The Gray Zones: Ambiguities in What do all these stories Hospital - PDF document

The Gray Zones: Ambiguities in What do all these stories Hospital and Physician have in common? Relationships Neither the problem nor Can you wait? the solution is clear. Must you act now? Steps to determine problem, solution: Triage Collegial Intervention Goal: Give each physician best chance to be successful. Health Conduct Quality Two or more?

What? Bylaws/Credentials Policy Authorizes: a) If health issue → Health Policy b) If behavior → Code of Conduct a) To guide those who intervene c) If quality → PPE b) To assure it’s “peer review” d) If serious/urgent → Bylaws/ Credentials Policy Collegial Approach First How? a) Do homework; know issues  Meet with the physician  Have a script b) Interview those who have reported/observed  Don’t let physician change subject/ control meeting c) Meet with physician, if  Counsel? necessary Don’t let lawyers knock Physician Health Issues you off course.

Impairment Can Be Impairment Can Be Caused By: Caused By: An impaired physician is An impaired physician is  Age  Age unable to practice medicine unable to practice medicine  Physical limitation  Physical limitation because of physical or because of physical or  Disease  Disease mental illness. mental illness.  Substance abuse  Substance abuse AMA AMA Possible Causes Stemming “Physicians who have been in from the Effects of Aging practice longer may be at risk for  Deterioration of cognitive skills or providing lower-quality care. physical dexterity Therefore, this subgroup of physicians may need quality  Memory loss improvement interventions.”  Decreased reaction time  Increased difficulty in staying focused — Annals of Internal Medicine , on task in highly stressful situations 2005; 142:260-273.  Hearing loss and visual impairment “For surgeons older than 60 years … significant differences in mortality rates were largely restricted to those with low procedure volumes... Among high- Age Discrimination in volume surgeons, however, there Employment Act (ADEA) were no significant differences in mortality rates …. — Annals of Surgery , 2006; 244(3):353-622

ADEA ADEA  Federal civil rights statute designed  Makes it unlawful “to discriminate to protect individuals 40 years of age against any individual with respect and older to his compensation, terms, conditions, or privileges of  Only applicable in an employment setting employment because of such individual’s age.”  (Unless you are in CT, NY or VT) Exception: “Bona fide occupational Narrow Exception qualification” or BFOQ  Age has successfully been established as  Age limit is “reasonably necessary” for a BFOQ primarily in occupations where the operation of the business, and, either: public safety is at stake:  “all or substantially all” of the disqualified  Airline pilots members are unable to perform duties, or  the unfitness of at least some members of  Bus drivers the class, plus the infeasibility of making  Law enforcement officers individual determinations  Firefighters Physicians or Other Practitioners?  A hospital could use age in credentialing Solutions to Address employed physicians if it could show Concerns About the Older that:  the use of age in credentialing actually Physician effectuated its goal (e.g., public safety), and  that there was no acceptable alternative which would equally advance the goal with less discriminatory impact

Establish a Rule Minimal Level of Risk  Reduce the Focus on Age  Increased uniformity and consistency  Substantially improve existing peer review processes  Ability to depersonalize an  Require comprehensive examinations otherwise very personal issue for all physicians at initial  Greater ability to protect patients appointment and reappointment Higher Level of Risk Also Consider  FPPE, including concurrent review  Informal discussions of a stated number of cases  Annual reappointment at a certain  Special staff category age  Additional CME for older physicians  Comprehensive physical and psychological evaluations First and Last Question: Follow your What is in the best interest Physician Health Policy of the patients?

Is it different if the physician is an employee? Leadership Leadership Who is the Disruptive Who is the Disruptive Drives Behavior Drives Behavior Practitioner? Practitioner? Identification (cont.) Identification (cont.) Identification Identification  Doesn’t understand  Doesn’t understand  Always Right  Always Right organization or authority organization or authority  Others — Especially Those in  Others — Especially Those in  No rules apply to him or her  No rules apply to him or her Authority Are Fools, or Worse Authority Are Fools, or Worse  Attacks immediately if  Attacks immediately if  Writing Incoherent  Writing Incoherent criticized or crossed criticized or crossed  Actively enjoys suing and  Actively enjoys suing and  Charismatic  Charismatic threatening suit threatening suit

Board Policies Board Policies Interviews Interviews  Report  Report  Those who observed  Those who observed  Interview  Interview  Assure confidentiality  Assure confidentiality  Action  Action  Listen  Listen  Follow-Up  Follow-Up  Prepare summary  Prepare summary Collegial Collegial Put it in bylaws. Put it in bylaws. Approach First Approach First Documentation Documentation “In The Box” is Critical is Critical 111 Define Precisely Define Precisely Required Behavior Required Behavior

“In The Box” Letter “In The Box” Letter Content Content Multiple Purposes Multiple Purposes  Bylaws/Policy requirement  Bylaws/Policy requirement  Save the doctor  Save the doctor  Long history, previous warnings  Long history, previous warnings  Alert counsel  Alert counsel  List of incidents  List of incidents  Head off injunction  Head off injunction  Detailed do’s and don’ts  Detailed do’s and don’ts  Alert successor  Alert successor  Or else… specific consequences  Or else… specific consequences  Solidify legal position  Solidify legal position Progressive Steps Discipline (medical staff bylaws/credentials policy) Specific requirement Progressive Discipline Progressive Discipline or else Discuss with physician Clarify expectations Training/Education  Identifying/recognizing Take Home Tips Take Home Tips problems early for When Your Are Working for When Your Are Working  Practice in intervention/“script” in the “Gray Zone” in the “Gray Zone” preparation  Awareness of evasive tactics

Your Tools:  Health Policy  Code of Conduct  Triage/Collegial Intervention (in Credentials Policy)  PPEP  Assurance of Legal Protection and Organization Support  Leaders Who Are Willing to Act