2. Chapter 8
Medical Staff
2

3. Chapter Overview
• Overview of medical ethics
• Medical staff organization
• Credentialing process
• Review of pertinent legal cases
– where physicians are most vulnerable
3

4. Principles of Medical Ethics
• Code of Medical Ethics
• Case: What’s Wrong With This Picture
– The Frustrated Patient
4

5. Executive Committee
• Recommends medical staff structure.
• Develops a process for reviewing credentials.
• Recommends appointments to the medical staff.
• Develops processes for delineating clinical privileges.
• Performance improvement activities.
• Peer review.
• Fair hearing process.
• Review & act on reports of medical staff
departmental chairpersons & medical staff
committees.
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6. Bylaws Committee
• Organization of the medical staff is described in its
bylaws, rules, & regulations.
• Bylaws must be approved by the governing body.
• Bylaws must be kept current & the governing body
must approve recommended changes.
• Bylaws describe various membership categories of
the medical staff (e.g., active, courtesy, consultative).
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7. Blood & Transfusion Committee
• Develops blood usage p & p
• Monitors transfusion services
• Monitors
– indications for transfusions
– blood ordering practices
– each transfusion episode
– transfusion reactions
7

8. Credentials Committee
• Oversees application process for medical staff
applicants, requests for clinical privileges, &
reappointments to the medical staff.
• Makes its recommendations to the medical
executive committee.
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9. Infection Control Committee
The infection control committee is generally
responsible for the development of policies &
procedures for investigating, controlling, &
preventing infections.
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10. Medical Records Committee
• Develops policies & procedures, including
– release, security, & storage
– determining the format of medical records
– monitoring records for accuracy
– completeness, legibility, & timely completion &
clinical pertinence
– ensures records reflect condition & progress of the
patient, including results of all tests & therapy
given & makes recommendations for disciplinary
action as necessary.
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11. Pharmacy & Therapeutics Committee I
• Policies & procedures
(e.g., selection, procurement, distribution, hand
ling, use, & safe administration of
drugs, biologicals, & diagnostic testing
material).
• Oversees development & maintenance of
formulary.
• Evaluates & approves protocols for the use of
investigational or experimental drugs.
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12. Pharmacy & Therapeutics Committee
II
• Oversees
– tracking of medication errors
– adverse drug reactions
– management, control, effective & safe use of
medications through monitoring & evaluation
– monitoring of problem-prone, high-risk, & high-
volume medications
12

13. Quality Improvement Council
Functions as a patient care assessment &
improvement committee.
13

14. Tissue Committee
• Surgical case reviews including
– justification & indications for surgical procedures.
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15. Utilization Review Committee – I
• Monitors & evaluates utilization issues such as
medical necessity and appropriateness of
admission & continued stay, as well as delay
in the provision of diagnostic, therapeutic, &
supportive services.
• Ensures each patient is treated at appropriate
level of care.
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16. Utilization Review Committee – II
• Objectives of the committee include:
– transfer of patients requiring alternate levels of
care
– promotion of efficient & 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
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17. MEDICAL DIRECTOR
Serves as a liaison between medical staff &
organization's governing body & management.
17

18. Medical Staff Privileges - I
• Screening Process
– Application
– Medial Staff Bylaws
– Physical & Mental Status
– Consent for Release of Information
– Certificate of Insurance
– State Licensure
– National Practitioner Data Bank
– References
– Interview Process
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19. Medical Staff Privileges - II
• Delineation of Clinical Privileges
• Governing Body & Final Action
• Reappointments
• Appeal Process
• Reappointments
19

20. Medical Staff Privileges - III
Cases
• Screening for Competency
• Misrepresentation of Credentials
– Evidence submitted supported physician falsely
indicated that he had American Board of Internal
Medicine certification.
– Board contended hearing examiner addressed
physician's credibility & found many statements to
support conclusion that physician intended to
misrepresent his board status.
No. 04AP-72 (Ohio Ct. App. 2004)
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21. Medical Staff Privileges - IV
• Limitations on Requested Privileges
– Must be accordance with bylaws
– Appeal procedures must be followed
• Hospital’s Duty to Ensure Competency
21

22. Physician Supervision &
Monitoring
• Peer Review
• Board responsibility to recognize
incompetence
• Suspension & termination of privileges
22

23. Disruptive Physicians
• Negative impact on an organization's staff and
ultimately affect the quality of patient care.
• Physician's ―inability to work with others‖
– sufficient grounds to deny staff privileges
• Demonstrated Inability to Work with Others
• Failure to Meet Ethical Standards
23

24. PHYSICIAN NEGLIGENCE
CASES
24

25. Misdiagnosing Accident Victim – I
A police department physician examined an
unconscious man who had been struck by an
automobile. The physician concluded that the
patient's insensibility was a result of alcohol
intoxication, not the accident, & ordered the police to
remove him to jail instead of the hospital. The
man, to the physician's knowledge, remained
semiconscious for several days & finally was taken to
the hospital at the insistence of his family. The patient
subsequently died. An he autopsy revealed massive
skull fractures.
Did the physician commit malpractice?
25

26. Misdiagnosing Accident Victim – II
Yes!
Although a physician does not ensure the correctness
of the diagnosis or treatment, a patient is entitled to
such thorough & careful examination as his or her
condition and attending circumstances permit, with
such diligence and methods of diagnosis as usually
are approved and practiced by medical people of
ordinary or average learning, judgment, and skill in
the community or similar localities.
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27. Failure to Respond: Emergency Calls
• Physicians on call in emergency dept expected
to respond to requests for emergency
assistance when such is considered necessary.
• Failure to respond is grounds for negligence
should a patient suffer injury as a result of a
physician's failure to respond.
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28. Delay in Treatment
• A physician may be liable for failing to
respond promptly if it can be established that
such inaction caused a patient's death, (See text
case: Blackmon v. Langley)
• Failure to Treat Evolving Emergency
28

29. Inadequate History & Physical
• Failure to obtain an adequate family history &
perform adequate physical
– violates a standard of care owed to the patient.
– (See text case: Foley v. Bishop Clarkson Memorial
Hospital)
• Failure to Document H & P
– See text case: Solomon v. Ct. Med. Exam. Bd.
29

30. Choice of Treatment:
Two Schools of Thought
• 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, &
reasonable medical experts.
• Use of unprecedented procedures that create an
untoward result may cause a physician to be found
negligent even though due care was followed.
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31. Failure to Order Diagnostic Tests
• A plaintiff who claims that a physician failed
to order proper diagnostic tests must show:
– It is standard practice to use a certain diagnostic
test under the circumstances of the case.
– The physician failed to use the test & therefore
failed to diagnose patient's illness.
– The patient suffered injury as a result.
31

32. Failure to Promptly Review Test
Results
• A physician's failure to promptly review test
results can be the proximate cause of a
patient's injuries.
– See text case: Smith v. U.S. Department of
Veterans Affairs
32

33. Efficacy of Test Questioned
• Physicians should be sure that the tests they order
are a valuable tool in diagnosing a patient’s
ailments.
• Not all tests are equal
– some can leave false impressions
• e.g., blood occult test
33

34. Imaging Studies/Radiology
• Failure to Order Appropriate Imaging Studies
• Image Misinterpretation Leads to Death
• Failure to Consult with a Radiologist
• Failure to Read Images
• Delay in Conveying Imaging Results
• Failure to Communicate X-Ray Results
34

35. Failure to Obtain Timely Diagnosis
• Physician can be liable for reducing a patient's
chances for survival.
• Timely diagnosis of a patient's condition is as
important as the need to accurately diagnose a
patient's injury or disease.
– Failure to do so can constitute malpractice if a
patient suffers injury as a result of such failure.
• See text case: Powell v. Margileth,
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36. Failure to Obtain 2 nd Opinion
• Physicians must seek 2nd opinions when required.
– See text case: Goodwich v. Sinai Hospital
• In this case, the record was replete with
documentation of questionable patient
management & continual failure to comply with
2nd-opinion agreements.
36

37. Failure to Refer
• A physician has a duty to refer his or her patient
whom he or she knows or should know needs referral
to a physician familiar with and clinically capable of
treating the patient's ailments.
• To recover damages, the plaintiff must show that the
physician deviated from the standard of care and that
the failure to refer resulted in injury.
– See text case: Doan v. Griffith
37

38. Practicing Outside Field of Competence
• Physicians should practice discretion when treating
patients outside their field of expertise.
• Standard of care required in a malpractice case will
be that of the specialty in which a physician is
treating, whether or not he or she has been
credentialed in that specialty.
– See text case: Carrasco v. Bankoff
38

39. Timely Diagnosis
• Liability for reducing a patient’s chances for survival
• Timely diagnosis as important as the need to
accurately diagnose
• Failure timely diagnose can result in a malpractice
suit
– if a patient suffers injury as a result of such failure
• Wronguful Death
39

40. Misdiagnosis
• Mitral Valve Malfunction
• Failure to Form a Differential Diagnos
• Appendicitis
• Diabetic Acidosis
40

41. Failure to Read Nursing Notes
• A physician can breach his or her duty of care
by failing to read nursing notes.
• See text case: Todd v. Sauls.
41

42. Failure to Use
Patient Data Gathered
• Assume Nothing
– Critical information often gets lost in the record
– Information critical to patient care must be readily
available
– Failure to Use Critical information
• Patient allergic to Latex has a Latex catheter
inserted
– Leads to chronic bladder disorder
42

43. Medication Errors
• Wrong Dosage
• Abuse in Prescribing Medications
• Wrongful Supply of Medications
43

44. Failure to Follow:
Different Course of Action
Failure of an attending physician to recognize
recommendations by consulting physicians—
who determine a different diagnosis &
recommend a different course of treatment in a
particular case—can result in liability for
damages suffered by the patient.
44

45. Failure to Provide Informed Consent
Physicians must inform their patients of the
known benefits, risks, & alternatives to
recommended procedures.
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46. Surgery
• The Phantom Surgeon
• Wrong Surgical Procedure
• Correct Surgery–Wrong Site
• Wrong Site Surgery: Fraud
• Foreign Objects Left In Patients
– Needle Fragment Left in Patient
46

47. Improper Performance of a Procedure
Improper performance of a procedure can result
in injury to the patient & liability for the
physician.
47

48. Failure to Maintain Adequate Airway
• See text case: Ward v. Epting
– Anesthesiologist failed to conform to the standard
of care.
– Deviation from the standard was the proximate
cause of the patient's death
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49. Pathologist
Misdiagnosis of Breast Cancer
• See text case: Anne Arundel Med. Ctr., Inc. v.
Condon
– Pathologist's failure to interpret invasive
carcinoma was a departure from standard of care
required, & was proximate cause of patient’s
injuries.
49

50. Aggravation of A Pre-Existing
Condition
• See text Case: Nguyen v. County of Los
Angeles
– Aggravation of a preexisting condition through
negligence may cause a physician to be liable for
malpractice.
– If the original injury is aggravated, liability will be
imposed only for the aggravation, rather than for
both the original injury & its aggravation.
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51. Loss of Chance to Survive
• A loss of chance to survive can result in
malpractice.
• See text cases:
– Boudoin v. Nicholson, Baehr, Calhoun & Lanasa
– Downey v. University Internists of St. Louis, Inc .
• Possibility of Survival Destroyed
– Griffett v. Ryan
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52. Lack of Documentation
• Value of maintaining records of treatment.
– Important for patient’s on-going care
– Important for family member care
– It may be many years after a patient has been
treated before litigation is initiated.
• Jury could consider failure to document as
sufficient evidence for finding a physician
guilty of negligence.
52

53. Premature Discharge
• Premature discharge of a patient is risky business.
• Intent of discharging patients more expeditiously is
often due a need to reduce costs.
• Dr. Nelson, an obstetrician & board member of the
American Medical Association
• discharge "should be based on medical factors &
ought not be relegated to bean counters.―
– Anita Manning, AMA Calls Drive-Thru Birth
Risky, USA TODAY, June 21, 1995, at 1.
53

54. Failure to Follow-up
Failure to provide follow-up care can result in a
lawsuit if such failure results in injury to a
patient.
54

55. Infections
• A Case for Best Practices
• Infections a Recognized Risk
• Preventing Spread of Infection
• Poor Infection-Control Technique
55

56. Obstetrics
• C-Section Delay Causes Injury
• Failure to Perform Cesarean Section
• Failure to Attend Delivery: Fetus Decapitated
• Failure to Perform Timely C-Section
• Wrongful Death of Unborn Fetus
56

57. Psychiatry - I
• Commitment
– Involuntary commitment
– Involuntary commitment ordered
– Continuation of Commitment
– Involuntary Commitment Invalid
– Commitment by spouse
– Commitment by parent
– Patient due process rights
– Release denied
– Recommended Discharge Denied 57

58. Psychiatry - II
• Electroshock
• Duty to Warn
– Exceptions to Duty to Warn
– Suicidal Patients
• Failure to Provide Appropriate Evaluation
– Reimbursement Denied for Inadequate Care
58

59. 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
59

60. Physician-Patient Relationship - I
• Personalize treatment
• Conduct a thorough Assessment
• Develop a problems list & comprehensive
treatment plan
• Provide sufficient time and care to each patient
• Request consultations when indicated & refer
if necessary
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61. Physician-Patient Relationship - II
• Closely monitor patient progress
– make adjustments to treatment plan as the patient’s
condition warrants
– Maintain timely, legible, complete, & accurate
records
– Do not make erasures.
– Do not guarantee treatment outcomes
• Provide for cross-coverage during days off
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62. Physician-Patient Relationship - III
• Do not over-extend your practice
• Avoid prescribing over the telephone
• Do not become careless because you know the
patient
• Seek advice of counsel should you suspect the
possibility of a legal action
62

63. REVIEW QUESTIONS – I
1. Discuss importance of delineating clinical
privileges.
2. Why is it important that the governing body
approve the appointment and reappointment of
physicians to the medical staff?
3. What, if any, sanctions should be imposed upon an
on-call physician who fails to respond to such call
when requested? Discuss your answer.
63

64. REVIEW QUESTIONS – II
4. Under what circumstances should a hospital be
liable for a physician's negligence?
5. Describe what options a hospital has in disciplining
a disruptive physician. What effect can a physician’s
disruptive behavior have on patient care?
6. When two physicians have opposing views as to a
patient's medical needs, what course of action should
the patient's attending physician follow?
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65. REVIEW QUESTIONS – III
7. Describe malpractice risks for radiologists
and attending physicians.
8. Is a poor outcome always an indication of a
negligent act? Explain.
9. When is a physician considered to have
abandoned his or her patient?
65