QUESTION:
We recently had a patient suicide reviewed through our sentinel event/root cause analysis process. The process did not identify any aspect of the matter that should be attributed to the attending physician’s provision of care. Is that the end of the matter? Do we also need to refer this matter to the medical staff’s peer review process for consideration? Would it have any authority to reach a different conclusion? How do these processes intersect?
ANSWER FROM HORTYSPRINGER ATTORNEY RACHEL REMALEY:
We get many questions like this. There are many quality review processes in health systems and hospitals that intersect with the medical staff’s peer review process and it is not uncommon for there to be questions about which process applies and which takes priority/has authority. This holds true not only for sentinel event root cause analysis, but also processes to manage utilization review, infection control, antibiotic stewardship, patient grievances, and even workplace investigations (e.g., HR investigations of sexual harassment complaints).
These processes are generally conducted without regard to whether the involved subjects are physicians or other hospital personnel. So, facts are being gathered, records reviewed, witnesses interviewed, documentation created, and factual conclusions made, often without the involvement of a medical staff peer review committee. This is normal and customary.
In the end, any of these processes might eventually identify an issue that requires referring to the medical staff. That’s because, in addition to identifying issues with facilities and equipment, procedures and systems, and hospital personnel – sometimes, these hospital‑based processes also identify with the performance or conduct of physicians or other privileged practitioners. And how to further review and address those practitioner‑specific issues falls within the sole jurisdiction of the medical staff credentialing and peer review processes.
Those processes allow you to take the initial concern referred by the hospital process (for example, a conclusion from a sentinel event root cause analysis, that the physician’s failure to fully comply with the time-out procedure was partially responsible for a wrong-site incision) and consider it, along with the practitioner’s other peer review information (for example, the practitioner’s history of behavior issues, carelessness, inattention to detail), to determine whether this new issue raises any concern about the practitioner’s ability to practice safely. If so, it is the medical staff peer review process that would also determine whether any collegial, progressive steps would be reasonable and might help the practitioner to improve and address the concern or, alternatively, whether more formal disciplinary action should be taken.
To provide clarity regarding this intersection between hospital and medical staff processes, it can be helpful to include in the medical staff peer review policies a list of indicators that, when identified, results in a matter being referred to the medical staff’s peer review support specialist (to be funneled into the medical staff’s peer review process). In addition to listing the more common indicators for review (e.g., specialty-specific FPPE indicators, OPPE outliers, areas where legal risk has been identified, patient complaints, reported concerns), you might also consider specifically listing referrals from personnel/committees reviewing broader aspects of hospital functions (e.g., referrals from a utilization review committee or case manager, representative of the Human Resources department, the quality director, the compliance department, the risk management department).
We are sometimes asked by physician leaders whether it is necessary for medical staff committees to conduct their own witness interviews and gather their own facts, rather than relying on witness summaries, written reports, and other documentation compiled by others, sometimes outside of the peer review process. It is not necessary to do this. You can review, and rely on, information generated or compiled by others. Of course, if you believe that it would be helpful to ask additional questions of a witness or an individual who previously submitted written comments – or if your medical staff committee believes it is necessary or helpful to meet with any of those individuals to better assess their credibility – you may do so (and nothing in the medical staff or hospital policies should prohibit it). In our observation, medical staff committees do not feel the need to do this in most cases. But, you do want to leave your options open.
Finally, you asked whether it would ever be appropriate for a medical staff committee to reach a different conclusion than the individual/committee that referred the matter to the committee (e.g., a sentinel event root cause analysis, a utilization review committee). In the end, each medical staff committee is charged with reviewing the matters in front of it and using the collective professional judgment of its members to reach a conclusion – even if that conclusion differs from those reached by other individuals or bodies that have reviewed the matter.
Whenever a committee reaches a conclusion that differs from the other individuals/bodies that have reviewed the matter (even if it’s a difference of opinion from another medical staff committee that has reviewed the matter at a prior level of review – such as when the MEC is reviewing a credentialing recommendation from the Credentials Committee), it is a wise practice to take a bit of extra time to consider, articulate, and document (for example, in the meeting minutes) the reasons that the committee is reaching a different conclusion. This is not only a good risk management strategy (bolstering your defense in the event that your actions are later challenged as unfair or as negligent), but also provides greater protections for medical staff members and other privileged professionals who are subject to review processes, by ensuring that when opinions differ, a bit of extra consideration is given to the matter prior to moving full steam ahead.
If you have a quick question about this, e-mail Rachel Remaley at rremaley@hortyspringer.com.