Medical Staff Quality and Compliance Analyst

This intriguing job ad was posted a few weeks ago by a large health system.  It would seem that this hospital is ahead of the curve when it comes to understanding the need for resources dedicated to the data requirements of the organized medical staff.

Performs related functions for tracking and data analysis of JHH Medical Staff and Affiliate Staff as it relates to compliance with Hospital requirements and Joint Commission standards. Will track staff quality data, initiate requests on a scheduled basis for related information, perform high-level analysis through use of sophisticated database software and other tools, identify problems and perform all necessary follow-up to resolve problems.

 Will independently be responsible for making sure that all appointed staff are in compliance with FPPE and OPPE standards as set forth by The Johns Hopkins Hospital and will work with administrative and clinical staff throughout Hospital to accomplish goals.

Also responsible for other compliance tracking and reporting, including medical staff education requirements; various database functions, (such as creating databases, systems and workflow design and implementation, automation of processes and advanced queries and reports in Microsoft Access and Excel, importing and exporting of data from a variety of sources to produce reports for own workflow as well as management review and analysis).

Will independently schedule, track, and follow-through on a wide variety of priorities, working both independently and with the Manager of Medical Staff Systems. Will function in a highly independent way, and be responsible for resolving a diverse set of complex problems.

If you’re a medical staff professional who enjoys statistics and data, this could be the job for you. 

Hmm, I wonder if Johns Hopkins would consider a remote employee…

Medical Staff Services Consulting

I recently had the pleasure of working on a consulting project with Buchanan & Associates Consulting.  Lynn, and the consultants who work with her, have a wealth of knowledge about the ever-changing field of medical staff services. 

This post is to help spread the word that the BAC web site recently moved to a new location on the web and can now be found at

"Buchanan & Associates Consulting"

Mission Hospital, It’s Time To Say You’re Sorry

You may know the story of Taylee Blischke, a newborn who nearly died in April 2009 at Mission Hospital in Mission Viejo, California. Morphine was mistakenly given to Taylee, instead of her mother who was holding the infant. California investigators say mother and baby had IVs that were mixed up.  To add insult to injury, the hospital initially accused the baby’s mother Jessica of being a drug addict and passing the morphine along to her baby through her breast milk. 

Fortunately, Taylee survived and now appears to be a healthy toddler. 

In May, the California Department of Public Health fined Mission $50,000 for the error.

What bothers me most about this story is not the mistake, or even the initial accusation, it’s the official, carefully worded response that was recently issued by the hospital:

Our healthcare organization is deeply concerned about an incident that occurred in which an infant was mistakenly administered a medication last year. Consistent with our commitment to our patients we have conducted a process review and provided ongoing education and training for our patient care teams with regard to administering medications. While this incident is regretful, we are thankful that both the mother and baby were discharged in healthy condition …”

“While the incident is regretful?”  Now that’s a statement that exudes compassion and sincerity.

What is so difficult about saying ‘We are so sorry that Taylee was injured while under our care.”  It’s what Todd and Jessica Blischke deserve to hear.

More: Newborn Medical Mixup

9/2/10 Addendum: 

This case has, understandably, sparked a strong emotional response from many readers.  My purpose in including it here was not to blame or shame anyone.  I know that in nearly every case of serious medical error, caregivers are distraught.

My purpose was to draw attention to how fearful many  organization leaders remain to simply saying “We’re sorry,” when a sincere apology could do everyone so much good.  Sadly, it seems to be a challenge for most of us to say those words when they are called for.    ~Rita~

I Care For You; I Am Your Doctor

“I care for you, I care about you, and I know you in ways no one else does; I am your doctor. ”

The physician patient relationship is unique, sensitive, and vitally important.  Imagine for a moment, that you are the physician who made the opening statement, and that the patient to whom you spoke those words has suddenly, unexpectedly, died.

You grieve, and you have a right to.  That patient and those who love him matter to you.

Now imagine that the death is attributable, at least in part, to a medical error that you made.  How do you deal with the stress of that knowledge?

Most physicians want to do what you or I would want to do if we made an unintentional error that harmed someone.  We’d want to offer a sincere, heartfelt apology, and tell those left behind that we are sorry.  We’d want to offer some explanation as to how such a devasting event could have happened, and share what we were doing to make sure it never happened again. 

Now imagine that you’re told that option is not available to you.  You are instructed by lawyers, insurance company representatives, and risk managers, not to speak about the event, not speak to any of the patient’s family members, not to return their phone calls, and not to attend the patent’s funeral.

Imagine how that would feel.

Too many physicians and grieving family members don’t have to imagine; they know.

Slowly, that tide is turning.  Healthcare is discovering that a more humanistic approach to medical errors not only helps the people directly affected, but helps protect organizations as well.  That is welcome news for both patients and caregivers.

The New York Times article When Doctors Admit Their Mistakes delves further into this complex issue.

Despite the best efforts of health care professionals, bad things can happen in hospitals. Up until more recently, when errors occurred, the scenario that played out was always the same. Clinicians, devastated but fearful of litigation, would shut down. Patients and their families, grieving but desperate to make sense of the event, would find that their doctors and nurses were no longer responsive or available. Eventually, the most important relationship in health care, that between patient and doctor, would cede to the most adversarial one, that between plaintiff and defendant.

Read When Doctors Admit Their Mistakes

Related:  Talking to Patients After Medical Mistakes

Most Challenging 2010 JC Standards

If you’re facing an upcoming accreditation survey, you’ll want to know what the Joint Commission is reporting as the most challenging standards so far this year.

Here is what is giving Hospitals and Ambulatory Care organizations the most trouble in 2010:


RC.01.01.01 The hospital maintains complete and accurate medical records for each patient.  (62%)
LS.02.01.20 The hospital maintains the integrity of the means of egress.  (50%)
LS.02.01.10 Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.  (44%)
EC.02.03.05 The hospital maintains fire safety equipment and fire safety building features.  (38%)
LS.02.01.30 The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke.  (37%)

See the full list in the August 18, 2010 issue of Joint Commission Online.

Ambulatory Care

HR.02.01.03 The organization grants initial, renewed, or revised clinical privileges to individuals who are permitted by law and the organization to practice independently. (48%)
MM.03.01.01 The organization safely stores medications. (25%)
IC.01.03.01 The organization identifies risks for acquiring and transmitting infections. (23%)
WT.05.01.01 The organization maintains records for waived testing (23%)
IC.02.02.01 The organization reduces the risk of infections associated with medical equipment, devices, and supplies. (22%) 

Frequently Asked Questions – Hospital Accreditation

Are you wondering what the Joint Commission’s thought process is for Ongoing Professional Practice Evaluation (OPPE) or whether specific privileges are required for the administration of moderate sedation?  Those and many other topics are covered under the Medical Staff section in JC’s Frequently Asked Questions.

DNV  and AOA’s HFAP accreditation programs also have FAQ’s related to questions about their Accreditation and Survey Processes.

Dear Doctor, Please See Beyond My Weight

“Patients who feel stigmatized about their weight are more likely to avoid routine preventive care, and when they do seek health services, they may receive compromised care.”  So states Rebecca M. Puhl, PhD, in a recent Medscape article.

I spoke recently with a friend who shared that she is suffering from chronic back pain and some related problems, likely related to a fall that occured years ago.  She visits a chiropractor regularly, and feels that she gets some temporary relief.  Concerned, I asked whether she had discussed the issue with her medical doctor; she sighed and recounted several discussions over the years with various physicians.

My friend’s stories revealed a recurring theme.  Spinal x-rays reveal some problems, but nothing that the physicians feel requires treatment.  In the end she says she always receives the same advice; go home, exercise and lose some weight.  She agrees those are good goals, but admits that exercise, even walking, is difficult for her because of her continual back pain, which has gotten worse over time.

Although she sees a medical doctor at least annually for a routine check-up, she is discouraged and feels there will never be any help for her from the medical community.  “I know that unless I succeed in losing weight, no doctor will ever take me seriously.”

Her story bothered me.  I wanted to say she wasn’t giving medicine a fair chance, but in reality I suspect that her experience is not so uncommon.

So here is what I ask.  If you work in the healing professions, please do your best not to let personal bias compromise the care you give to patients who may not live up to all of your expectations.  They are someone’s friend, someone’s parent, someone’s child; we’re counting on you.