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.