QUESTION:
A doctor on our medical staff recently wrote an inappropriate comment to a coder after she requested that he provide clarification to some medical record documentation.  The comment included profanity, and did not answer the coder’s question, but it was not otherwise aggressive or insulting.

As Chief of Staff, my inclination is to simply send the practitioner a “knock it off” email and then leave it alone.  It was inappropriate, sure, but why make a mountain out of a molehill?

Is this consistent with good peer review?

OUR ANSWER FROM HORTYSPRINGER ATTORNEY RACHEL REMALEY:

Medical Staff leaders have a lot of flexibility to determine those interventions that are most appropriate for a given situation.  With that said, there are some principles that tend to promote “good” peer review and which we would suggest you consider as you decide to proceed:

• First, there is value in keeping a good record of everything that is reviewed through the peer review process (whether informal or formal peer review efforts). So, if you have not already done so, we recommend that you refer this matter to the Hospital personnel who support the peer review process (often the Medical Staff Services director or a dedicated quality/professional practice evaluation professional) and ask that they keep a record of this reported concern in their databases.  Further, a copy of any written report of this matter should be kept in the practitioner’s confidential file.

• Second, it is a good idea to pull the practitioner’s peer review history before you decide how to review and manage this incident. If this practitioner has a history of other professionalism issues, you might choose to pursue the matter differently.  So, while you’re talking to the Medical Staff Office/PPE professionals about logging in the new reported concern, it is a good idea to also ask that the practitioner’s peer review history be pulled so that you can review any relevant information.

• Third, before you finalize your decision on how to proceed, please make sure you consult the Medical Staff Bylaws and relevant policies (in this type of case, that will probably be the Medical Staff Credentials Policy, Medical Staff Professionalism Policy, and Rules and Regulations) to identify the specific rule(s) that have been violated and, additionally, identify whether your policies call for the matter to be referred to a specific individual or body for a fact inquiry and further management. While many Medical Staff Bylaws and policies give the Chief of Staff the authority/discretion to manage low-lying peer review matters collegially and informally, some dictate that all reported concerns of professionalism will immediately be referred to a particular individual or body (e.g., the Leadership Council or CMO).

• Fourth, if you find that your policies give you the discretion to manage the matter collegially and informally, understand that there is value in a peer review process that is methodical. The general, at-large Medical Staff will feel more confident in the peer review system if they observe consistency and feel that the process gives the same treatment to every practitioner.  This does not mean that your Bylaws and policies should not give Medical Staff leaders discretion to tailor the response to match the conduct at issue.  But, be sure that flexibility is not taken to the extreme.  It would undermine trust in the process if one practitioner were given a formal, written reprimand for the type of note you are dealing with, while another was simply told in passing to “knock it off.”  So, as you move forward, consider – Is the approach that you have in mind consistent with how similar issues have been handled in the past?

• Fifth, many modern peer review policies (including Medical Staff Professionalism Policies) give leaders the discretion to manage low level issues through informal “mentoring” efforts (or other similar efforts, sometimes termed “collegial conversations,” “cup of coffee conversations,” etc.). Acknowledging that these types of conversations happen – and are part of our peer review process – helps to ensure that they are protected and avoids claims that these efforts are being conducted in bad faith, outside the process.  Informal efforts need not be verbal, if you think that a written communication (e.g., email or a brief letter) would be better.  Letters of guidance, letters of education, and other similar writings (e.g., letters of awareness) are often used to serve a similar purpose – to inform a practitioner about an opportunity for improvement without, as you put it, “making a mountain out of a molehill.”  The tone is often direct and to the point, setting forth the need to comply with the relevant standard going forward, but without getting too confrontational.  For informal communications such as this, there is usually no response from the practitioner required or expected.

Even though these communications are informal, a copy should be placed in the practitioner’s confidential file.  We recommend letting the practitioner know – and inviting him or her to respond if he or she wishes to do so (in which case you should keep the response in the file, too).

• Finally, most modern “good” peer review processes have built in oversight. So, whenever a case is managed by a leader or leadership body (e.g., a committee), the results should be reported to a central source (either through recording the disposition in an electronic system or reporting the outcome to an individual, such as the PPE professional) so that data can be tracked and studied regarding all cases that are identified for peer review, who is handling them, how they are being handled, etc.  This not only helps to promote consistency in the process, but also helps to avoid reported concerns falling through the cracks and not being addressed.