Paging Dr Woo...
September 18, 2016 12:30 AM Subscribe
Who at a hospital is responsible for compliance to medical "norms"? What happens if a doctor starts prescribing things that fall outside of medicine or his/her expertise?
Who is responsible at a hospital for making sure that doctors follow certain protocols, prescribe medicine appropriately, don't do unnecessary procedures and don't start doing things that are not considered standard medical care? Is that a single position? What would that be called? Is it a department? Is this a compliance officer?
And what happens to a doctor who is found to be prescribing medicine inappropriately or using unorthodox or "woo" treatments that the hospital doesn't support? Are they fired? Fined? Kicked out?
Curious about the nitty gritty of how hospitals work and how they ensure all their doctors are following their expectations of care. I'm particularly interested in the US - but other countries would be interesting to me too for comparison.
Who is responsible at a hospital for making sure that doctors follow certain protocols, prescribe medicine appropriately, don't do unnecessary procedures and don't start doing things that are not considered standard medical care? Is that a single position? What would that be called? Is it a department? Is this a compliance officer?
And what happens to a doctor who is found to be prescribing medicine inappropriately or using unorthodox or "woo" treatments that the hospital doesn't support? Are they fired? Fined? Kicked out?
Curious about the nitty gritty of how hospitals work and how they ensure all their doctors are following their expectations of care. I'm particularly interested in the US - but other countries would be interesting to me too for comparison.
At the hospital I work at, the medical staff are self governing under a set of policies and a governing body. There is also professional practice evaluation, which is required (I believe) if you're accredited by the Joint Commission, which basically every hospital in the US is. You can read a bit more here and by googling OPPE and FPPE. TJC has standards for certain elements of medical staff work. These are standards for how doctors lose privileges at a specific hospital; it varies by state how doctors may lose their medical licenses (although it's generally very difficult, I believe) and by speciality how they may lose board-certified status in their speciality.
posted by MadamM at 4:47 AM on September 18, 2016
posted by MadamM at 4:47 AM on September 18, 2016
Also, insurance finding makes a huge impact on what doctors do and don't do.
In hospitals everybody is watching eachother. There really isn't a lone wolf doing wierd things.
posted by AlexiaSky at 6:44 AM on September 18, 2016 [2 favorites]
In hospitals everybody is watching eachother. There really isn't a lone wolf doing wierd things.
posted by AlexiaSky at 6:44 AM on September 18, 2016 [2 favorites]
At one level, no one. At a different level, colleagues and supervisory staff at the hospital, and at a third level, various government agencies.
So based on what I know about my local hospital here in Connecticut, a doctor has quite a lot of freedom in how he practices. In the example I know best, one doctor had by far the highest number of podiatric surgeries. Was that because he had a different flow of patients (plausible in this case) or because he had a tendency to use surgery where other doctors used more conservative treatment (also plausible)? There is basically no check on this.
However, there is a Chief of Surgery, and a Directory of Podiatry at the hospital. The podiatrists meet as a group and discuss cases. They may also set standards of treatment. If there was a serious rash of some particular problem, e.g. re-admissions, they would learn about it and be empowered to look into it. They may be alerted by complaints from insurance companies about that sort of thing.
Our state government is pretty aggressive about a few things, e.g. prescriptions for drugs of addiction. Doctors get notices about patients who get prescriptions for the same drug from multiple doctors. Among the other effects, I suspect that's a deterrent against excessive prescriptions for certain drugs.
I don't think there is much protection against woo. A doctor is certainly free to suggest that a patient try some herbal concoction when they have a reason to avoid prescribing a pharmaceutical.
posted by SemiSalt at 6:49 AM on September 18, 2016 [1 favorite]
So based on what I know about my local hospital here in Connecticut, a doctor has quite a lot of freedom in how he practices. In the example I know best, one doctor had by far the highest number of podiatric surgeries. Was that because he had a different flow of patients (plausible in this case) or because he had a tendency to use surgery where other doctors used more conservative treatment (also plausible)? There is basically no check on this.
However, there is a Chief of Surgery, and a Directory of Podiatry at the hospital. The podiatrists meet as a group and discuss cases. They may also set standards of treatment. If there was a serious rash of some particular problem, e.g. re-admissions, they would learn about it and be empowered to look into it. They may be alerted by complaints from insurance companies about that sort of thing.
Our state government is pretty aggressive about a few things, e.g. prescriptions for drugs of addiction. Doctors get notices about patients who get prescriptions for the same drug from multiple doctors. Among the other effects, I suspect that's a deterrent against excessive prescriptions for certain drugs.
I don't think there is much protection against woo. A doctor is certainly free to suggest that a patient try some herbal concoction when they have a reason to avoid prescribing a pharmaceutical.
posted by SemiSalt at 6:49 AM on September 18, 2016 [1 favorite]
I'm a hospital pharmacist and this is part of my job. One medical norm we track pretty closely is making sure doctors don't over-prescribe antibiotics. Or that quality guidelines are followed for common conditions - like if you had a stroke, you should have a blood thinner prescribed afterwards to prevent it happening again. Nearly all the drugs that are given in the hospital are purchased by the pharmacy so the director of pharmacy has a big role in stopping doctors from trying to order something risky or unproven. There is a committee called the Pharmacy & Therapeutics committee (P&T) at each hospital that decides what is on the formulary and sets policies. It's run by the pharmacy director and has doctors on it too. There is a Quality department too, usually run by a nurse, that enforces compliance with what the Joint Commission (the organization that accredits hospitals) says we must do -- google "Core Measures."
posted by selfmedicating at 7:23 AM on September 18, 2016 [8 favorites]
posted by selfmedicating at 7:23 AM on September 18, 2016 [8 favorites]
At my hospital the physician staff are responsible to the director of their practice, who typically address minor deviations from standard practice ("Bob, you keep ordering ENT consults for anyone with a stuffy nose"), followed by the director of their division or department, who might address bigger, more systemic issues. Serious errors at my hospital go to a Patient Safety Committee, who look to see if there are systems issues like EMR warnings or workflow problems that need to be changed in addition to recommending actions like remediation or censure for the physician.
Depending on the seriousness of the problem and whether there are other concerns about performance, the consequences might be remediation, loss of hospital credentials, (meaning they could not continue to practice at that hospital) reporting to the medical board (which has its own investigative role and may suspend/remove the physician's license to practice at all in that state), or, in extreme cases like sale of narcotics or deliberate harm to patients, reporting to the police.
Concerns about repeated professionalism violations, improper research practices, or issues with residents or residency programs go up different chains of responsibility, but the process is basically the same.
As you've seen, there is a LOT of scrutiny at all different levels (nursing, physicians, pharmacy) and that reflects both the complexity of the work we do and the fact that most clinical actions involve multiple people and many opportunities for error. (Physician orders a medication. Pharmacy prepares it. Nurse administers it. Lots of openings for wrong choice of drug or dose, failure to take allergies or comorbid conditions into account, wrong preparation or dispensing to the wrong patient, administration to the wrong person or in the wrong way, failure to observe unexpected side effects or allergies).
posted by The Elusive Architeuthis at 9:44 AM on September 18, 2016
Depending on the seriousness of the problem and whether there are other concerns about performance, the consequences might be remediation, loss of hospital credentials, (meaning they could not continue to practice at that hospital) reporting to the medical board (which has its own investigative role and may suspend/remove the physician's license to practice at all in that state), or, in extreme cases like sale of narcotics or deliberate harm to patients, reporting to the police.
Concerns about repeated professionalism violations, improper research practices, or issues with residents or residency programs go up different chains of responsibility, but the process is basically the same.
As you've seen, there is a LOT of scrutiny at all different levels (nursing, physicians, pharmacy) and that reflects both the complexity of the work we do and the fact that most clinical actions involve multiple people and many opportunities for error. (Physician orders a medication. Pharmacy prepares it. Nurse administers it. Lots of openings for wrong choice of drug or dose, failure to take allergies or comorbid conditions into account, wrong preparation or dispensing to the wrong patient, administration to the wrong person or in the wrong way, failure to observe unexpected side effects or allergies).
posted by The Elusive Architeuthis at 9:44 AM on September 18, 2016
Sorry, I didn't remember that you're specifically interested in "woo" therapies once I got rolling. Theoretically, any physician can do any medical therapy. The thing that is keeping me, an internist, from just starting to do plastic surgery at my hospital is that 1) I wouldn't know what the hell I'm doing and I know that, 2) the hospital has not credentialed me to do plastic surgery (meaning that they have examined my qualifications to do certain procedures and have approved me to use hospital facilities for that purpose), and 3) if somehow I did do it, I would basically lose my shirt and my license the first time there was a problem with one of my incompetent surgeries and someone decided to sue me.
Now, if you're not using hospital facilities and the therapies are basically low-risk, there is a lot more leeway for that kind of thing. I know several family practitioners who have expanded their practice to include things like cosmetic Botox. They do some training via workshops and CME and just add it to their repertoire. As long as they're doing it competently I have no problem with this. There has to be some mechanism to incorporate new developments into your practice. I myself just went to a couple of workshops to improve my joint injection technique, because I have a hard time finding orthopods in my area who take Medicaid and I want to be able to offer it to my patients. Now it's kind of up to me to decide which joints I feel competent to deal with (with the approval of my boss, and I'm credentialed to do this stuff by my hospital). If you are a private practitioner and you have your own office, you're basically the only person deciding if you're competent to do that stuff (except for certain procedures where the company providing the equipment requires you to do a training session, like Nexplanon contraceptives).
There can also be a fine line between "cutting edge" and "woo." Lots of orthopedists and sports medicine doctors are doing things like injections of platelet rich plasma for injuries despite the absence of compelling evidence that it works. It may just be too soon to tell; it may just be injections of expensive placebo. When I was training, fecal transplants for C. diff infections were considered kind of far out and last-ditch; now they're totally mainstream and routinely offered after someone has failed two rounds of antibiotics.
Then you get into real woo stuff, like long-term antibiotics for chronic Lyme, or chelation therapy for autism or whatever. Again, if you're not using hospital facilities there's not nearly as much oversight, and there's a lot of leeway for practitioners to work in the way they feel is best. There can be surprisingly little corrective action in these cases as the practitioners are almost always working independently and not under the oversight of a larger institution, and the people receiving the therapies are usually not particularly inclined to sue because they've bought into the practitioner's theories and/or are desperate. In those cases the medical board is the only real oversight, and they do tend to give a lot leeway to somewhat wacky therapies as long as people aren't actually being harmed other than in the wallet, or the provider isn't flouting standards of care in other areas. Bob Sears, for example, isn't being investigated by the medical board for being anti-vaccine, he's being investigated for writing an exemption letter citing reasons that were not borne out by his own notes (i.e., falsifying the medical record) and for failing to do an appropriate exam for someone who had head trauma.
posted by The Elusive Architeuthis at 11:27 AM on September 18, 2016 [3 favorites]
Now, if you're not using hospital facilities and the therapies are basically low-risk, there is a lot more leeway for that kind of thing. I know several family practitioners who have expanded their practice to include things like cosmetic Botox. They do some training via workshops and CME and just add it to their repertoire. As long as they're doing it competently I have no problem with this. There has to be some mechanism to incorporate new developments into your practice. I myself just went to a couple of workshops to improve my joint injection technique, because I have a hard time finding orthopods in my area who take Medicaid and I want to be able to offer it to my patients. Now it's kind of up to me to decide which joints I feel competent to deal with (with the approval of my boss, and I'm credentialed to do this stuff by my hospital). If you are a private practitioner and you have your own office, you're basically the only person deciding if you're competent to do that stuff (except for certain procedures where the company providing the equipment requires you to do a training session, like Nexplanon contraceptives).
There can also be a fine line between "cutting edge" and "woo." Lots of orthopedists and sports medicine doctors are doing things like injections of platelet rich plasma for injuries despite the absence of compelling evidence that it works. It may just be too soon to tell; it may just be injections of expensive placebo. When I was training, fecal transplants for C. diff infections were considered kind of far out and last-ditch; now they're totally mainstream and routinely offered after someone has failed two rounds of antibiotics.
Then you get into real woo stuff, like long-term antibiotics for chronic Lyme, or chelation therapy for autism or whatever. Again, if you're not using hospital facilities there's not nearly as much oversight, and there's a lot of leeway for practitioners to work in the way they feel is best. There can be surprisingly little corrective action in these cases as the practitioners are almost always working independently and not under the oversight of a larger institution, and the people receiving the therapies are usually not particularly inclined to sue because they've bought into the practitioner's theories and/or are desperate. In those cases the medical board is the only real oversight, and they do tend to give a lot leeway to somewhat wacky therapies as long as people aren't actually being harmed other than in the wallet, or the provider isn't flouting standards of care in other areas. Bob Sears, for example, isn't being investigated by the medical board for being anti-vaccine, he's being investigated for writing an exemption letter citing reasons that were not borne out by his own notes (i.e., falsifying the medical record) and for failing to do an appropriate exam for someone who had head trauma.
posted by The Elusive Architeuthis at 11:27 AM on September 18, 2016 [3 favorites]
In my outpatient clinical practice and in my hospital, there are quality improvement committees whose jobs are to investigate complaints or incident reports made by other staff, colleagues, and patients. If the complaint is founded and not like an egregious criminal activity, some kind of corrective action is taken -- maybe a mandatory review course, or a chart review process, or limitation of practice privileges. In a few cases I've been close to, if there is a clear pattern and intervention isn't working, a provider will lose their hospital privileges or be fired from a group.
On top of investigation of incidents, there is a regular review process -- usually every one to two years -- where every provider must be reapproved by a credentialling committee of their employer and/or hospital. During this review, they look at incident reports, lawsuits, look at the providers cases and scope of practice over the past interval, as well as any criminal acts (such as DUIs, assaults, which ordinarily should have been reported as soon as they occur) and they decide whether to allow continued practice at their institution. In the current legal climate, the formal bodies of a medical organization are extremely concerned about opening themselves to liability because of a reckless provider. That having been said, if an extremely popular or high revenue generating or very senior staff physician is practicing witchcraft, they are less likely to be reported, or given the benefit of the doubt when telling their side of the story.
There is a separate process for review which happens at the state level, as it is the state (we're talking U.S. here) that issues licenses. The state's regular renewal process is somewhat more anonymous, you have to show that you've remained current in your field (by either completing X number of hours of medical education or maintaining board certification in your specialty). Of course, they also look at criminal activity and complaints at the state level. Now, there is a separate complaint process at the state level where people (and typically these are patients, not colleagues or coworkers) can make complaints to a Medical Quality Assurance Board. These complaints are investigated by people who are relatively removed from the situation, who don't know the doctors or the institution and as such, every complaint is given equal weight even if it's made by an unstable person, or someone who has an ax to grind so they all get the same treatment. Almost every physician I know who's been in practice long enough has had to respond to one of these, including myself, and it's terrifying, because they are almost always done for reasons not having to do with clinical competence; it might range from not prescribing the medication that the patient thought they needed after reading the Internet to having a long standing feud with a neighbor. In every case the physician has to give a written response and in many cases may have to go to the capital to appear in person before a board. The quality assurance board has the ability to place limits on your license, levy fines, and suspend people and they do these things frequently. There is a series of federal licensure examinations you must complete after your medical education, but after this is done the first time, no government agency requires retesting.
Every insurance company that you contract with has a "credentialling" process but I've always had the impression that this is a rubber stamp, as long as you're not a felon and you've got an active license you're good.
Each medical specialty society grants certification in a specialty and they all have their own list of criteria to maintain certification including attendance of educational conferences, some kind of chart review, and a periodic certification examination. Specialty board certification is not required to get a license, but many employers require it, and being current with your specialty board often supplants the continuing medical education requirement for state licensure. I've never heard of a complaint process going through your specialty board and I'm not sure if complaints directed to them get redirected to the state or not. The role of the medical specialty boards is really just a certification that you've demonstrated a certain level of competence in your field.
posted by Slarty Bartfast at 11:59 AM on September 18, 2016 [1 favorite]
On top of investigation of incidents, there is a regular review process -- usually every one to two years -- where every provider must be reapproved by a credentialling committee of their employer and/or hospital. During this review, they look at incident reports, lawsuits, look at the providers cases and scope of practice over the past interval, as well as any criminal acts (such as DUIs, assaults, which ordinarily should have been reported as soon as they occur) and they decide whether to allow continued practice at their institution. In the current legal climate, the formal bodies of a medical organization are extremely concerned about opening themselves to liability because of a reckless provider. That having been said, if an extremely popular or high revenue generating or very senior staff physician is practicing witchcraft, they are less likely to be reported, or given the benefit of the doubt when telling their side of the story.
There is a separate process for review which happens at the state level, as it is the state (we're talking U.S. here) that issues licenses. The state's regular renewal process is somewhat more anonymous, you have to show that you've remained current in your field (by either completing X number of hours of medical education or maintaining board certification in your specialty). Of course, they also look at criminal activity and complaints at the state level. Now, there is a separate complaint process at the state level where people (and typically these are patients, not colleagues or coworkers) can make complaints to a Medical Quality Assurance Board. These complaints are investigated by people who are relatively removed from the situation, who don't know the doctors or the institution and as such, every complaint is given equal weight even if it's made by an unstable person, or someone who has an ax to grind so they all get the same treatment. Almost every physician I know who's been in practice long enough has had to respond to one of these, including myself, and it's terrifying, because they are almost always done for reasons not having to do with clinical competence; it might range from not prescribing the medication that the patient thought they needed after reading the Internet to having a long standing feud with a neighbor. In every case the physician has to give a written response and in many cases may have to go to the capital to appear in person before a board. The quality assurance board has the ability to place limits on your license, levy fines, and suspend people and they do these things frequently. There is a series of federal licensure examinations you must complete after your medical education, but after this is done the first time, no government agency requires retesting.
Every insurance company that you contract with has a "credentialling" process but I've always had the impression that this is a rubber stamp, as long as you're not a felon and you've got an active license you're good.
Each medical specialty society grants certification in a specialty and they all have their own list of criteria to maintain certification including attendance of educational conferences, some kind of chart review, and a periodic certification examination. Specialty board certification is not required to get a license, but many employers require it, and being current with your specialty board often supplants the continuing medical education requirement for state licensure. I've never heard of a complaint process going through your specialty board and I'm not sure if complaints directed to them get redirected to the state or not. The role of the medical specialty boards is really just a certification that you've demonstrated a certain level of competence in your field.
posted by Slarty Bartfast at 11:59 AM on September 18, 2016 [1 favorite]
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Of course there's always a grey area where the treatment chosen might or might not be optimal but still appropriate. I'm working in a teaching hospital and so I also have to justify my treatment plans to students. So there's a lot of visibility, lots of people around.
So it's not really possible for me to prescribe anything outlandish.
There's much less oversight in the outpatient setting, at least in my country.
posted by M. at 1:45 AM on September 18, 2016