Presenting a live 90 ‐ minute webinar with interactive Q&A Disruptive Physicians: Disruptive Physicians: From Credentialing to Disciplinary Action Minimizing Liability for Poor Quality of Care, Negligent Credentialing and Physician Lawsuits THURS DAY, NOVEMBER 4, 2010 1pm Eastern | 12pm Central | 11am Mountain | 10am Pacific Today’s faculty features: T d ’ f l f S uzanne A. Fidler, M.D., J.D., CPHRM, S enior Director of Risk Management and Patient S afety Officer, Desert Regional Medical Center , Palm S prings, Calif. Michael R. Callahan, Partner, Katten Muchin Rosenman , Chicago Julian Rivera, Partner, Brown McCarroll, LLP , Austin, Texas The audio portion of the conference may be accessed via the telephone or by using your computer's speakers. Please refer to the instructions emailed to registrants for additional information. If you have any questions, please contact Customer Service at 1-800-926-7926 ext. 10 .
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Disr pti e Ph sicians From Disruptive Physicians: From Credentialing to Disciplinary Action Strafford Legal Webinars Thursday November 4 2010 Thursday, November 4, 2010 4
The Challenges of Addressing Disruptive Behavior in the Disruptive Behavior in the Community Hospital Setting Suzanne A Fidler M D J D CPHRM Suzanne A. Fidler, M.D., J.D., CPHRM Senior Director of Risk Management Patient Safety Officer 949 ‐ 631 ‐ 0055 drfidler@physicianforlaw.com 5
The Joint Commission (TJC) The Joint Commission (TJC) “Behaviors that undermine a culture of safety” • • All accreditation programs must adopt a code of All accreditation programs must adopt a code of conduct that defines disruptive, unacceptable behaviors. (EP 4) • Leaders create and implement a process for managing disruptive and inappropriate behaviors. (EP 5; TJC, Sentinel Event Alert, Issue 40, July 8, (EP 5; TJC, Sentinel Event Alert, Issue 40, July 8, 2008) 6
One Approach Administration delegates the preparation of the policy to • the Chief of Staff Chief of Staff collaborates with the Medical Staff attorney Chi f f S ff ll b i h h M di l S ff • to draft policy At the General Staff Meeting, the policy is presented to At the General Staff Meeting, the policy is presented to • the medical staff 7
P Problems? bl ? Physicians voice opposition to the policy • Several physicians set up an ad hoc committee to discuss Several physicians set up an ad ‐ hoc committee to discuss • the policy Other physicians bring sample policies from organizations • such as the American Medical Association Some physicians threaten to move their practices • 8
Ph Physicians’ Perspective i i ’ P ti Medical staff is self ‐ governing • Physicians are not the only offenders Physicians are not the only offenders • Peer Review • Competition, economic tool Competition, economic tool • Recredentialing process • Outspoken or unpopular physicians may be perceived as • “disruptive” 9
P Protections Offered t ti Off d Establish a clear channel to report disruptive behavior • Objective data collection Objective data collection • Ensure code of conduct is incorporated into the medical • staff rules and bylaws Hospital maintains a culture that is supportive and • inculcates a positive collaborative culture of safety 10
Focus on Rehabilitation, Focus on Rehabilitation, Not Discipline Adopt a standardized mechanism to investigate and • document disruptive behavior p Establish an informal review process • Collegial intervention should be established • Administration provides education and training d d d d • Appropriate referral process for physicians requiring • evaluation, diagnosis, and treatment g Monitoring procedure for the physicians and safety of • patients 11
D Dr. Mean M Dr. Mean is an electrophysiologist who is well trained • from a distinguished medical program from a distinguished medical program. He moved to the community to establish a private • cardiology practice. Dr. Mean typically gets irritated if he is paged and the • nurses cannot answer all his questions such as the interpretation of the rhythm strips the list of the patient’s interpretation of the rhythm strips, the list of the patient s medications, and the content of the physicians’ progress notes. 12
P ti Patient Bob t B b Patient Bob is a 40 year ‐ old executive with a long history • of smoking hypertension and obesity of smoking, hypertension, and obesity. He is at risk for heart disease and has been admitted for • further cardiac testing. Dr. Mean plans to perform an electrophysiology study in • the morning if the patient has no further chest pain. 13
N Nurse Sally S ll Nurse Sally is a recent graduate from a local nursing • school and this is her third month working the night shift. g g Around 9 p.m., patient Bob complains of chest pain. • Nurse Sally checks Bob’s vital signs, listens to his heart, • and follows the cardiac protocol by administering and follows the cardiac protocol by administering nitroglycerin. After 10 minutes, patient Bob states that his chest pain • has not improved. 14
P Paging Dr. Mean i D M Nurse Sally places a call to Dr. Mean’s exchange. • Dr. Mean does not call back within 15 minutes and patient Dr Mean does not call back within 15 minutes and patient • Bob still has chest pain. Nurse Sally places a second call to Dr. Mean’s exchange. • Dr. Mean does not call back, so Nurse Sally places a third • call to Dr. Mean. 15
D Dr. Mean’s Call M ’ C ll Dr. Mean calls back. • Nurse Sally begins to present to Dr Mean the purpose of Nurse Sally begins to present to Dr. Mean the purpose of • • her call using the SBAR for effective communication per the hospital’s standards. Dr. Mean interrupts her and demands to know why she Dr Mean interrupts her and demands to know why she • did not give patient Bob additional nitroglycerin. Before Nurse Sally can answer, Dr. Mean barks the • following orders: get a stat EKG, start a nitroglycerin drip, send cardiac enzymes, get a blood gas, then call me with the results. He hangs up before Nurse Sally reads back the orders. • 16
R Results Return lt R t Nurse Sally receives the results and places a call back to • Dr. Mean. Dr. Mean returns the call and asks Nurse Sally to read the • results. As Nurse Sally starts to read back the results Dr Mean As Nurse Sally starts to read back the results, Dr. Mean • interrupts her and asks her to read the blood gas. Nurse Sally did not recall that Dr. Mean had ordered the • blood gas. 17
I t Interaction ti Dr. Mean begins to scream at Nurse Sally, calling her an • “idiot” and demanding that he speak to the charge nurse. Nurse Sally becomes tearful and gets her charge nurse. • In the meantime, Dr. Mean hangs up. • The charge nurse pages Dr. Mean and Dr. Mean again The charge nurse pages Dr. Mean and Dr. Mean again • yells, asking why Nurse Sally did not get a blood gas. Nurse Sally enters an incident report into the hospital • computer system. p y 18
I Issues Identified from Case Study Id tifi d f C St d Dr. Mean’s interactions • ‐ Interrupting Interrupting ‐ Yelling, barking orders Dr. Mean did not abide by the read ‐ back protocol Dr. Mean did not abide by the read back protocol • Dr. Mean did not promptly return pages • Nurse Sally’s performance and experience • Patient Bob’s medical care • 19
C Consistent, Fair Approach i t t F i A h Regardless of the following: Dr Mean is the Chair of Cardiology Dr. Mean is the Chair of Cardiology • Dr. Mean is extremely popular with the Administration • and facilitates hospital fund ‐ raising Dr. Mean is the only electrophysiologist in the community • and brings a lot of business to the hospital. Dr. Mean plays golf weekly with the President of the f f • Medical Staff 20
H How to Handle t H dl If this is Dr. Mean’s first incident (“ informal cup of • coffee”). ) If Dr. Mean has a pattern of this behavior and this is his • third incident. Nurse Sally has performance issues and Dr Mean was Nurse Sally has performance issues and Dr. Mean was • advocating on behalf of the patient. Dr. Mean is unpopular with the staff who are eager to • submit incident reports but overlook other physicians who act similarly. 21
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