Hiding a Problem Doctor in Plain Sight

Safe[2] How much important information is locked away from those who need it in your organization?  And how much added expense and potential patient harm does that create, at a time when national efforts are focused on eliminating both?

Because of legitimate concerns related to privacy and confidentiality, hospital leadership allows, and even encourages, protecting sensitive information.  However, that action often creates the unintended consequence of hiding valuable data behind locked doors. 

Let’s consider the case of Dr. Z, a General Surgeon on the staff of Mythical Hospital.

The Quality Management Department has identified a trend related to Dr. Z’s practice, a pattern of unexpected post-operative complications causing an increased length of stay. Depending on hospital policies, that trend may be reported to a Department Chair, a Quality Committee, etc.  The information may also be placed in a file to be reviewed every two years at the time of the physician’s reappointment to the medical staff.

Infection Control has also detected a trend in Dr. Z’s patients.  Part of the reason they have a longer than average length of stay is that they have a higher than average post-operative infection rate.  Depending on hospital policies, that trend may be reported to the Department Chair, an Infection Control Committee, etc.

The Patient Advocate’s Office, which handles patient complaints, has received several regarding the way Dr. Z talks to patients and families. The Advocates have worked hard to develop good service-recovery techniques and have done their best to re-engage Dr. Z’s disgruntled patients.  They have also reported the trend in their monthly reports to hospital administration, and they know that the CEO has spoken personally to Dr. Z regarding improving his communication skills.   

Speaking of complaints, Nursing Leadership has received a few from the surgical nursing staff regarding Dr. Z’s demeaning attitude toward them in the OR.  The Perioperative Surgical Director has spoken to Dr. Z about the matter, and believes that there has been some improvement.

The Medical Records Review Committee has sent two letters to Dr. Z in the past year regarding his documentation practices.  While Dr. Z does complete his records in a timely fashion, the documentation is often sloppy, contains unapproved abbreviations, and even some inappropriate remarks about other members of the staff.  The issue remains on their agenda for further review.

Enter Risk Management, which is called in to investigate a post-op complication resulting in serious harm to one of Dr. Z’s patients.  During their investigation Risk discovers that the surgery took far longer than expected, there was injury to surrounding tissue, possibly due to poor surgical technique, and that the family is very unhappy and intends to file a lawsuit against both the physician and the hospital. The Risk Management files are protected by attorney-client privilege, and are reviewed by the hospital’s legal counsel. 

Surgeon[1] Two years have passed and it’s time for Dr. Z’s appointment and privileges to be reviewed.  The Medical Staff Office gathers information to assure that Dr. Z’s credentials are up-to-date and that he remains in good standing with the State licensing board, etc.  A query is made to the National Practitioner Data Bank, which reveals no new settlements or disciplinary actions over the past two years.  The physician’s quality file is pulled and given to the Department Chair to review.  The Department Chair again sees the data regarding Dr. Z’s post-op complication trend and extended length of stay.  He notes the issue in his comments, and adds that he has personally spoken with Dr. Z about the matter.  However, he doesn’t feel it warrants a recommendation for non-reappointment to the staff, and so recommends that Dr. Z’s appointment and privileges continue as requested. 

Everyone at Mythical Hospital is working hard to do the right thing to protect patients and the organization.  They also don’t want to unnecessarily harm the reputation of a staff physician.  But none of them have the whole picture.  So how can the problem of the missing pieces be solved? 

With appropriate technology support, the information can then be compiled and combined with Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) data and (frequently) reported through the Department Chair, the Credentials Committee, the Medical Executive Committee and finally in summary to the Board, which has the ultimate responsibility for appointing and reappointing members of the medical staff. 

There must be a central repository for all data related to a physician’s practice.  The logical repository is the Medical Staff Services Department.

Because Dr. Z practices in nearly every hospital.

Medical Staff Services Awareness Week


In 1992, the United States Congress, by House Joint Resolution 399, and George Bush, President of the United States, issued a proclamation designating the first week of November as “National Medical Staff Services Awareness Week.”

President Bush’s proclamation read, in part:


National Medical Staff Services Awareness Week – 1992

By the President of the United States of America
A Proclamation

The professionals who direct or manage medical staff services, from hospital communications to the accreditation of physicians and nurses, play an important role in our Nation’s health care system. In addition to serving in hospitals and other primary care facilities, these professionals also work in health maintenance organizations, medical societies, State licensing boards, and consulting firms. By administering rules and regulations, by ensuring accreditation compliance, and by providing a wide range of support to physicians, medical staff coordinators help to promote the quality and efficiency of health care.

Today many medical staff services professionals are striving to promote efficiency and professionalism in health care by working through the legal financial, and regulatory requirements that have increased along with new challenges and opportunities in the health care industry. This week, we acknowledge the value of such efforts.



In the years since this proclamation was issued, the work of Medical Staff Services Professionals has increased in complexity and significance. Our commitment to excellence, leadership and professional growth is ongoing.

The over 4000 members of the National Association Medical Staff Services,
as well as our colleagues in healthcare administration, law, and quality,
are pleased to Celebrate

National Medical Staff Services Awareness Week
November 7 – 13, 2010


CSI St. Elsewhere? Hospital Infection Control

They lurk where you least suspect, preying on the weak and ill. Their attacks can be devastating, even deadly, and like many enemies they gain strength in numbers.  

The soldiers defending the front lines are armed, not with guns and grenades, but with chlorhexidine glutonate and similar compounds. They engage the enemy where it hides; often just inches from the hand of a fevered toddler or a beloved grandmother. These front-line defenders, as well as others who battle this often unseen enemy, protect us and those we love. Their dedication and training can mean the difference between life and death. 

Who are the enemy kingpins?  MRSA and Clostridium difficile are among the most-widely feared, but there are many others.  

Enter, Philip Carling, an epidemiologist at Caritas Carney Hospital in Dorchester, Mass.  According to an article in today's Wall Street Journal, Ten Steps to Preventing Infections in Hospitals, Dr. Carling went undercover to spray a solution containing fluorescent markers around patient rooms in dozens of hospitals. After cleaning crews left he went over each room with a black light, causing any spot the crews missed to glow fluorescent.

"Toilets sparkled. But bathroom light switches and door knobs did not. Telephones, nurse-call buttons and grab rails were all routinely contaminated."

There is work to be done.

But what about the Officers who direct the battle?   

Stephen Streed, director of epidemiology at Lee Memorial Health System in Florida, says "Don't underestimate the motivational power of data."  Dr. Streed tracks infection rate by surgeon—and then posts a list annually in his four hospitals. The list is coded to protect anonymity, but each surgeon knows his or her ranking.

"They growl a bit, but then they find their way to my office and ask, 'Why am I in the bottom third of this list?' " Dr. Streed says. Those at the bottom soon improve. "It's a very, very powerful tool."

Handwashing The WSJ article also reminds caregivers that mother knows best.  "The key to preventing infection is simple: Listen to your mother. "Wash your hands and clean your room."

Infection control is not just the role of a few doctors and nurses, it is a vital component of everyone's job.

Read the full text of Ten Steps to Preventing Infections in Hospitals.

Related Information:  Not On My Watch Prevention Campaign

Are Physician Suspensions for Incomplete Medical Records Reportable to the NPDB?

Files02 Is a physician suspension for incomplete medical records that lasts 31 days or longer reportable to the National Practitioner data bank? 


Most hospitals consider the action administrative and, therefore, do not file a report with the NPDB.  However, Katten Muchin and Rosenman Law recently posted a response they received from Daryl Gray, Director of the Division of Practitioner Databanks regarding reportable matters.  That response stated in part "Delays in completing medical records are not uncommon and not all suspensions should be reportable, repeated offenses and/or lengthy time lapses during which the records are not completed can certainly lead to actual or potential adverse affects on patient health, and therefore a report may be required."

There's more.

Katten Law posed a question to the NPDB regarding a hypothetical scenario of a physician deliberately withholding information, or submitting misstatements on an application for hospital membership and privileges. Their basic question was, is this an action reportable to the NPDB? 


In essence, the response stated that "in the “hypothetical” presented, “there was a purposeful failure to disclose information to the hospital. The NPDB views intentional misrepresentations to the hospital body making determinations about clinical competence of providers almost per se as having the potential to adversely affect the health or welfare of a patient." 

An updated Data Bank Guide Book is in the works.

Read the full text of Katten Law's NPDB response summary here.

Via the NAMSS Blog

Joint Commission Perspectives – October, 2009

The Joint Commission has made the October, 2009 Special Issue of Perspectives available online.  The issue contains a summary of changes coming in the 2010 JC standards and national patient safety goals, which bring the Joint Commission standards into better alignment with CMS Conditions of Participation. 

The October issue of Perspectives also includes comments regarding the Medical Staff Chapter's changes in telemedicine standards (see pages 18-19), which become effective on July 15th.   

On a side note, John Herringer, Associate Director, Department of Standards Interpretation for The Joint Commission, spoke at this year's annual NAMSS conference. During his presentation he mentioned that even though the standard for Focused Professional Practice Evaluation (FPPE), MS.08.01.01, became effective January 1, 2008, surveyors are still finding organizations without an established process for focused review.  Mr. Herringer reminded the audience that this standard is not going away and processes and policies must be developed in order to meet it, as well as the standard for Ongoing Professional Practice Evaluation (OPPE).

NAMSS Conference Photos 2009

I was sitting at the gate in Chicago last week waiting for my flight to Reno to attend the 33rd Annual NAMSS Conference when someone across the way said “Hi; aren’t you Rita Schwab?”  I looked up and there was Emily Berry, the editor of the HcPro Credentialing Resource Center Blog.  Emily and I have talked a number of times, but we’d never met.  It’s always fun to meet a fellow blogger in person!  (By the way, Emily has posted some of her NAMSS photos here.) 

The view from my window at the hotel was wonderful:
Speaking of bloggers, I also snapped a picture of Carole La Pine, the NAMSS Blog Content Expert:

 The Mayor of Reno Nevada declared October 3 -7 as “Days to Honor the National Association Medical Staff Services” and the proclamation was displayed in the registration area.
Melinda Whitney of Quality Management Consulting in Columbus, Ohio played the disruptive Dr. Glinda Witch, in Catherine Ballard’s presentation “How We Get To A Fair Hearing.”
I was honored to receive the Joan Covell Carpenter Award for the article The Ugly Truth About Credentialing and Privileging, which was published in the May/June 2009 issue of Synergy.
As always, there were many great networking opportunities, and I passed my Simple Data Solutions business card off on anyone who would take it!  Next year’s NAMSS Conference will be held in Orlando, FL October 2-6, 2010.

NAMSS – Not Just For Women Anymore

The title of this post is a quote from an Alaska delegate to the National Association Medical Staff Services Conference in Reno, NV.  We chatted for a few minutes last night and she commented that she was glad to see more men working in the profession and attending the conferences, and then said “NAMSS – Not just for women anymore.”

It was too true, and too clever not to post here. Thanks Rose!



Looking For A Few Good Hospital Blogs?

50_top_hospital_blogs Nurseblogger recently complied their list of The Top 50 Hospital Blogs; which happily, included Supporting Safer Healthcare.

The categories include:

  • Hospital Blogs
  • Children’s Hospital Blogs
  • Specialized Hospital Blogs
  • Working at Hospital Blogs
  • Hospital Association Blogs
  • Hospital CEO Blogs
  • Blogs About and For Hospitals
  • Blogs For Patients

Stop over and peruse Nurseblogger’s list of the best hospital blogs; you may find a few new sites to add to your favorites.