Five into one equals $15 million Part III: A vision of efficiency

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1 THE NEWSLETTER FOR VOLUNTEER / ELECTED MEDICAL STAFF LEADERS Vol. 10 No. 5 May 2000 medical staff for briefing INSIDE A proposed revision to one of its medical staff standards could mean approval by the JCAHO of expedited credentialing at last. Turn to p. 7 for full details about the revision, as well as tips on designing and implementing a JCAHO-compliant fast-track credentialing system in your hospital. A recent and quite bizarre case of malpractice in New York City s Beth Israel Medical Center raises crucial questions for hospitals about needed changes in the areas of credentialing and quality assurance. See p. 9. Public Citizen s latest Health Research Group Ranking of State Medical Boards Serious Disciplinary Actions finds that the number of such actions decreased last year, increasing patient safety concerns. But a Federation of State Medical Boards official questions these conclusions. See p. 10 for details. Inside: Please fill out and return the enclosed reader survey Would you like free information on external peer review (EPR)? If so, go to our Web site, to sign up for a limited quantity of our EPR monograph. Visit to sign up for your FREE newsletter and visit our online store, for daily discounts and specials! Five into one equals 15 million Part III: A vision of efficiency Editor s note: This is the last part of a three-part series on how a health care system merged five medical staffs into one integrated staff with the help of The Greeley Company, a division of HCPro in Marblehead, MA. The reason for the merger was to meet Medicare s Conditions of Participation (COP) for achieving a single provider number in order to receive an anticipated 15 million reimbursement increase over a threeyear period. Editor s note: Our latest benchmarking survey examines the issue of medical staff leadership compensation. We asked each survey respondent for the size of his or her institution s medical staff. Medical staffs of 299 people or fewer are considered small; those with staffers are considered medium; and institutions with more than 800 on staff are viewed as large. Out of 135 respondents, almost half (66) had small staffs, followed by medium-sized institutions (54). The large staff category was the smallest, with 15 responses. MSB For the first month, MSB provided an overview of the project, including the five hospitals profiles, the steps the system took to obtain a single provider number, the keys to success, and additional merger benefits. Last month, MSB took a closer look at how the system attained several of those keys to success, and this month, MSB will focus on the vision it took to create a more effective medical staff. Mission impossible: Five Benchmarking survey: Medical staff leadership compensation Approximately two-thirds of hospitals compensate their physician leaders thanks the 135 readers who responded to this survey. > p. 2 It looks like more than half of United States hospitals currently compensate their medical staff leaders, with 66% (89) of survey respondents doing so and the 25% who do not saying they will start doing so soon. And that s good news. That s 66% more than were paid about 20 years ago. Nobody was paying back then, comments Richard E. Thompson, MD, a strong advocate of > p. 3

2 Five into one < p. 1 medical staffs have to merge into one to meet Medicare s COP to obtain a single provider number so that the system can receive increased Medicare reimbursements. Further, they have to do so in four months to meet a year-end deadline. Mission accomplished: By 1999 year-end, the five staffs became one integrated staff. But here s the kicker: The five original medical staffs are actually happy about the outcome, sources say. However, it took more than time and effort to merge the staffs so quickly and effectively. It also took vision, asserts Al Fritz, medical staff practice director at The Greeley Company. A vision of autonomy The vision was for a less bureaucratic, more effective, and integrated medical staff that promoted divisional autonomy, says Fritz. What defines a less bureaucratic medical staff? One that has fewer medical staff departments, has fewer medical staff committees redefining attendance requirements, allows physician leaders to extend their term of leadership if they re doing a good job, and successfully amends bylaws without a full vote of the entire staff, answers Fritz. The Physician Advisory Committee (PAC) consisting of three physicians selected by each of the five medical executive committees (MECs) wrote into the integrated system bylaws concepts for a new vision of the medical staff, fulfilling not only the COP, but also quality and credentialing functions, says Fritz. These concepts range from medical staff organization to the specifics of the credentialing process. Specifically, these concepts, with the steps it took to turn them into reality, are as follows: 1. The medical staff Create a single medical staff while preserving hospital division autonomy, control, and selfgovernance Create two classes of medical staff membership: Active currently a member in good standing on any of the medical staffs who may vote and hold office; and Associate any person who holds medical staff membership other than active status and may not vote or hold office 2. The MEC Design a system MEC composed of 15 members three from each hospital medical staff Any three members of the MEC could ask for a super majority vote, which means passage requiring a vote of 13 to 15 members Division MECs continue to function as before, with each division electing its officers and appointing members for the system MEC The system MEC elects its chair, who serves as the chief medical officer representing the medical staff to the system board Division MECs have the responsibility of preparing for fair-hearing processes, whereas the system MEC conducts the hearings 3. Credentialing processes Physicians designate their primary hospital to keep the physician s credentialing files No reapplication is required at the time of integration The division MEC is responsible for credentialing recommendations, and the system MEC makes the final credentialing recommendations to the system board Fritz notes that the hospitals share credentialing information in so far as the credentials procedure manual is a systematic document. Also the system MEC recommends to the system board all appointment and reappointment and privileging issues. If there is conflict at one hospital with another, the system MEC resolves the issue with input from each of the divisional MECs, he explains. Page 2 Medical Staff Briefing May 2000

3 4. Operational processes Hospital-based or exclusive physician contracts are to remain unchanged and not to become a medical staff integration issue Emergency on-call time requirements remain the same unless a physician chooses to increase them Medical staff dues stay the same, and each division decides how to use them The current individual hospital s medical staff bylaws are the operating rules of that hospital division, and they may be only changed by the hospital division Maintaining independence Divisional autonomy is a top concern among physicians, notes Fritz. To maintain that autonomy, the PAC intentionally keeps intact the hospital-specific MECs. In turn, these hospital-specific MECs report to a system-wide MEC, composed of equal numbers of physicians representing each MEC. But what about conflict resolution between the division and system MECs, when a hospital-specific MEC disagrees with a recommendation from the system MEC? Physician leaders wrote into the system bylaws that the issue would be discussed at a joint conference, and the position of the joint conference would be reviewed by the governing authority, answers Fritz. Any two members of the system MEC could call for a super majority approval, he adds. Fritz notes that while each hospital does not have its own set of medical staff bylaws, each facility does have its own medical staff operating procedure manual that allows each medical staff to organize itself at each facility the way it wants. Therefore, divisional operating procedures support the system s set of bylaws, Fritz says. Benchmarking survey < p. 1 compensation for medical staff leaders. He defines a medical staff leader as a doctor who chooses to remain primarily a clinician but accepts some organizational tasks. The figure was even higher among medium-sized hospitals, of which a full 80% currently pay their medical staff leaders. Respondents with small staffs were less likely to compensate their medical leaders, with slightly more than half reporting that they do not. Finally, 73% of responding hospitals with large staffs compensate their medical staff leaders, 7% behind medium-sized facilities. Thompson says that not paying physician leaders is financially unsound for even the smaller hospitals. It s a huge mistake not to pay physician leaders. Even smaller hospitals will end up spending more money if they don t pay leaders, he stresses. The survey results showed that in 45% of the hospitals that compensate their physician leaders, both the hospitals and their medical staffs pay for the extra compensation, usually split evenly between the two. Thirty-four percent of respondent hospitals pay the full amount on their own, and medical staffs pay for the total amount of medical leaders > p. 4 Who pays medical staff leaders? Page Figure 1 Just the medical staff (21%) Just the hospital (34%) Both the hospital and medical staff (45%) 3 Medical Staff Briefing May 2000

4 Benchmarking survey < p. 3 salaries in 21% of respondents institutions, usually through increased dues (see figure 1). Who gets paid? Thompson lists the following as the four physician leadership positions that should be compensated: President of medical staff/chief of staff Chair/head of clinical departments Chair of the credentials committee Chair of performance/quality committee As it turns out, the positions most commonly compensated among our respondents were as follows: Editor s note: Percentages below add up to more than 100% because some institutions pay for more than one leadership position. President of medical staff/chief of staff (97%) Chair/head of clinical departments (48%) Chair of credentials committee (42%) Medical director/vice president of medical affairs (VPMA) (29%) Other (34%) Most paid leaders are compensated annually, according to 69% of survey respondents. Twenty-one percent are paid monthly, 11% are paid by the hour, and 7% have other payment arrangements (by task, by meeting, etc.) (see figure 2). Average pay The group that is least likely to receive compensation medical directors/vpma is nevertheless the highest-paid, earning about 66,020 per year, according to our survey. But Thompson explains he does not consider the VPMA a medical staff leader position because VPMAs are members of the American College of Physician Executives, who have MDs as well as Master s in Business Administration degrees, and fall more squarely under the category of hospital executives. Most medium-to-small staff hospitals, he says, do not have VPMAs, adding that they receive a set yearly compensation as employees in these hospitals. Next in line are presidents of medical staff/chiefs of staff, who earn about 24,170 per year, followed by an average rate of 14,475 per year paid to leaders in the other category. The least well-paid groups were credentialing committee chairs, at about 7,975 per year, and department chairs, who get 6,444 per year on average, according to survey results. Thompson considers these last two averages on the low side. Figure 2 How are leaders compensated? Other (by task, meeting, etc.) (7%) By the hour (11%) Annually (69%) Monthly (21%) Note: Some hospitals use more than one payment method. Why some don t pay Financial constraints is an important reason why hospitals don t compensate their medical staff leaders, particularly among nonprofit, small, and rural health facilities. But there are other reasons that respondents cited, including the following: Medical staffs have not brought up the issue. In some cases, staffers feel it is their duty to contribute as leaders and do not expect to receive additional compensation. Leadership duties are a prerequisite for joining the medical staff. State law mandates that medical staff members absorb leadership duties. Page 4 Medical Staff Briefing May 2000

5 Unwanted influence by additional compensation. One survey respondent stated that physicians feel they might be influenced by the added compensation. Medical staffs must share the cost of compensating leaders with the hospital. Some respondents stated their hospitals won t pay medical staff leaders until the medical staff picks up a portion of the tab, generally 50%. Planning to compensate The main reasons given by respondents who plan to pay their physician leaders included increasing pressure from their medical staffs for compensation and difficulty in finding volunteers. The increasing workload for physicians has become a serious issue, respondents stated, and hospitals hope to ease the problem by making it financially attractive to perform these leadership duties, which can sometimes reduce the time they can devote to private practice. But Thompson strongly disagrees. The norm today should be that leadership positions don t take a lot of time at all, he says. Physicians today should not be overburdened. If they are, Thompson explains, it s because their hospitals have failed to streamline their systems. The best way to start, he advises, is to hire a full-time medical staff coordinator (MSC) who is certified by the National Association Medical Staff Services. An MSC can take over many of the time-consuming chores that medical staff leaders used to have to perform. Also, streamlining can be achieved by defining lists of specific tasks and by delegating responsibilities. Work with the heads of committees or departments instead of having to wait for full committees to meet, Thompson advocates. It now should take one-tenth of the time leadership positions used to require per month. It s good for business Many hospitals consider paying leaders a nonrevenue-producing proposition, Thompson states, but if they paid and trained these leaders to make better decisions, they d ultimately save a lot of money. Thompson stresses that all hospitals will benefit from paying their medical staff leaders. By paying its medical staff leaders, a hospital is telling them, We really need your leadership; you re not just a token doctor on the committee, he explains. Also important, Thompson adds, is the fact that paying a physician leader ensures that leader will more readily devote more time to those responsibilities and be available for more than breakfast, lunch, and supper meetings. Announcing msleader.com Our new Web site, msleader.com, will be up and running by the middle of this month. Please visit for essential information, useful links and ideas, and much more. Medical Staff Briefing Subscriber Services Coupon q I m a NEW subscriber. Start my subscription for q one year, 337 q two years, 607 q Payment enclosed. q Please bill me. q Please bill me using PO # Charge q AmEx q MasterCard q VISA Signature Card # Expires Your credit card bill will reflect a charge to Opus Communications, the publisher of Medical Staff Briefing. Name & Title Organization Address City State ZIP Phone ( ) Fax ( ) Mail to: Opus Communications P.O. Box 1168, Marblehead, MA Call: 800/ Fax: 800/ customer_service@hcpro.com Internet: N0001 Medical Staff Briefing May 2000 Page 5

6 Medical staff matters The unacceptable applicant Part 1: What makes an applicant unacceptable? By Richard E. Thompson, MD Editor s note: It s not unusual for credentialing professionals to occasionally encounter an unacceptable medical staff applicant. This month s column provides insights into defining and identifying the unacceptable applicant. In a one-page Standard for Hospitals (1919), the American College of Surgeons (ACS) invented credentialing (though not by that name), and listed criteria for acceptable applicants:... that membership upon the staff be restricted to physicians and surgeons who are (a) full graduates of medicine in good standing, legally licensed to practice in their respective states, (b) competent in their respective fields, and (c) worthy in character and in matters of professional ethics. It appears the ACS intended to protect hospitalized patients, medical professionalism, and the reputations of bona fide practitioners on a hospital staff. Today, these three purposes remain the same with a fourth added: Within the limits of both fairness to applicants and patient/community need, organizational interests must also be protected. And that doesn t mean economic advantage. Rather, the goals are to protect the organization s positive public image, assets, and integrity. Today, these four objectives to protect patients, professionalism, practitioners, and the organization relate to processing applications from all independently acting practitioners. The ability to screen out applicants who are not full graduates, legally licensed is now the norm, thanks to the JCAHO s and attorneys insistence on validation of applicant-submitted information. But occasionally an impostor or unlicensed practitioner slips through the cracks. Such rare happenings are often sensationalized, justifiably demanding intense focused effort to re-evaluate, revise, and retest our own procedures. Further, such occurrences make us mistakenly think that this is the heart of credentialing and privileging. However, everyday activities are critically important to a greater number of patients. Take, for example, the mundane task of ensuring, within reason, that credentials and performance of an applicant match the intended nature of the individual s practice. And periodically, hospitals must confirm basic credentials and maintenance of dependable clinical performance. To do this requires identification of applicants who may practice undependably in some areas and others who are not worthy in character and... in matters of professional ethics. Don t be fooled. Clinically undependable practitioners know how to present themselves as highly respected and sought-after. They have no problem providing three reference letters because most physicians fear not writing one when asked to do so. So don t just count and file these reference letters read them! And be aware of the between-the-lines warnings. For example: We are delighted to learn that Dr. Smith is planning to move to your area, and we re sure you ll probably learn to like him. He has practiced here for the last seven years, and all but a few of his patients have left the hospital without incident. Physician-specific performance data provides more objective information than a letter. But data available are not useful. Statistics like number and percent of variations from clinical guidelines can be misleading because of the good and bad reasons for departing from clinical guidelines when planning care for a patient. Hospitals must isolate physician factors before trending data through a cause-and-effect analysis. The character and ethical behavior of an applicant are not easy to determine, but you can avoid being fooled by an unacceptable applicant by following a key maxim: The application form must not be the end of your inquiries, but only the beginning. Next month, Part 2: Strategies for denying unconditional appointment and privileges to unacceptable applicants. Page 6 Medical Staff Briefing May 2000

7 CREDENTIALING INFORMATION FOR MEDICAL STAFF LEADERS msb credentialing The JCAHO could approve expedited credentialing soon Expedited credentialing, also known as fast-track or streamlined credentialing, is likely to be approved by the JCAHO by modifying one of its medical staff standards, reports Hugh Greeley, chair of The Greeley Company, a division of HCPro, in Marblehead, MA. The JCAHO s Professional and Technical Advisory Committee met in March to review a draft modification of MS.5.1.1, which would permit this activity, under specific conditions, according to Carol Cairns, CMSC, CPCS, president of PRO-CON in Coal City, IL. Conventional credentialing Here s how conventional credentialing works. When a hospital s medical staff office gets the necessary application materials and primary source verifies the applicant s credentials, the application moves on to the appropriate department head for review. From there, it proceeds first through the credentials committee and then through the medical executive committee (MEC). This process can take weeks because committee members have to be rounded up for these meetings. Finally, the application reaches the governing board for final approval. This traditional approach, which can take up to four months, presents serious problems for hospitals, particularly in the area of temporary privileging, according to Rick Sheff, MD, practice director of medical staff credentialing and quality at The Greeley Company. A typical example might be the case of an applicant waiting to be approved to join a hospital s medical staff who is scheduled to conduct a procedure before the credentialing process is completed. Another is when temporary privileging is needed for a locum tenens physician who will be providing coverage for a limited time. The credentialing process simply takes too long to adequately assess and approve a practitioner who is urgently needed. Other problems often arise, says Sheff, because applicants simply do not submit applications in time, forcing the hospital to approve temporary privileges without conducting a thorough credentialing check. Understandably, many hospitals have turned to expedited credentialing (which can take only four to six weeks), even without official JCAHO sanction. Expedited credentialing is not new Expedited credentialing is not a revolutionary practice. Hospitals have done expedited credentialing for many years, says Sheff, but in the last year-and-a-half or so some have received Type I s during their accreditation surveys because the JCAHO objects to the practice among these hospitals of excluding a full meeting of the MEC. In the expedited credentialing process right > p. 8 Medical Staff Briefing May 2000 Page 7

8 Expedited credentialing < p. 7 now, the MSO primary source verifies an applicant s information and, if it presents no red flags such as an unexplained gap in a résumé moves it through quickly, on to the department chair, bypassing the traditional credentials committee, and going straight to a designated representative of the MEC. After MEC approval, it goes to a governing board subcommittee for final approval. What does the draft standard propose? The proposed modification to MS requires that the MEC meet in full committee. But it permits a subcommittee of the hospital s governing board to make appointment and privileging decisions. The proposal also outlines the following conditions under which a hospital cannot place an application into an expedited system: Submission of an incomplete application Adverse or limited recommendation by the MEC Successful challenge to licensure or registration Involuntary termination of medical staff membership at another hospital Involuntary limitation, reduction, denial, or loss of clinical privileges Adverse final judgment in a professional liability case What does MS mean to you? The JCAHO s possible approval of expedited credentialing, says Sheff, is not only good news for physicians, but also for hospitals. For physicians, he says, it means they will be able to obtain their privileges, or those of the staff they need on board, more quickly. Hospitals can save time and money, as well as decrease risk and increase patient safety possibly even eliminating the temporary privileging process. With expedited credentialing, Sheff explains, a medical staff can establish a standard that, at a minimum, would guarantee that a hospital quickly can get the core information on an applicant, which then would be approved by the department chair. And the temporary privileging process can be eliminated because most of the applicants will meet the necessary core requirements, as will most applicants. Now what? What do those MSOs that have been using expedited credentialing have to do to comply with the new standard? According to Sheff, they need to make sure to include the full MEC in the process. While this initially will mean a slowing down of their expedited process, they will soon get back up to speed. Should hospitals where expedited credentialing is entirely new now use it? How should it implement one that stays in line with the new standard? I recommend that all hospitals consider this new flexibility, says Greeley. And if such flexibility is needed, each should amend its governing board bylaws or create a governing board policy appointing a subcommittee to handle expedited credentialing matters. Ideally, Greeley adds, the governing board s subcommittee should be composed of the chief executive officer, especially if he or she is a board member; the chief of staff (who is often a board member); and the chair of the credentials committee. These individuals are often in the hospital at the same time and attend all MEC meetings. This subcommittee would report regularly to the board. Alternatively, the governing board could work with the MEC to create an institutional policy and procedure to guide both the medical staff and the board, Greeley continues. If the medical staff wanted to further expedite the credentialing process, it would need to revise its own bylaws as well as create a medical staff policy and procedure to address expedited processing. Page 8 Medical Staff Briefing May 2000

9 Bizarre sentinel event points to system flaws The recent case of a prominent New York City obstetrician who carved his initials on the abdomen of a patient after completing a cesarean delivery has added fuel to the already growing fire of distrust on the part of the public toward their physicians and health care facilities. On top of distrust, these incidents can be expensive both to a hospital s pocketbook and to its image. Last September 7, Alan Zarkin, MD, announced to those present in the operating room with him at Beth Israel Medical Center the patient s husband and mother, an internist, two nurses, an anesthesiologist, and an assistant that he was going to sign his work and proceeded to carve the initials AZ on patient Liana Gedz s abdomen so quickly there was no time to intervene. Literally with the stroke of a hand, a patient was harmed, a physician s reputation was ruined, and a hospital was left struggling to regain its credibility. In fact, as part of that struggle, the hospital must hire an independent consultant to review its credentialing practices. A little history Beth Israel promptly revoked Zarkin s privileges, yet he continued to practice medicine for the next three months, in private practice as well as in the role of new medical director of Choices Women s Medical Center in Queens. He treated about 560 patients, says Robert Sullivan, Gedz s attorney. Further, the chair of Beth Israel s obstetrics and gynecology department Zarkin s former boss met with Zarkin at Choices a short time after the incident to discuss a possible midwifery program at the clinic to be managed jointly by Choices and Beth Israel, according to published reports. Although Donald W. Hoskins, MD, vice president of medical affairs and medical director of Beth Israel Medical Center, stressed the hospital s disapproval and lack of knowledge of the meeting, the damage was done. Some questions What mechanisms had failed at Beth Israel that allowed for such a thing to happen in the first place? Why was Zarkin able to continue to practice? Why did the New York State Health Department wait until January 7 to suspend his medical license and initiate an investigation? At the 5.5 million malpractice suit, Zarkin s defense was a frontal lobe brain disorder that causes irrational and unpredictable behavior. (The lawsuit was settled for a reported 1.7 million.) Hoskins stresses that Beth Israel had no way of predicting such an incident. We consider this a single-episode event that was not preventable. No data in the National Practitioner Data Bank or in the hospital s records, he adds, alerted Beth Israel of any problems. Every two years he got reappointed, and we received a favorable letter about him from an independent doctor. Not good enough But Herman Williams, MD, medical director of external peer review at The Greeley Company, a division of HCPro, in Marblehead, MA, says this is not enough. You just don t wake up one morning and do something like that. There are certain subtle behaviors and events that lead up to a sentinel event like this and they should always be documented, he says. Eighty percent of problems that occur are due to system errors, Williams explains, adding that hospitals need to do more root-cause analyses and carefully document all questionable incidents. A medical staff must use the concept of trending behavior, he says, which can alert them to potentially problematic or high-risk areas, he says. The medical staff model is steeped in retrospective mode, Williams says, explaining that most serious investigations are launched after the fact. They need to be in a prospective > p. 11 Medical Staff Briefing May 2000 Page 9

10 Do fewer disciplinary actions by state medical boards equal greater patient risk? It could be that patients are at greater risk for injury in states with poor disciplinary records for physicians, according to a recent report ranking medical boards by the number of disciplinary actions they took last year. It is likely that patients are being injured or killed more often in states with poor disciplinary records than in states with consistent top performances because providers in those states might well be barred from practice in states with better disciplinary records, concluded Public Citizen s Ranking of State Medical Boards Serious Disciplinary Actions in The report is based on the Federation of State Medical Boards (FSMB) Annual Summary of Board Actions, and comes on the heels of its March release. The rankings report lists the number of serious disciplinary actions taken by state medical boards last year as 2,696, down slightly (by 36) from Best and worst Alaska ranked number one as the best performing state, reporting serious actions per 1,000 physicians last year. Rounding out the top five were North Dakota (8.77), Wyoming (8.15), Idaho (7.02), and Oklahoma (5.95). The worst states were Delaware, Nebraska, Tennessee, Minnesota, and Hawaii, all with fewer than two serious disciplinary actions last year. The report cites New York (14th), Michigan (19th), and California (20th) as being the large states that have shown the most improvement, from 40th, 49th, and 37th, respectively, in Public Citizen says its method to calculate each state s rate of serious disciplinary actions (defined in its report as revocations, surrenders, and probations/restrictions ) is to take the number of actions by state as reported by the FSMB and divide it by the American Medical Association s data on nonfederal physicians as of December 1998 and then multiply the result by 1,000 to get state disciplinary rates. A call for improvements The Public Citizen report concluded that stateby-state performance is spotty, but that the following changes could lead to improvement: Adequate funding Adequate staffing Proactive investigations (rather than only following up on complaints) Use of relevant data from all sources, such as Medicare and Medicaid Boards should gain independence from state medical societies and other governmental bodies A reasonable statutory framework for disciplining physicians A challenge to Public Citizen s rankings But how accurate is it to assume that the states with the highest numbers of reported disciplinary actions are the states with the best patient safety records? It s not, according to FSMB executive vice president James R. Winn, MD, who attacks Public Citizen s ranking method on several fronts. The incidence of malpractice claims per state is not uniform per 1,000, he says. California has a very high rate; Wyoming and Idaho don t. That doesn t mean that Wyoming and Idaho have better physicians. Winn suggests that in some states the population may simply be less litigious. You re missing the boat when you re trying to rank boards one against the other, he says, adding that it isn t fair to use disciplinary data to rank one board against the other because each board is different. Some are advisory in nature, he says, with no investigative staff and no resources; some are large but underfunded; some are small but Page 10 Medical Staff Briefing May 2000

11 well-funded and with large staffs. Also, Winn continues, a decline in reported complaints to a particular medical board does not necessarily indicate a problem. It could be, for instance, that the state s attorney general has a backlog of cases, or that it has declined to prosecute some. Another factor, Winn says, is that more use is being made of impaired physician programs, through which, for example, a physician addicted to drugs can be confidentially restricted from his or her practice while undergoing treatment. This type of restriction is not reported as a disciplinary action. Serious v. prejudicial actions Semantics brings us to Winn s second point of contention with the Public Citizen findings. Public Citizen defines serious actions differently than we do, says Winn, who was pleased with what the FSMB report showed to be an increase in this type of actions last year (3,838, compared to 3,767 prejudicial actions reported in 1998). That s 1,142 more actions than the 2,696 listed in the Public Citizen report. (Editor s note: MSB was unable to reach Public Citizen for comments by press time.) Winn defines prejudicial as an action taken by a board that affects adversely the privileges of the licensee to practice medicine. Such actions, he explains, could range from a simple modification requiring a physician to get consultations in certain areas of practice to full revocation of a license. Public Citizen reports have tended to focus solely on severe cases, which brings the total number of disciplinary actions down, he says. System flaws < p. 9 mode. When the first event occurs, they should document it and state that this is not allowed. Hoskins says there were, in fact, two events on record about Zarkin prior to this incident, but that they didn t suggest he was capable of this type of extreme behavior. This leads to an important question: What level and frequency of abnormal behavior should trigger an evaluation process? The first documented incident about Zarkin was in February 1998, when he used intemperate language toward a clerk. Tellingly, as a direct result of the second recorded incident, in December 1998, Zarkin was sent for psychiatric and physical evaluation. Hoskins says the hospital took no further actions because Zarkin s assessment was normal. But Gedz and her husband s comments to the press may indicate that the number of complaints about Zarkin, although undocumented, may have been much higher. Gedz told of remarks by Zarkin of a sexual nature, citing one he made about a patient s pubic hair. Sullivan cited numerous other undocumented complaints made before the September incident. Nurses may be afraid to lose their jobs and physicians of being sued for slander, Williams says. Health department findings The New York State Health Department found that Beth Israel conducted a prompt investigation and suspended Zarkin in a timely fashion, but the rest of its findings were not so positive. This case indicates hospitals shouldn t take reporting incidents to the state health department casually. The worst misconduct, according to the Health Department, was that Beth Israel failed to file a required incident report to the New York Patient Occurrence Report Tracking System (NYPORTS). Also, in its report to the Office of Professional Medical Conduct, Beth > p. 12 Medical Staff Briefing May 2000 Page 11

12 System flaws < p. 11 Israel didn t provide specifics about the incident, describing it as gross misconduct. The OPMC found it significant that previous misconduct reports from Beth Israel had been very specific, and said that because of this and the hospital s failure to report to NYPORTS, swifter action was not taken against Zarkin. We reported only to the OPMC because there was no break in hospital protocol and this was a random act, explains Jim Mandler, spokesperson for Beth Israel. The health department also found clear indications that up to one year before the incident Zarkin s behavior was inappropriate, but the hospital took no action and did not document complaints. Health department documents state this was not the first time Beth Israel had been cited for violations in the operation of its OB/GYN department and quality assurance program. In addition to 14,000 in penalties, Beth Israel must (1) submit a Plan of Corrections; (2) submit quarterly reports detailing corrective actions; (3) hire an independent consultant to conduct an in-depth analysis of the management and oversight of its of OB/GYN department, with a focus on quality assurance and provider credentialing; and (4) secure a second consultant to analyze and suggest hospital-wide improvements to its quality assurance and credentialing procedures. Hospital response Beth Israel s response has been swift. Perhaps the most important change is that the hospital centralized its credentialing system. Every single complaint now must come through the medical director s office, Hoskins explains. And we trend behavior now and keep track of absolutely everything, confirming Williams recommendations. Further, Hoskins adds, We ve now included and underscored the importance of the behavioral aspect. This is now out there as being just as important as any other aspect of the quality of care. Medical Staff Briefing Editorial Advisory Board Milton B. Good, MD Fairview General Hospital Cleveland, OH Suzanne Perney, Publisher/Vice President, sperney@hcpro.com Dale Seamans, Executive Editor, dseamans@hcpro.com Maria Rodriguez-Gil, Managing Editor, mrodriguez-gil@hcpro.com Richard E. Thompson, MD, Contributing Editor, President, Thompson, Mohr & Associates, Dunedin, FL William H. Roach Jr., JD Partner, Gardner, Carton & Douglas Chicago, IL Lisa Taylor, Esq. Partner, St. John & Wayne Newark, NJ Hugh P. Greeley Chair, The Greeley Company Marblehead, MA Robert G. O Driscoll, MD Saint Barnabas Medical Center Livingston, NJ Jodi A. Schirling, CMSC Alfred I. dupont Institute Wilmington, DE Raymond E. Sullivan, MD, FACS Waterbury Hospital Health Center Waterbury, CT William A. Thompson, MD, MBA John D. Archbold Memorial Hospital Thomasville, GA Medical Staff Briefing (ISSN ) is published monthly by Opus Communications, Inc., a division of HCPro, 200 Hoods Lane, Marblehead, MA Subscription rate: 337/year or 607/two years (13 copies maximum); back issues are available for 30 each. Copyright 2000 Opus Communications, Inc., a division of HCPro. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of Opus Communications or the Copyright Clearance Center at 978/ Please notify us immediately if you have received an unauthorized copy. For editorial comments or questions, call 781/ or fax 781/ For renewal or subscription information, call customer service at 800/ , fax 800/ , or customer_service@hcpro.com. Visit our Web site at Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the Marketing Department at the address above. Opinions expressed are not necessarily those of MSB. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions. Printed on recycled paper Page 12 Medical Staff Briefing May 2000