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Chapter 10
Medical Staff Organization and
Physician Liability

Learning Objectives
Describe medical staff organization and committee structure.
Describe the credentialing and privileging process, and the purpose of physician supervision and monitoring.
Know medical errors involving patient assessment, diagnosis, treatment, discharge, and follow-up care.
Explain how the physician–patient relationship can be improved.

Chapter Overview
Overview of medical ethics
Medical staff organization
Credentialing process
Review of pertinent legal cases
Where physicians are most vulnerable

Medical Staff Organization

Committees

Executive Committee (1 of 2)
Recommends medical staff structure
Develops a process for reviewing credentials
Recommends appointments to the medical staff
Develops processes for delineating clinical privileges

Executive Committee (2 of 2)
Performance improvement activities
Peer review
Fair hearing process
Reviews and acts on reports of medical staff departmental chairpersons and medical staff committees

Bylaws

Organization of the medical staff is described in its bylaws, rules, and regulations.
Bylaws must be approved by the governing body.
Bylaws must be kept current and the governing body must approve recommended changes.
Bylaws describe various membership categories of the medical staff (e.g., active, courtesy, consultative).

Blood and Transfusion
Develops blood usage policies and procedures
Monitors transfusion services
Monitors
Indications for transfusions
Blood ing practices
Each transfusion episode
Transfusion reactions

Credentials
Oversees application process for medical staff applicants, requests for clinical privileges, and reappointments to the medical staff
Makes its recommendations to the medical executive committee

Infection Control
Generally responsible for the development of policies and procedures for investigating, controlling, and preventing infections

Medical Records
Develops policies and procedures, including:
Release, security, and storage
Determining the format of medical records
Monitoring records for accuracy
Completeness, legibility, and timely completion, and clinical pertinence
Ensures records reflect condition and progress of the patient, including results of all tests and therapy given and makes recommendations for disciplinary action as necessary

Pharmacy and Therapeutics
(1 of 2)
Policies and procedures (e.g., selection; procurement; distribution; handling, use, and safe administration of drugs, biologicals, and diagnostic testing material)
Oversees development and maintenance of formulary
Evaluates and approves protocols for the use of investigational or experimental drugs

Pharmacy and Therapeutics
(2 of 2)
Oversees:
Tracking of medication errors
Adverse drug reactions
Management, control, and effective and safe use of medications through monitoring and evaluation
Monitoring of problem-prone, high-risk, and high-volume medications

Quality Improvement Council
Functions as a patient-care assessment and improvement committee

Tissue
Provides surgical case reviews, including:
Justification and indications for surgical procedures

Utilization Review (1 of 2)
Monitors and evaluates utilization issues such as medical necessity and appropriateness of admission and continued stay, as well as delay in the provision of diagnostic, therapeutic, and supportive services
Ensures each patient is treated at the appropriate level of care

Utilization Review (2 of 2)
Objectives of the committee include
Transfer of patients requiring alternate levels of care
Promotion of efficient and effective use of resources
Adherence to quality utilization standards of third-party payers
Maintenance of high-quality, cost-effective care
Identification of opportunities for improvement

Medical Director
Serves as a liaison between medical staff and organization’s governing body and management
Responsibilities include enforcing the bylaws of the governing body and medical staff and monitoring the quality of medical care in the organization

Medical Staff Privileges (1 of 2)
Screening process
Application
Medical staff bylaws
Physical and mental status
Consent for release of information
Certificate of insurance
State licensure
National practitioner data bank
References
Interview process

Medical Staff Privileges (2 of 2)
Delineation of clinical privileges
Limitations on privileges requested
Practicing outside field of competency
Governing body responsibility
Misrepresentation of credentials
Appeal process
Reappointments

Common Medical Errors
Patient assessment
Diagnosis
Treatment
Discharge
Follow-up care

Patient Assessments
Involve the systematic collection and analysis of patient-specific data necessary to determine a patient’s care and treatment plan.
A patient’s plan of care is dependent on the quality of assessments conducted by practitioners of various disciplines (e.g., physicians, nurses, dietitians).

Patient Assessments:
Cases
Unsatisfactory History and Physical
Assessment of Unconscious Patient
Failure to Obtain a Second Opinion
Assessments Sometimes Require Referral to a Specialist
Aggravation of Patient’s Condition

Diagnosis (1 of 5)
Refers to the process of identifying a possible disease or disease process, thus providing the physician with treatment options

Diagnosis (2 of 5)
Failure to diagnostic tests
Ophthalmologist Fails to Order Tests
Misdiagnosis of Appendicitis
Efficacy of test questioned
Failure to promptly review test results

Diagnosis (3 of 5)
Timely diagnosis
Failure to Read X-Ray Report
Radiologists Fail to Make a Timely Diagnosis
Failure to Monitor Patient

Diagnosis (4 of 5)
Imaging studies
Failure to Order Appropriate Imaging Studies
Image Misinterpretation Leads to Death
Failure to Consult with Radiologist
Failure to Read Images
Delay in Conveying Imaging Results
Failure to Communicate Imaging Results

Diagnosis (5 of 5)
Most frequently cited injury event in malpractice suits against physicians
Medicine is not an exact science and linking a patient’s symptoms to a specific ailment is complicated at best.
Sometimes things go wrong despite all the advances of modern medicine.
Diagnoses based on spurious test results
Can lead to harmful treatments

Misdiagnosis:
Cases
Mitral Valve Malfunction
Failure to Form a Differential Diagnosis
Appendicitis
Diabetic Acidosis
Pathologist Fails to Diagnose Cancer
Radiologist Misreads Patient’s X-rays
Failure to Make a Timely Diagnosis
Wrongful Diagnosis of AIDS

Accident Victim:
Misdiagnosis (1 of 2)
The police department physician examined an unconscious man who had been struck by an automobile.
The physician concluded the patient’s confusion was due to intoxication and he was placed in jail instead of a hospital.
The man remained semiconscious for several days and was finally taken to a hospital at the insistence of family; he subsequently died.
The autopsy revealed massive skull fractures.
Did the physician commit malpractice?

Accident Victim:
Misdiagnosis (2 of 2)
Yes!
A patient is entitled to a thorough examination as his or her condition and attending circumstances warrant.
This did not happen.

Treatment
The attempt to restore the patient to health following a diagnosis
Involves the application of various remedies and medical techniques, including surgery and medications

Forms of Treatment (1 of 2)
Active treatment is directed immediately to the cure of the disease or injury.
Causal treatment is directed against the cause of a disease.
Conservative treatment is designed to avoid radical medical therapeutic measures.
Palliative treatment is designed to relieve pain and distress with no attempt to cure.

Forms of Treatment (2 of 2)
Preventive/prophylactic treatment is aimed at the prevention of disease and illness.
Supportive treatment is directed mainly to sustaining the strength of the patient.
Symptomatic treatment is meant to relieve symptoms without effecting a cure.

Treatment:
Choice of Treatment
Two schools of thought doctrine:
Applicable in medical malpractice cases in which there is more than one method of accepted treatment.
Under this doctrine, a physician will not be liable for medical malpractice if he or she follows a course of treatment supported by reputable, respected, and reasonable medical experts.
Use of unprecedented procedures that create an untoward result may cause a physician to be found negligent.

Treatment:
Cases (1 of 5)
Selecting the wrong treatment
Delay in treatment
Lab Results Buried in Files
Untimely Cesarean Section
Failure to treat known condition

Treatment:
Cases (2 of 5)
Failure to treat evolving emergency
Failure to respond to emergency calls
Medication errors
Wrong Dosage
Abuse in Prescribing Medications
Wrongful Supply of Medications

Treatment:
Cases (3 of 5)
Surgery
Retained Surgical Items
Phantom Surgeon
Wrong Patient Surgery
Correct Surgery: Wrong Site

Treatment:
Cases (4 of 5)
Wrong Site Surgery
Wrong Site Surgery: Fraud
Foreign Objects Left in Patients
Needle Fragment Left in Patient
Procedure Improper
Inadequate Airway

Treatment:
Cases (5 of 5)
Improper Positioning of Arm
Sciatic Nerve Injury

Preventing Surgical Mishaps (1 of 2)
Require second opinions
Qualified credentialed physician for proposed procedure
Patient informed as to risks, benefits, and alternatives
Consent forms executed
Equipment, supplies, and staff prepared for procedure

Preventing Surgical Mishaps (2 of 2)
History and physical exams completed
Pre-anesthesia assessment conducted
Correlation of pathologic and diagnostic findings
Vital signs and surgical site assessments continuously monitored

Discharge and Follow-Up Care
The premature discharge of a patient is risky business.
The intent of discharging patients more expeditiously is often a result of a need to reduce costs.

Discharge and Follow-Up Care:
Cases
Untimely Discharge
Failure to Provide Follow-Up Care
Failure to Follow-Up on Test Results
Abandonment

Abandonment
Elements necessary to recover damages:
Medical care unreasonably discontinued
Discontinuance against patient’s will
Failure to assure follow-up care for patient
Foresight: Failure could result in patient injury
Actual harm was suffered by patient

Infections
Failure to effectively manage infection
Poor infection-control technique
Preventing spread of infection

Psychiatry (1 of 2)
Commitment
Involuntary commitment
Involuntary commitment ed
Continuation of commitment
Involuntary commitment invalid
Commitment by spouse
Commitment by parent
Patient due process rights
Release denied

Psychiatry (2 of 2)
Untimely discharge
Electroshock therapy
Duty to warn
Exceptions to duty to warn
Suicidal patients
Flawed evaluation
Inadequate care

Principles of Medical Ethics:
Code of Medical Ethics (1 of 3)

Principles adopted by the American Medical Association are not laws, but rather standards of conduct that define the essentials of honorable behavior for the physician.

A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights.
A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities.

Principles of Medical Ethics:
Code of Medical Ethics (2 of 3)
A physician shall respect the law and also recognize a responsibility to seek changes in those requirements that are contrary to the best interests of the patient.
A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law.
A physician shall continue to study, apply, and advance scientific knowledge; maintain a commitment to medical education; make relevant information available to patients, colleagues, and the public; obtain consultation; and use the talents of other health professionals when indicated.

Principles of Medical Ethics:
Code of Medical Ethics (3 of 3)
A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care.
A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.
A physician shall, while caring for a patient, regard responsibility to the patient as paramount.
A physician shall support access to medical care for all people.

Physician–Patient Relationship (1 of 3)
Personalize treatment.
Conduct a thorough assessment.
Develop a problems list and comprehensive treatment plan.
Provide sufficient time and care to each patient.
Request consultations when indicated and refer if necessary.

Physician–Patient Relationship (2 of 3)
Closely monitor patient progress.
Make adjustments to treatment plan as the patient’s condition warrants.
Maintain timely, legible, complete, and accurate records.
Do not make erasures.
Do not guarantee treatment outcomes.
Provide for cross-coverage during days off.

Physician–Patient Relationship (3 of 3)
Do not over-extend your practice.
Avoid prescribing over the telephone.
Do not become careless because you know the patient.
Seek the advice of counsel should you suspect the possibility of a malpractice claim.
Maintain the patient’s privacy rights.

Review Questions (1 of 2)
Describe various principles identified in the medical code of ethics.
Explain medical staff organization and committee structure.
Describe the privileging and credentialing process.
Describe common medical errors as they relate to patient assessment, diagnosis, treatment, and follow-up care.

Review Questions (2 of 2)
Explain how the physician–patient relationship can be improved.
Describe common legal issues for behavioral health professionals.