January 31, 2019

QUESTION:        When a concern is raised about the behavior of a Medical Staff member, we’ve typically referred it to our department chairs. The chairs give it their best shot, but we were wondering if there’s a better way?

ANSWER:            Yes! There are many drawbacks to asking a single individual — regardless of who that person is — to deal with difficult behavioral matters.

First, the department chair is often either a competitor or partner of the physician under review. This can make it difficult for the department chair regardless of whether an actual “conflict of interest” exists.

Also, depending on the size of a department, the department chair may not deal with many behavioral concerns. As a result, the chair never obtains enough experience to become truly comfortable addressing behavioral issues.

Individual department chairs have no built-in opportunity to brainstorm about the issues under review. If they want to seek assistance, they have to find another physician leader and bring that person up to speed.

Thus, we recommend that a core group of physician leaders — referred to as a Leadership Council — handle behavioral concerns. The Leadership Council might be comprised of the Chief of Staff, Chair of the Professional Practice Evaluation/Peer Review Committee, and Chief Medical Officer. The advantages of using a Leadership Council to handle behavioral concerns include:

  • consistency across departments (no more variability based on the personality of individual department chairs);
  • easier to avoid conflicts of interest;
  • permits department chairs to preserve their working relationships with physicians under review;
  • expertise through experience;
  • emphasizes the importance of the issue and enhances the credibility of the physician leadership because a group of leaders – not a single person – is speaking with the physician under review; and
  • problems are discussed by a small group, which promotes the exchange and development of ideas.

For more information on Leadership Councils and other important topics, please join us at Disney’s Yacht and Beach Club Resort in Orlando, FL on March 7-9, 2019 for The Peer Review Clinic.

September 13, 2018

QUESTION:        We are reviewing an application from a new applicant who has excellent credentials with respect to his education, training, experience and current clinical competence.  However, the applicant has had trouble working with others and was even subject to a behavioral performance improvement plan at his last hospital.  The Credentials Committee is split over how important behavior really is when a candidate otherwise has excellent credentials.  How should we proceed?

ANSWER:            This is a question we hear often.  You finally find a physician who has excellent credentials, but acts out a little.  While everyone has a “bad hair day” once in a while, it is a mistake to bring someone into your organization whose behavior will undermine your culture of safety.

This is the terminology used by The Joint Commission when it issued its 2008 Sentinel Event Alert.  According to the Sentinel Event Alert:

“Intimidating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes, increase the cost of care, and cause qualified clinicians, administrators and managers to seek new positions….All intimidating and disruptive behaviors are unprofessional and should not be tolerated.”

The Sentinel Event Alert was followed by the adoption of a leadership standard that required hospitals to adopt a code of conduct or professionalism policy.

Recognizing the importance of working professionally and respectfully with others, most credentials policies require applicants to demonstrate an “ability to work harmoniously with others, including interpersonal and communication skills sufficient to enable them to maintain professional relationships with patients, families, and other members of health care teams.” The bottom line is that behavior matters in the quality of care you provide in your hospital.

So in credentialing the applicant, get as much information from previous hospitals and past employers about his or her ability to work with others.  Ask for a copy of the behavioral performance improvement plan.  Ask for a copy of the underlying concerns that led to the adoption of the performance improvement plan.  Request a copy of any correspondence that relates to behavioral concerns.  And don’t forget to make follow-up phone calls to references and to others who may have worked with the applicant in the past to get a candid evaluation of any problems.

A physician who experienced a problem period because of personal issues, but then improved should not be problematic.  A physician with a longstanding pattern of inappropriate and unprofessional behavior is not likely to change when he or she lands at your hospital.  Don’t forget the middle option of conditional appointment which can also be useful in laying out expectations and consequences should the inappropriate behavior reoccur.

Please join us in our national program – Credentialing for Excellence – where we discuss this and other credentialing challenges.

December 1, 2016

QUESTION:        Our Medical Staff policies call for a multi-specialty peer review committee to address concerns about a physician’s clinical skills, and a small Leadership Council to address behavioral concerns.  What happens if there are concerns about a physician that involve both clinical and behavioral issues.  Which process should we use?

ANSWER:            One option is to have the multi-specialty peer review committee address the clinical matter while the Leadership Council separately addresses the behavioral concern.  However, if the clinical and behavioral concerns are related, it may be best to have the same committee review both.  Using two committees may result in a less effective review.

Another option is to have a single committee address both the clinical and behavioral concerns.  However, if this approach is used, it should be explicitly described in your policies.  Otherwise, no matter what review path is chosen, the physician in question might claim that the review is invalid because it was conducted by the wrong committee.

We recommend that language similar to the following be in the Professional Practice Evaluation Policy (for clinical concerns):

If a matter involves both clinical and behavioral concerns, the Chairs of the Leadership Council and the Professional Practice Evaluation Committee (“PPEC”) shall coordinate the reviews.  The behavioral concerns may either be:

(i)         addressed by the Leadership Council pursuant to the Professionalism Policy, with a report to the PPEC, or

(ii)        addressed by the PPEC pursuant to this Policy, with the provisions in the Professionalism Policy being used for guidance.

Similar language should be included in the Professionalism Policy.

To learn more about these and similar issues, please join us in sunny Naples on February 2-4, 2017 for The Peer Review Clinic!

May 12, 2016

QUESTION:        Several registrants at our recent Complete Course for Medical Staff Leaders in San Antonio asked related questions:  Where should quality concerns expressed by a Medical Staff member be documented (particularly when the physician who has been counseled about behavior that undermines a culture of safety has alleged that the counseling is retaliatory)?  And, how should collegial interventions be followed up?

ANSWER:            All quality concerns should be assessed and followed up.  Where the assessment and follow-up documentation is placed depends on the nature of the concerns. Allegations of retaliation are becoming very common, and likely to be used in the event of a professional review action in a hearing or litigation by an attorney for the physician.  Documenting that the concerns have been reviewed and, if there is merit to them, addressed may be critical to the defense of a professional review action.

No one – even a Medical Staff member – is entitled to confidential peer review information about how another professional may have been counseled or how a particular issue has been resolved if the resolution involves confidential information. Anyone reporting a concern should be advised that all concerns are taken seriously, but that confidentiality must be respected.

Documentation submitted by a physician who raised a concern can be maintained in that physician’s file along with brief documentation as to whom the concern was directed appropriately, depending on the nature of the concern.  If the concern led to changes in policy, and if that policy change is not a confidential peer review matter, that resolution could be maintained in several places, including in the physician’s file, and the physician informed of the outcome.  However, raising a concern does not justify behavior that is disrespectful of others or interferes with the delivery of care.  It is also important to document collegial interventions in a constructive way, thanking the physician for meeting, summarizing the key points of any meeting and expectations for behavior going forward, and inviting the physician to respond in writing for the file. If the behavior continues, documentation of progressive steps, perhaps leading to conditional reappointment, is important.

If a physician raises multiple concerns over time, that pattern in itself may become disruptive.  It can be tempting to “consider the source” and not take a complaint seriously if the concerns are raised by a physician whose behavior has been the subject of many reports by team members, and if that physician has a pattern of attributing leaders’ interventions as retaliatory.  Don’t succumb to that temptation!  Rise above it and remember that someday a hearing panel, the Board or even a judge may be reviewing your documentation.