litigated around the country, and many of them revolve around physicians who have falsified their credentials to get on a hospital medical staff. For those who missed it last December, a study by Ken Kizer and Beatrice Yorker in the Journal of Forensic Sciences documented that at least 90 health care providers have been prosecuted for the serial murder of patients in recent decades. They note that high-tech healthcare facilities are the most common environments, and according to Beatrice Yorker, "the number of suspected victims of serial healthcare killers is shocking at over 2,000 worldwide."  Only good credentialing and risk management practices coupled with honest sharing of information will serve as an effective antidote. I want to emphasize this last point, because I am still shocked by how frequently I find healthcare practitioners and institutions resistant to sharing factual information they possess about the poor performance of applicants to other medical staffs. Just this week I was working with the attorneys for a hospital that had received positive references on an applicant from two medical training programs. Document discovery in subsequent litigation clearly revealed that the applicant has been an atrocious and problematic resident whose cognitive, technical, and behavioral skills were grossly inadequate. It is sad, but no wonder, that some credentials committees now request that applicants provide the actual service rotation evaluations from their training program(s) rather than simply relying on a program director reference.

When it comes to disseminating information important to effective credentialing, one resource that has proven its merit is the Disciplinary Alert Service of the Federation of State Medical Boards (FSMB). Many of you may not be aware that this FSMB service alerts medical boards by e-mail within 24-48 hours when one of their licensees is disciplined in another state. This is an extremely valuable service, particularly in our highly mobile society where physicians may practice in more than one locale or take advantage of the growth in telemedicine practice to practice in multiple states. In this light, it is not surprising that 88% of physicians disciplined in 2006 had two or more medical licenses. As we entered the summer months, the National Practitioner Data Bank began its own related initiative, the Proactive Disclosure Service. Under the program, hospitals, health plans, and other subscribers are notified within one business day when the data bank gets a report on a physician or other practitioner. Reports include board discipline, malpractice payments, and professional society actions.

A somewhat related piece of summer news is the decision in July by the California Board of Medicine to end its physician diversion program by June 30, 2008.  Why would they take such an action? Because the board concluded that running this confidential program that supports and monitors physicians who have drug, alcohol, or mental problems was not achieving its purpose of protecting the public. Repeated audits uncovered frequent lapses in the oversight of the physicians referred to it. Many hospitals/medical staffs rely entirely on similar state or medical society-sponsored programs to monitor practitioners once they have been identified as "impaired." Hospital credentials committees may want to make some hard inquiries to find out just how effective the agencies to which they make referrals are. Indeed, in the future, we may see a trend toward greater comanagement of impaired physicians by medical staffs and the third parties to which this task has traditionally been outsourced.

On an entirely different front, The Joint Commission (formerly JCAHO) appears to have hoped the distractions of summer would divert attention from its revisions to medical staff standard 1.20.  Ignoring the mountains of criticism previously directed at its improvident efforts to micromanage medical staff bylaws, the regulator has issued a standard that will require rewrites of most bylaw documents. Newly promulgated M.S. 1.20 requires compliance by July 2009 and given the lead time many staffs need to amend their governing documents, now is the time to analyze your bylaws and begin to identify the necessary changes. The greatest rewrites will need to be undertaken by those forward-thinking organizations that have created user-friendly policies and procedures outside the bylaws to facilitate effective medical staff functioning. Meanwhile, some of the country's most recognized health lawyers recently articulated their concerns over the new standard in a joint letter to The Joint Commission. They plan wide circulation of the document in an effort to create a tidal wave of backlash from the community of healthcare organizations and providers who will be affected. (If you would like an electronic copy of this letter, please send an e-mail to toddsagin@comcast.net.)

Don't hold your breath waiting for further change. Start planning those bylaws modifications now. Some of you have found this summer that The Joint Commission doesn't take a vacation and those unannounced survey visits can pounce even in the heat of August. A consequence of unannounced surveys is that they make it harder for surveyors to meet with physicians who can't get away from busy schedules without at least some notice. One unintended result is that surveyors are likely to meet more with employed and hospital-based physicians rather than those in private practice. Some surveyors have been expressing concern that the unannounced visit process is causing a loss of physician viewpoints from the site visit. If this is so, it certainly runs contrary to The Joint Commission's goal of having its scrutiny focus more on the real bottom line of clinical care at the hospital than on the existence of structures and documents. We'll all have to pay attention to this worry if it turns out to have real substance.

Meanwhile, the days are getting shorter week by week with ever more to cram into them. Make sure you get some rest and relaxation squeezed in before Labor Day. Fall is sure to pick up the pace in our turbulent world of healthcare delivery, and new challenges will continue to flow-announced or unannounced.

Best regards,
Todd Sagin, MD, JD

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