Medical Staff Organization and Physician Liability © Luis Louro/Shutterstock It’s Your Gavel… RIGHT PATIENT, WRONG SURGERY The plaintiff was diagnosed with a herniated disc at L4-L5. His surgeon performed a laminectomy. During a review of the plaintiff’s postoperative X-rays, the surgeon noted that he had mistakenly removed the disc at L3-L4. The plaintiff testified that after the surgery, his condition progressively worsened. The plaintiff’s expert testified that removal of the healthy disc caused the space between L3-L4 to collapse and the vertebrae to shift and settle. Even the defendant’s expert witness testified that the removal of the healthy disc would increase the likelihood that the plaintiff would be more susceptible to future injuries. The trial court directed a verdict against the defendant based on the defendant’s own admission and that of his expert that he was negligent and that his negligence caused at least some injury to the patient. The defendant appealed. 1 WHAT IS YOUR VERDICT? Learning Objectives The reader, upon completion of this chapter, will be able to: • Describe medical staff organization and committee structure. • Describe the credentialing and privileging process. • Discuss the purpose of physician supervision and monitoring. • List and discuss common medical errors and how they lead to litigation. • Explain how the physician–patient relationship can be improved. This chapter provides an overview of medical ethics, medical staff organization, the credentialing process, and a review of cases focused on the legal risks of physicians. The cases presented highlight those areas in which physicians tend to be most vulnerable to lawsuits. 10.1 PRINCIPLES OF MEDICAL ETHICS The medical profession has long subscribed to a body of ethical guidelines developed primarily for the benefit of the patient. As a member of this profession, a physician must recognize responsibility to patients first and foremost, as well as to society, to other health professionals, and to self. The following 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. Code of Medical Ethics I. A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights. II. 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. III. 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. IV. 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. V. 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. VI. 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. VII. A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health. VIII. A physician shall, while caring for a patient, regard responsibility to the patient as paramount. IX. A physician shall support access to medical care for all people. 2 The following correspondence in the form of a reality check describes one episode of a frustrated patient’s journey of being passed from physician to physician, eventually finding one she thought would help her find the answers to her mysterious disease. The patient’s hope for answers and possible treatment in this reality check were dashed. The patient began to lose trust in the medical profession. I listened as she explained to me, “I was troubled as I stood looking at the code of medical ethics that hung so prominently in the physician’s waiting room. All the right words were there, only one thing was missing.” I asked her what was missing. She looked at me and emphatically said, “Practice.” 10.2 MEDICAL STAFF ORGANIZATION The medical staff is formally organized with officers, committees, and bylaws. At regular intervals, the various committees of the medical staff review and analyze their responsibilities, clinical experiences, and opportunities for improvement. The responsibilities of a variety of medical staff committees are described here. Executive Committee. The executive committee oversees the activities of the medical staff. It is responsible for recommending to the governing body such things as medical staff structure, a process for reviewing credentials and appointing members to the medical staff, a process for delineating clinical privileges, a mechanism for the participation of the medical staff in performance improvement activities, a process for peer review, a mechanism by which medical staff membership may be terminated, and a mechanism for fair hearing procedures. The executive committee reviews and acts on the reports of medical staff departmental chairpersons and designated medical staff committees. Actions requiring approval of the governing body are forwarded to the governing body for approval. Executive committee members generally include the chief of staff, medical staff officers, and department chairs. The chief executive and chief nursing officers are generally nonvoting members of the committee. My Hopes for Help Crumble When I went to your office, it was with great hopes that someone was finally going to piece together all of the bizarre symptoms I have been experiencing over the last several months and get to the cause of my pain. I was quite frankly shocked by how I was treated as a patient—especially one experiencing a health crisis. A medical student examined me. He wrote my history and current health problems on a small “yellow sticky pad.” You were not in the room when he examined me, and then I saw you for approximately 10 minutes. You took the business card of my New York doctor and said you were going to call him, and then call me regarding what you thought the next steps should be. I called you on Friday because my local doctor said that you had not called, and I was told you were on vacation until yesterday. I had asked that you call me. You never did. I called you yesterday again, but you did not answer nor did you return my call. On Monday, I received a letter from a medical student, I assume. Although I empathize with the demands on your time, I have never seen a handwritten letter, which I received, informing me of test results I provided to you prior to my appointment with you. You never mentioned the liver enzyme elevations or my February test from New York. Moreover, no mention was made regarding any plan to help me alleviate immediate problems. Doctor, I am not a complainer or a person with a low pain tolerance. Since moving here, I’ve had fainting episodes, severe chest pain and pressure, leg and arm pain and stiffness, congestion on the left side when the pain kicks in, and by 3 o’clock I have to go home and lie down because I’m so weak and tired. I cannot continue to exist like this. It is not normal. If you’re too busy and don’t want to take me as a patient, you will not offend me. Frankly, I need attention now to get these things resolved. Testing my cholesterol in a month will not address the problem. I’ve been treated for that for three years. Please call or write to me so I can get another doctor if I have to. —Anonymous The physician never responded. Discussion 1. Discuss how the caregivers failed in their delivery of care and, more importantly, how the patient’s needs were never fully addressed. 2. How would you address this patient’s care with the hospital’s leadership and governing body? 3. Should conduct of this nature be reported to any particular agency or should the matter just go unchecked? Bylaws Committee. The functioning of the medical staff is described in its bylaws, rules, and regulations, which must be reviewed and approved by the organization’s governing body. Bylaws must be kept current, and the governing body must approve recommended changes. The bylaws describe the various membership categories of the medical staff (e.g., active, courtesy, consultative, and allied professional staff) as well as the process for obtaining privileges. Blood and Transfusion Committee. The blood and transfusion committee develops blood usage policies and procedures. It is responsible for monitoring transfusion services and reviewing indications for transfusions, blood ordering practices, each transfusion episode, and transfusion reactions. The committee reports its findings and recommendations to the medical staff executive committee. Credentials Committee. The credentials committee oversees the application process for medical staff applicants, requests for clinical privileges, and reappointments to the medical staff. The committee makes its recommendations to the medical executive committee. Infection Control Committee. The infection control committee is generally responsible for the development of policies and procedures for investigating, controlling, and preventing infections. Medical Records Committee. The medical records committee develops policies and procedures as they pertain to the management of medical records, including release, security, and storage. The committee determines the format of complete medical records and reviews medical records for accuracy, completeness, legibility, and timely completion. Medical records are also reviewed for clinical pertinence. The committee ensures that medical records reflect the condition and progress of the patient, including the results of all tests and therapy given, and makes recommendations for disciplinary action as necessary. […]
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