Sorry Works – A Personal Example from Buckeye Surgeon

 Buckeye Surgeon speaks personally about the benefits of being able to say ‘I’m sorry.’ “As soon as the word “sorry” left my lips, I could almost detect a physical change sweeping over her. Her shoulders relaxed. She smiled warmly. The lines in her face smoothed out. She had heard what she needed to hear. It’s OK, she said.”

It’s been my experience that most physicians welcome the opportunity to speak openly to their patients who are disappointed or upset.  It’s the fear of that honesty being used against them later in court that holds them back.  That, and over-zealous attorneys and risk managers.

Buckeye Surgeon also quotes a recent New York Times article which reported on the effect of a new disclosure policy at one large mid-western hospital: “Rather than trying to conceal the circumstances of medical errors or poor outcomes, hospitals and doctors at the University of Illinois-Chicago are disclosing all the details and even apologizing to patients. As a result, malpractice claims have dropped by half since the policy was instituted.”

Sometimes an “I’m sorry” is all the patient really wants.

Imposter Physician Roams Children’s Hospital in Florida

JACKSONVILLE, Fla. — Police are asking for the public’s help identifying and locating a phony physician seen walking the halls of a Jacksonville children’s hospital in a medical coat, badge and stethoscope.

The imposter was caught on surveillance video photo at Wolfson Children’s Hospital, but police said they have no idea who he is or why he was in the hospital, WJXT reported.

See the video on WKMG, Channel 6, Orlando, FL

Priorities

A question I frequently ask myself is “What is most important, and am I managing my life in such a way that the most important goals get top priority?”   It seems like such a simple matter, keeping one’s priorities straight, but for most of us I suspect it’s a constant struggle.

For example, I currently hold a fascinating and challenging job.  I learn something new nearly every day, and stretch continually to balance the constantly shifting landscape of the role.  Long days are more the norm than the exception, high stress more common than not.  Add to that a nearly two hour daily commute, and it’s easy to see where I devote the majority of my time and energy. 

So I’ve been thinking…  What is most important and am I managing my life in such a way that the most important goals get top priority?

It’s time for some serious reflection on that question.

Hospital Acquired Conditions Reduce Medicare Reimbursement on October 1, 2008

 Are you confused about the difference between the National Quality Forum’s twenty-eight “never” events and the eight (or more) events for which CMS will begin limiting reimbursement on October 1, 2008?  I was. 

Here’s the scoop:

CMS Hospital Acquired Condition (HAC) initiative, begins October 1, 2008

Medicare will no longer pay the hospital at a higher rate for the original eight conditions or any conditions added to the list in the final rule, if they were acquired during the hospital stay.

These events, if hospital acquired, will qualify for decreased Medicare reimbursement as of October 1, 2008:

  1. Object inadvertently left in after surgery
  2. Air embolism
  3. Blood incompatibility
  4. Catheter associated urinary tract infection
  5. Pressure ulcer (decubitus ulcer)
  6. Vascular catheter associated infection
  7. Surgical site infection- Mediastinitis (infection in the chest) after coronary artery bypass graft surgery
  8. Certain types of falls and trauma

CMS is proposing to expand the list of conditions that need to be reported if present when a patient is first admitted and is seeking public comment on whether they should be added to the list in the final rule to be announced later in 2008: 

  1. Surgical site infections following certain elective procedures
  2. Legionnaires’ disease (a type of pneumonia caused by a specific bacterium)
  3. Extreme blood sugar derangement
  4. Iatrogenic pneumothorax (collapse of the lung)
  5. Delirium
  6. Ventilator-associated pneumonia
  7. Deep vein thrombosis/Pulmonary Embolism (formation/movement of a blood clot)
  8. Staphylococcus aureus septicemia (bloodstream infection)
  9. Clostridium difficile associated disease (a bacterium that causes severe diarrhea and more serious intestinal conditions such as colitis)

CMS Proposes to Expand Quality Program for Hospital Inpatient Services in 2009

And here are the 28 “Never” Events from the National Quality Forum, which contain some overlap with the CMS list, but are not the same. 

  1. Artificial insemination with the wrong donor sperm or donor egg
  2. Unintended retention of a foreign object in a patient after surgery or other procedure
  3. Patient death or serious disability associated with patient elopement (disappearance)
  4. Patient death or serious disability associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation or wrong route of administration)
  5. Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO/HLA-incompatible blood or blood products
  6. Patient death or serious disability associated with an electric shock or elective cardioversion while being cared for in a healthcare facility
  7. Patient death or serious disability associated with a fall while being cared for in a healthcare facility
  8. Surgery performed on the wrong body part
  9. Surgery performed on the wrong patient
  10. Wrong surgical procedure performed on a patient
  11. Intraoperative or immediately post-operative death in an ASA Class I patient
  12. Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the healthcare facility
  13. Patient death or serious disability associated with the use or function of a device in patient care, in which the device is used or functions other than as intended
  14. Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility
  15. Infant discharged to the wrong person
  16. Patient suicide, or attempted suicide resulting in serious disability, while being cared for in a healthcare facility
  17. Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a health care facility
  18. Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a healthcare facility
  19. Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in neonates
  20. Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility
  21. Patient death or serious disability due to spinal manipulative therapy
  22. Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances
  23. Patient death or serious disability associated with a burn incurred from any source while being cared for in a healthcare facility
  24. Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility
  25. Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider
  26. Abduction of a patient of any age
  27. Sexual assault on a patient within or on the grounds of the healthcare facility
  28. Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of the healthcare facility

Kadlec Decision Reversed by Appeals Court

Information excerpted from an article by Michael Callahan, Katten Muchin Rosenman LLP, Chicago, IL
(Emphasis mine.)

The 5th Circuit Court of Appeals on May 8, 2008, (No. 06030745) reversed the District Court’s opinion which included a holding that Lakeview Medical Center and Lakeview Anesthesia Associates had a duty to disclose to Kadlec Medical Center that Dr. Berry, a former partner with LAA, had a drug problem after Kadlec made inquiry after Berry applied to Kadlec for medical staff membership. This finding and multi-million dollar jury verdict against Lakeview and LAA caused something of an uproar throughout the industry because no court had previously held that such a duty existed. The result was also unsettling for many hospitals because most have been faced with the ethical and legal question of how to respond to third party inquiries about current and former medical staff physicians who have had quality of care or impairment problems.

The holding can be summarized (in part) as follows:

1. A party has an affirmative duty to avoid affirmative misrepresentations in referral letters to another hospital. Here, Lakeview provided a neutral letter regarding Berry which contained only factual, neutral information and did not attempt to recommend Berry for appointment. LAA, on the other hand, stated that Berry was "excellent" and a very good clinician even though they had previously fired him two months earlier because of his addiction to Demerol and his treat to patients.

2. Once a party does disclose information about a physician which creates a "misapprehension" about qualifications or certainly misleads, it has an obligation to clarify the information provided. Here, given LAA’s representations that Berry was excellent and "will be an asset to [his future employer's] anesthesia service, they had a "duty to cure these misleading statements by disclosing to Kadlec that Dr. Berry had been fired for on-the-job drug use."

Lessons learned? The basic message here is that a hospital is better off saying nothing about an impaired or unqualified physician or giving only neutral information as was the case with Lakeview. If a hospital chooses to respond to the questionnaire or other inquiry, it must not mislead and must be truthful. This raises important ethical and legal policy questions because all hospitals rely on each other in attempting to determine whether new applicants or existing members are truly qualified and do not pose a threat to patients. If information is purposefully withheld because there may not be a particular duty, problems like Kadlec will continue to occur. The positive impact that the district court opinion had is that it made hospitals more mindful of needing to make more detailed and truthful disclosures keeping in mind that they must be based on hard evidence and documentation and not rumor or innuendo. Many hospitals also have begun to require physicians to sign absolute, versus qualified, waivers and releases as part of the appointment/reappointment process in order to avoid retaliatory lawsuits in response to a truthful disclosure of an impairment or questionable competency which led to non-appointment/reappointment.

Michael R. Callahan
Health Care Department
Katten Muchin Rosenman LLP

Previous MSSPNexus Blog Posts on the Kadlec Case:
Jury Finds In Favor of Kadlec Medical Center – June 2006
Weakness in Medical Vetting – Letters to the Editor – October, 2005
Major New Case Will Impact Credentialing – June 2005

Hospital specialists assume national and state leadership roles

From The Indy Star – Submitted by Joe Steuteville

Two St. Francis Hospital & Health Centers staff members have been elected to lead a national and state chapter of medical service professional organizations.

Janet O’Hair recently was elected president of (the) National Association Medical Staff Services and Belinda Sherlock is the president of the Indiana Association of Medical Staff Services. Their elections mark the first time two professionals from the same health-care facility have simultaneously led the organizations.

Read the rest of the Indy Star article

More Gems from the Estes Park Institute Healthcare Conference

 Here are a few more tidbits from my Estes Park Institute conference notes:

Collegial Intervention:

  • The suicide rate for male physicians is 1.5 X higher than the general population.
  • The suicide rate for female physicians is 2 X higher than the general population.
  • Collegial intervention programs can help.  Develop policies that encourage early intervention by medical staff leaders, and procedures that legally protect their efforts.

Conflict of Interest:

  • When a member of a voting body has a conflict of interest with regard to a matter under consideration, not only should the individual refrain from voting on the matter, they should leave the room (or be asked by the Chair to leave if necessary) prior to any discussion about the issue.  Minutes should reflect that the individual with the conflict left prior to any discussion.

Environment of Care:

  • The need for medication prescribed to modify mood and behavior was significantly reduced (40% or more) when a nursing home was redesigned to be esthetically pleasing and comfortable, suggesting the enormous impact our environment has on wellness and healing.

Leadership:

  • The higher an individual’s rank in an organization, the less honest feedback they can expect to receive, both positive and negative.  Leaders must find ways to seek and reflect on feedback.

Legislation:

  • The Patient Safety and Quality Improvement Act was passed in 2005.  The open comment period for rules ended 4/12/08, and final rules are expected to be published by the end of 2008.

Risk Management:

  • Presenters encouraged timely group debriefing after a near-miss event.  If something adverse almost happened, what prevented it?  If it was prevented simply by chance, not by fail-safe measures, prompt redesign can be facilitated by the group.
  • When recommending process changes, defer to knowledge and experience over rank.

Future Directions:

  • Web-based healthcare is literally, just around the corner.  One presenter forecast that within five years web-based subscription healthcare, paid for in nominal monthly fees, will serve as a resource for basic health information and physician referral.  Patients will use these services as a way to manage and coordinate their care. The repeatedly asked question was, “Will patients receive this information and referral service from your organization or from someone else’s?”

DNV Healthcare Seeks Deemed Status from CMS

In 2006 this blog commented on the application for CMS deemed status by Ohio-based TUVHS. We didn’t hear much about the application after that, but now we know that TUVHS was bought by DNV (Det Norske Veritas), an international certification body, and an application for deemed status has now been submitted to CMS by DNV Healthcare.

From the DNV Web Site:

DNV continues its expansion and focus on healthcare through the formation of DNV Healthcare Inc. and by acquiring TUVHS, the US based organization providing hospital accreditation to the NIAHOSM program. 

This latest development fully supports DNV’s initiative to gain deeming status from the Centers for Medicare and Medicaid (CMS) in the US and to provide US hospitals with an alternative hospital accreditation option.

If approved, DNV stands to become the first new option for hospital accreditation in over 40  30 years. Information about DNV’s application and the need for alternative accreditation is available at www.newaccreditation.com.  Deadline for comments to CMS about the application is May 27, 2008.

The Role of Senior Leadership in Credentialing, Clinical Privileging, and Peer Review

Effective, thorough practitioner credentialing, clinical privileging, and professional peer review are vital components of safe patient care.  The importance of these complex functions is being reinforced this week at the Estes Park Healthcare Leadership conference. 

This conference attracts senior executive, board, and medical staff leaders from hospitals around the country.  Program topics include strategic planning, financing, legislation, technology, patient experience, medical staff relations, and yes, credentialing, privileging, and peer review

Sessions led by Charlotte Jefferies and Linda Haddad, Senior Partners in the law firm of Horty Springer, provided these items of note:

Credentialing/Privileging

  • Make sure any privilege criteria developed is specialty specific, not department specific.  Department-specific criteria may lead to anti-trust allegations.
  • Encourage recruiters to work closely with the medical staff office.  Recruiting a physician who does not meet the hospital’s application criteria can create difficult and expensive problems for an organization.
  • Associate any requests for temporary privileges with a well-documented patient care need.
  • Share all pertinent information discovered during the credentialing/recredentialing process with the ultimate decision makers, i.e., the Governing Board. 

Peer Review

  • Develop objective measures for actions and outcomes controlled by physicians.
  • Share credible data routinely, not just when a problem arises.
  • Remember that an organization cannot manage what it does not measure.
  • Encourage early intervention by by medical staff leaders.
  • Review concerns and findings with the affected physician, provide ongoing feedback.
  • Establish the source of authority and responsibility in peer review matters by advising physician leaders to respond on hospital, not personal, letterhead.

And for both, developing and following well-formulated policies can save the day.