When Tempers Flare

When jumbo jets collided in the Canary Islands on March 27, 1977, 583 passengers and crew died in the ensuing inferno; the worst aviation accident in history.  Investigation revealed mis-communication between the tower and cockpit, and the fact that the first-officer was apparently too intimidated by the more experienced captain to question his actions.

The aviation industry responded by developing Crew Resource Management training, which focuses on the cognitive and interpersonal skills needed to manage a flight

Recently, there has been considerable interest in developing methods to prevent intimidation and mis-communication in the healthcare setting, as evidence mounts that disruptive behavior is a significant patient safety issue.   

Historically, disruptive behavior among caregivers has been tolerated.  Unless combatants resorted to fisticuffs (or scalpels), we tended to look the other way when tempers flared.  ‘After all’ we thought, ‘patient care is a high-pressure job, it’s good to cut caregivers (and administrators, department heads, etc.) a little slack.’  In retrospect, that really wasn’t as magnanimous as it seemed.  Bad behavior left unchallenged escalates; participants grow increasingly hostile and abusive, and communication grows more stilted.  No one is happy; no one wins.     

Disruptive behavior was reported in 177 events submitted to the Pennsylvania Patient Safety Authority from May 2007 to October 2009. In many of the events patient care was compromised, according to data published in a June 16, 2010 press release.

“Of the 177 events, 73 (41%) were due to conflicts between healthcare clinicians, 30 (17%) to procedures not followed, and 17 (10%) to absence of responses or delays.”

Every health system, including the military, faces this challenge.  In response, the U.S. Department of Defense has published the Professional Conduct Tool Kit, which can be downloaded for free from their Patient Safety Program website.  The DoD site sites, “The (Professional Conduct) toolkit is designed for health professionals who may be serving in leadership roles or who are seeking resources for addressing behaviors that negatively impact patient safety and that disrupt the clinical work environment.”

None of us can afford to allow ourselves to be intimidated when it comes to addressing this vital patient safety issue.


Credentialing – A Frustrated Physician’s Perspective

The Happy Hospitalist is not so happy at the moment. What has stirred up Dr. Happy’s inner curmudgeon? 

Physician Credentialing.

As my experience is on the other side of that particular desk, I’ve excerpted a few portions of his recent post on the topic, and added some commentary below.

“For physicians to do a hospital admission or daily visits or procedures inside a hospital they must first obtain hospital credentials.”

Absolutely true. 

“Every hospital has their own set of rules.”

Mostly true.  There are some universal standards which guide physician credentialing in the U.S., many of which are set by CMS Hospital Conditions of Participation, but there are also a myriad of specific rules that organizations establish to assure safe patient care within their walls.  For example, Hospital A may have the staff, equipment and ability to perform cardiac catheterization, but Hospital B may not.  Therefore, a perfectly qualified physician may not be permitted to even request cardiac cath privileges in Hospital B.

 “I recently applied for hospital privileges to another hospital…  In this case, they sent me a packet of information almost 40 pages long.  They mark everything I need to sign with tiny little sticky pads. About 10-15 tiny little sign and date here sticky pads dotted the hospital credentialing paperwork.  Forty pages of legal mumbo jumbo.”   

I suspect this is absolutely true.  (Be glad someone took the time to add those helpful little sticky notes!)  First there is the actual application, which has questions ranging from name, address, phone, etc, to experience and education questions that start with the day you gleefully threw your cap into the air during medical school graduation. 

Then there is the “Release of Information and Authorization” form, which is written by lawyers and usually contained in one page of squint-inducing fine print.  This form authorizes anyone who ever knew you to spill everything they know without fear of being sued in retaliation.   

Next comes the “Delineation of Clinical Privileges Request” form.  This one can range from one page to ten or more, and it outlines both the privileges a physician in a given specialty may request at the hospital, and often the criteria he/she must meet in order to request the privilege.

Remember that cardiac cath procedure at Hospital A?  It may be that an applicant there has to produce evidence of having performed X number of them within the past two years before the little “I request this” box may be checked on Hospital A’s form.  Could be however, that should one be filling out Hospital C’s forms at the same time, the criteria for requesting the privilege at Hospital C is different, as those requirements are set by the hospital’s medical staff leadership.  There are some legitimate reasons for that, but admittedly, it can get pretty confusing for physicians on multiple hospital staffs.

Next comes any additional information the hospital may decide to collect or share with you,  which could include a copy of the Bylaws, Rules and Regulations of the organized medical staff.  We’re talking some fun reading there.  Although the age of electronic communication has, thankfully, given us opportunity to just send you a link where you can go online and read to your heart’s content, rather than requiring us to add a 20-100 page document containing the rules and requirements of medical staff membership, which yes, you are expected to follow. 

There could also be additional requests for information about your last TB test, Hepatitis B inoculation. etc., if those matters are handled by the Medical Staff Office.

“Have you ever been charged with a crime?  Have you ever been convicted of a drug or alcohol related offense?  Have you ever been sued?  Not lost a lawsuit, just sued.  Have you ever been treated for depression?”

All of these seem pretty legitimate except that last one.  If indeed, the question was worded as “have you ever been treated for depression?” or for that matter, have you ever been treated for cancer or diabetes, there needs to be a little re-wording done.  It’s really none of our business if you’ve “ever been treated” for something.  What is our business is whether you are currently dealing with a health issue that could impede your ability to effectively manage the privileges you’ve requested.  For example, a surgeon who is unable to stand for long periods of time due to a health condition needs to say so.  Reasonable accomodation could likely be made, i.e., an adjustable stool could be placed in the OR.  If, on the other hand, a normally happy hospitalist is presently dealing with debilitating depression, he or she may not be able to make effective decisions on critical patient care issues.  The goal of medical staff services administration is both to protect patients, and to assist valuable members of the medical staff when a need arises.  

Could (hospitals) be held liable for allowing a bad apple to practice medicine in their walls.  A physician who has been licensed by the government and certified by their specialty society as an expert capable of providing excellent care?  

The answer to this is so Yes.  Consider the case of Putnam General Hospital and John Anderson King.  Beyond the issue of protecting the hospital however, is the issue of protecting patients.  The vast majority of physicians take that very seriously; as do the vast majority of credentialers.  It may not always seem like it, but we’re really on the same page on this one.

If you have a hospitalist seeing you at your hospital, you can rest assured their past has been raked through the coals and their history and credentials have been picked apart by government agencies, specialty societies and even the hospital you find yourself in.

And that’s really the point, isn’t it?  Because of all these rules, some of which are pretty onerous, hospital patients can feel reasonably assured that their physician has been thoroughly investigated. 

Then Happy Hospitalist adds, absurdly so, a sentiment with which I can at least in part, agree.  As a medical staff services consultant, I know that there is considerable room for improvement in this process in many hospitals.  As HH implies, physician credentialing can be driven over the top by fear, but knowledge and an understanding of the intended purpose are far better drivers. 


Single Medical Staff Requirement – July 15, 2010

Each hospital with an individual Medicare provider agreement must have a single medical staff and a medical executive committee, according to CMS Conditions of Participation, 42 C.F.R. §482.22.  This rule applies whether or not the hospital is part of a unified system. While system credentials committees are acceptable, because credentials committee’s are not mentioned under the CoPs, joint medical staffs and medical executive committees are not permitted.

In the past, hospitals accredited by the Joint Commission have been able to have shared medical staffs and MECs, but as of July 15, 2010, a new JC element of performance states:   “For hospitals that use Joint Commission accreditation for deemed status purposes: There is a single organized medical staff.” 

According to CMS, this has always been a CoP requirement.

There is a very good explanation of this change in Joint Commission requirements in Horty Springer’s Question of the Week from April 29th.

And Now, A Word From Our Sponsors

I’m trying out a couple of sponsorship opportunities here on Supporting Safer Healthcare.  You’ll see both  Google ads and career ads from Indeed.com when you scroll down the far right sidebar. 

Big SaleI’ve long resisted random ads because I didn’t want readers to have to put up with dancing flashing advertisements that would be more annoying than informative.  However, I’ve been pleased with what I’ve seen displayed in those little boxes so far. 

The ads are specifically targeted to the interests of readers who are likely to visit this site.  They feature products, services, and career postings related to patient safety, medical staff services management, risk management, and healthcare administration.

Help WantedSo keep your eye on what pops up over there – maybe it will be the job of your dreams, or if you’ve already got that, a product that will make the job of your dreams even better!

And now, back to our program…

TJC Telemedicine Standard On Hold

RadiologyBeen knocking yourself out over the past few months to get your telemedicine providers credentialed before the looming July 15th Joint Commission standards change? 


The NAMSS Blog provides an update on the July Joint Commission deadline for credentialing telemedicine providers. It’s now being held until March 2011, and likely will be changed before then. 

Although it would be easy to feel grouchy toward TJC for creating a standard that’s been making credentialers around the country jump through hoops, and then placing it on hold at the 11th hour, The Joint Commission is actually the hero, not the villain in this story.   They have long supported the credentialing-by-proxy standard which allowed hospitals to rely on the credentialing of other Joint Commission approved organizations when it came to credentialing the many (many…many…) teleradiologists and other physicians who provide remote care in today’s hospitals.  The CMS Conditions of Participation however, did not support that viewpoint.  And, as we know, it (literally) requires an act of Congress to change the CoP’s. 

So, although it would have been nice if this change could have occured a bit sooner, at least the push-back on the July 15th deadline is good news for medical staff services professionals, particularly those who work in hospitals and for teleradiology groups.

Blogging, Then And Now

KeysI’ve been blogging about healthcare since 2004.  I believe that blogs (and bloggers) age in dog years, so I figure that makes this blog about 30 years old, a veritable “grown up” in the world of blogs.

As with all technology-based endeavors, there has been monumental change in the blogosphere since 2004.  

What I like better now  

  • There are many more healthcare blogs providing high-quality information
  • Blogs are far better looking, some of the 2004-2005 models were pretty homely
  • Blogging software has improved, giving writers more creative options
  • Bloggers garner more respect and are more often seen as “real” writers
  • High-quality bloggers can make a little money from their writing, for example, KevinMD and Clinical Cases and Images.

What I liked better in the early days 

Time passes, perspectives change, but now and then it’s good to go back to the old neighborhood, visit with old friends, and reminisce.

Pennsylvania Patient Safety Advisory

The Pennsylvania Patient Safety Authority has issued it's latest Advisory Report. 

The eleven-member Authority was established in 2002 by the Pennsylvania Medical Care Availability and Reduction of Error Act (MCARE Act).

Based on reports of medical errors that it receives from hospitals, birth centers, and ambulatory surgery centers around the State, the Authority releases a quarterly best-practice and staff education report.

The current issue covers various topics including:

  • Improving the Safety of the Blood Transfusion Process
  • Tubing Misconnections: Making the Connection to Patient Safety
  • Probiotic Use for Clostridium Difficile Infection
  • OR Fire Prevention Video
  • Management of MRSA in Ambulatory Surgical Facilities
  • Quarterly Update on the Preventing Wrong-Site Surgery Project

The report offers insights not available in all states, since most do not yet have a mandatory reporting requirement.  See the graph at Dead by Mistake to determine whether your state has a medical error reporting requirement.