New Medical Director for Joint Commission

Joint Commission has announced the appointment of a new Medical Director, an Internist from the University of Pennsylvania Health System, Ana Pujols-McKee, M.D.

“In this role, Dr. McKee will represent The Joint Commission enterprise as she focuses on and develops policies and strategies for promoting patient safety and quality improvement in health care. Her specific responsibilities will include providing support to The Joint Commission’s Patient Safety Advisory Group; overseeing work related to the development of the Sentinel Event Policy, National Patient Safety Goals and Sentinel Event Alerts; supervising the Sentinel Event Database; and overseeing the functions of the Standards Interpretation Group and the Office of Quality Monitoring. Dr. McKee also will provide clinical guidance and support to the Joint Commission Center for Transforming Healthcare, Joint Commission Resources and Joint Commission International.”

Patient Care Gone Right

I spent some time last week with a relative who underwent surgery at Akron General Medical Center.  From the time we arrived at the pre-surgical waiting area until she was discharged three days later, it was a case of patient care gone right.

So often we in the medical blogging community write about all the things that can and do go wrong in today’s complex healthcare environment, it’s nice to remember that quite often, it all goes rather well.

The patient asked specific questions about her case, and voiced preferences regarding certain treatment options prior to surgery.  The responses she received from the technical, nursing and physician staff were thorough and respectful.  Family members were kept well informed during and after the procedure.

The staff who cared for her during her stay were generally upbeat and quick to respond to her needs.

It’s scary to turn the life of someone you love over to strangers.  For all of you who provide excellent, safe patient care every day, thank you.

Top Risk Management Blogs

Masters in Risk Management states on its web site that it “strives to provide readers with the best information available about risk management degrees,” as well as “information about career opportunities and more.”

The group recently posted their selection of the Top 50 Risk Management Blogs.  Blogs are listed alphabetically in five categories:

  • Business Risk Management
  • Insurance Risk Management
  • Disaster Risk Management
  • Credit and Financial Risk Management
  • Health Risk Management

 Supporting Safer Healthcare is honored to have been included under Health Risk Management.

Mark Weinberger, Runaway Doctor

The January issue of Vanity Fair features an article by Buzz Bissinger about Mark Weinberger, an Indiana surgeon who spent three years in the Italian Alps evading millions of dollars in debt, family problems, and more than 350 malpractice suits.

Evidence presented in the malpractice cases claims that Dr. Weinberger defrauded insurance companies and injured patients by recommending and performing numerous unnecessary surgeries.

The Vanity Fair article brings forward the question, ‘how can patients protect themselves from a fraudulent and dangerous practitioner?’  First, it is important to note that one of the reasons this case is newsworthy is because it is so rare.  Exceedingly few physicians engage in deliberately harmful patient care for profit. 

However, there is a red flag worth noting in this case.  The author states:  “Once he opened that new clinic, it was his own shop. He read his own CAT scans. There were no partners. He very rarely had to deal with hospitals. There was no one else overseeing him.”

While solo practice in a “one stop clinic” setting is not of itself indicative of a problem practitioner, some of the normal safeguards, such as hospital credentialing, are not present.  Therefore, patients need to be particularly diligent in their research before entrusting themselves to the care of a “lone” provider with no ties to any hospital or large group practice.

Read Vanity Fair’s interview with the author

Patient Experience and Patient Grievance Process Linked

Patient experience, and thus patient satisfaction scores, are intrinsically linked with how a hospital or other healthcare organization handles its patient complaint and grievance process. 

In addiiton to making good business sense, there are specific CMS regulations and Joint Commission standards that outline how hospitals and ambulatory surgery centers must manage patient grievances. 

Lisa Venn, JD, MA, CHC, writes in Improving Patient Experience – A Critical Look at the Patient Grievance Process “Dissatisfied patients take their business elsewhere and in this era of decreasing revenue, increasing competition and heightened patient expectations, no hospital can afford to lose business.  Dissatisfied patient may also complain to regulators, accreditors, and/or sue, creating additional financial and reputational risk to the organization.”

The Joint Commission web site reports that 15% of the Sentinel Events they investigate come to their attention through patient complaints.


Ms. Venn also provides a Power Point presentation, Establishing A Hospital Patient Grievance Process,  which outlines the steps hospitals must take in order to create or refine their patient grievance structure in accordance with CMS regulations.

For organizations seeking better ways to track and report patient grievances, Simple Data Solutions offers an affordable Patient Comment & Grieivance Tracking Database.

Social Media – New World, New Rules

A scan of recent tweets by various healthcare writers led to a couple of thought-provoking articles regarding the pitfalls of social media, one was via  Kevin Pho, the other Ves Dimov

#1 – Human Resources and Medical Staff Credentialers Beware:

The applicant looks promising, you think he/she may be a good fit for the organization.  Whether you’re seeking to hire a new employee or gather data on an applicant for medical staff membership and privileges, your next step may be to dig a little into the individual’s online life.  After all, if it’s on the Web it’s fair game, right?  So you’re off for a little browsing in Facebook, Twitter, Linkedin, etc.

Due dilligence? 

Perhaps, but as with many aspects of hiring and/or credentialing, there are some gray areas to consider before you use the information you find to make any decisions.

HR Morning reminds us that what we may step into is… A potential case of TMI.

You know all the questions you’re not allowed to ask (job) applicants:

  • their age
  • their religion
  • their sexual preference
  • their race or national origin, and
  • their medical condition.

You’re quite likely to stumble onto the answers to many of those questions with a foray into the applicant’s social media presence, and you can’t un-see what has been seen.  Now what?

Visit Morning HR for more information on developing a policy that may help keep your organization out of court. 

The legal boundaries are a little less clear when considering applicants for medical staff membership and privileges, but if you review social media in your credentialing/recredentialing process, it is important to develop and follow a policy that strictly outlines what type of information will be shared with the members of the Credentials Committee, Medical Executive Committee and Governing Board.  If in doubt, consult with your legal department. 

#2 – You’re Accountable for What You Post Online – Even if You Don’t Sign Your Name

NBC Chicago reports that Dr. Jay Pensler is suing three patients who anonymously posted negative reviews of his work.  With the availability of sites like RateMDs and Dr. Score, as well as a myriad of other “tell us what you think” venues on the web, some may think they can publicly vent their unhappiness in a big way with no possible legal repercussions.  Not so, as these three patients discovered.

Both of these reports remind all of us to be wary of  the lure of the instant gratification of web self-expression.  It’s not called the “world-wide” web for nothing, and there’s no way to get your words, photos, videos, and podcasts back once they’re tangled in the web.

PSA:  Post Responsibly.

CMS to Expand Hospital Compare in 2011

CMS plans to add new patient safety measures in the areas of hospital acquired conditions and healthcare associated infections, to the Hospital Compare Web site in 2011.

CMS also intends to begin utilizing displays of composite measures summarizing both process and outcome measures. This information collection request covers consumer research on displays, labels, and explanatory language to insure that the Web site is understood by viewers in a manner consistent with CMS’s intended communication message.

Federal Register, November 19, 2010

Joint Commission FAQs – Medical Staff

Here are a few recent Joint Commission FAQ’s related to medical staff standards:

Q. Are organizations required to verify affiliations at other health care organizations, and if yes, for how many years back must the verifications be done?


Q. Can organizations use data from outside organizations in lieu of collecting their own data to accomplish the Ongoing Professional Practice Evaluation (OPPE)?  Can outside data be used for low volume practitioners?


Q:  Medical and Cognitive specialties (IM, FP, psychiatry, other med specialties, etc…) are very tough to identify meaningful data that can be evaluated. Is there any guidance that The Joint Commission can offer to assist organized medical staffs?


More FAQ’s from Joint Commission.

Reminder – NAMSS Recertification Due By December 1st

This is a reminder to those who need to recertify this year with the National Association Medical Staff Services:  (Those who received initial certification in 1980, 1983, 1986, 1989, 1992, 1995, 1998, 2001, 2004 or 2007. )

December 1, 2010

Single Certification
NAMSS Member $100
Non-Member $250

Dual Certification
NAMSS Member $125
Non-Member $275

Required Credits:

Single Certificants:
30 hours of continuing education; 15 of which must be NAMSS approved.

Dual Certificants:
45 hours of continuting education; 25 of which must be NAMSS approved.

Eligible CE Dates:
November 1, 2007 through December 1, 2010

So Many Patients, So Little Time?

Emily Berry’s HcPro Credentialing Resource Center Blog asks an important question in a recent post:

“It’s not uncommon for practitioners to hold privileges at more than one facility. But can a practitioner’s ambitions put patient care in jeopardy? Should medical staffs set a limit on how many different facilities they allow their privileged practitioners to practice at, or set limits on patient case load at each facility?”

I have attended medical executive committee meetings where this very issue was debated, usually in connection with patient care.  As a rule, rather than setting any practice standards for the medical staff, the MEC votes to warn individual practitioners that they must see their patients more frequently, on a more timely basis, or must improve their medical record documentation. 

It’s not a simple issue; much depends on a physician’s specialty and practice pattern.  For example, a skilled cardiac electrophysiologist or an infections disease specialist may be privileged at a number of area hospitals and successfully meet the needs of patients at each. 

The case that Ms. Berry cites, however,  involves an OB-Gyn, a speciality in which response time is often critical.   And what about the orthopaedic or urologic surgeons on your staff?  If they care for patients at multiple hospitals and serve on multiple call schedules, is their ability to deliver timely, quality care impacted?  In reality, how could it be otherwise?

Medical staff leaders are often reluctant to establish rules that infringe upon their colleague’s personal practice choices, but this is an issue that deserves thoughtful review.  Patients need physicians who are able to attend to them in a reasonable amount of time and who are not so exhausted they can barely function, and doctors need to care for themselves as well as their patients.