Media report surgeon horror stories: Would your facility credential them?
Don’t be pressured — verify their experience, competence
Reports of a surgeon inserting a screwdriver in a patient’s spine and another whose license was revoked after his state board for professional medical conduct said his continued practice would put patients in imminent danger have made outpatient surgery managers sit up and pay new attention to credentialing.
Surgeon Robert Ricketson, MD, is being sued for malpractice because he inserted a piece of a screwdriver into a patient’s spine, instead of a titanium rod, the patient’s sister claims. Reports say it is at least the eighth time the physician has been sued for malpractice. At the time of the surgery, the physician’s medical license already had been suspended in Oklahoma, revoked in Texas, and was under review in Hawaii, where the procedure was performed, according to reports.
The lawsuit says that after the surgery began, Ricketson realized the rod he planned to insert was missing. Instead of waiting for a supplier to deliver the device, he used a hacksaw to cut a stainless steel screwdriver, then tightened it into place in the patient’s spine, the suit says. Days later, the screwdriver snapped in half. Attorneys say that after surgery to remove the screwdriver, a nurse discovered it in the operating room trash and notified the family. The patient underwent more surgeries, but he eventually became a paraplegic. The patient’s sister contends that he died in June at age 76 because of complications from the surgery.
"This doctor had shown previous evidence of drug abuse and incompetence in other states," said Mark Davis, attorney for the sister. "[He ] should never have been allowed to step foot into an operating room."1
Do you think that such reports are isolated? Consider another recent case: The medical license of plastic surgeon Pankaj T. Desai, MD, has been suspended in New York after the state health commissioner’s office determined that his continued practice of medicine would pose an imminent danger to public health.
Desai is accused of 225 counts of professional misconduct that include lying about his credentials, misinforming patients about the risks of surgery, falsifying medical records, and causing medical errors at an ambulatory surgical center (ASC).
"Any physician applying for privileges in an ASC should go through a rigorous credentialing and privileging process," explains Raymond Grundman, senior vice president of development at Aspen Healthcare, a Milwaukee-based surgery center development and management firm. Grundman also is a surveyor and a member of the board of directors for the Wilmette, IL-based Accreditation Association for Ambulatory Health Care (AAAHC).
The Joint Commission on Accreditation of Healthcare Organizations is developing new standards to address physician competency, says Kimberly Page, BSN, JD, associate project director in the division of standards.
The new standards should be released within the next six months and could take effect as early as 2005, she says.
To ensure physicians in your program are competent, take these precautions:
• Spell out ramifications of fraudulent statements. Discuss your credentialing/privileging application with an attorney in your state to update how specific, pertinent questions on drug use, loss of privileges, and other important and sensitive issues are asked of applicants, says Melinda E. Whitney, RN, MS, CPHQ, FACHE, CMSC, director of the Quality Management Consulting Group, a Columbus, OH-based consulting company that assists medical leaders with medical staff issues. "Have very specific legal language on ramifications of fraudulent statements," she advises.
In addition, falsification of the application can be reported to the National Practitioner Data Bank (www.npdb-hipdb.com/), where it would be a permanent part of the practitioner’s record, Grundman says.
• Perform primary source verification. The New York case mentioned above shows the primary source verification of areas such as completion of a fellowship wasn’t done by all facilities, Whitney says. "That underscores the reason we don’t hurry or push through a practitioner package without completion of primary source verification," she says.
It isn’t a process of making a single phone call and the surgeon is ready to operate, Whitney says. "Educating your supervisor is the first right way of setting up a good process, so you’re not allowing that kind of an expectation to develop," she adds.
Grundman agrees that the process shouldn’t be rushed. "You have to do your homework, have all the documentation, have the credentialing committee review them before you grant privileges," he advises. "If you short-circuit the system, you’re introducing the opportunity for mistake or errors to be made — errors in judgment or errors in factual data collection."
Profiles with the Chicago-based American Medi-cal Association or the Chicago-based American Osteopathic Association are considered primary source verification, says Michelle Kelly, CMSC, supervisor of medical staff services at Ingham Regional Medical Center in Lansing, MI. Kelly’s facility caught a "fake" doctor several years ago who had been working for more than a decade at other facilities with false credentials.
"We don’t ask the applicants to provide us with documentation that they have been in this or that program," Kelly says. "If [surgery programs] are, they aren’t doing credentialing as they should."
• Evaluate the physician’s current competency. Look at the applicant’s current inpatient privileges, which preferably are at a hospital that is accredited by the Joint Commission, Whitney suggests. Next, evaluate those inpatient privileges to confirm they are similar to the privileges being sought for outpatient surgery, she says.
Kelly’s facility contacts peer references who are provided by the applicant. The peer references are asked specific questions such as:
— Are you aware of anything we should know about this applicant that would adversely affect his or her ability to practice medicine?
— Are you aware of any medical condition or substance abuse problem that might impair or limit his or her ability to practice medicine within the scope of privileges requested?
— Would you recommend this person for professional staff membership and clinical privileges?
"We provide them with a copy of the privilege sheet and ask if privileges are appropriate," Kelly says. Also, she contacts the medical staff services offices at hospitals at which the applicants say they have been affiliated in the past five years. Kelly verifies that the applicant is a member of the professional staff and asks for a copy of the privileges. She also asks the same questions given to peer references (above). She contacts the department chairmen to ask the same questions.
The Joint Commission is putting an emphasis on obtaining performance improvement data, such as data from the applicant’s peers who are acquainted with that person’s work, and information that actually that relates to the person’s performance, "so you have some substantiative information on that person to made judgment on their clinical competency," Page says.
The AAAHC also recommends peer evaluation. "How we define peer evaluation is that current competence is verified in writing by individuals personally familiar with the applicants’ clinical, professional, and ethical performance and, when available, by data based on analysis of treatment outcomes," Grundman says.
Patient complications aren’t the only treatment outcome, he emphasizes. Instead, look for factors such as board certification and the number of procedures that the applicant has performed, he suggests. "Volume does have an effect on determining competence." Don’t simply look for negative evidence, Grundman advises.
"Look at positive peer evaluations and patient satisfaction results specific to that practitioner," Grundman says. Look for applicants’ experience being proctored, particularly with new procedures, he says. "Get a report from the proctor on the result of that training," Grundman says.
• Verify the applicant’s claims history.
Confirm the applicant’s claims history, regardless of what he or she says, Kelly advises.
Look to the National Practitioner Data Bank to verify whether any settlements have resulted from negative outcomes, Grundman advises.
However, keep in mind the database doesn’t include pending lawsuits, Kelly points out. Also, insurance companies don’t always give you information if it’s a pending claim, she adds.
To research pending claims, you can query the court cases within a state’s county by contacting your state attorney general’s office to ascertain the proper process, Whitney says.
Comprehensive search services such as Boca Raton, FL-based Accurint (www.accurint.com) also may be selected to research an applicant, she adds. Consult your attorney before starting a new background search initiative to assist with creation of the policies/procedures for such an initiative to prevent the appearance of discrimination, Whitney emphasizes.
Also, check the Office of Inspector General (OIG) Exclusion List to ensure that the physician hasn’t been excluded from participating in any government-funded programs such as Medicare. You can check the OIG Exclusion List on-line at http://exclusions.oig.hhs.gov/search.html. Also, your Medicare Fiscal Intermediary should publish a list of licensed staff excluded from or reinstated to Medicare.
• Have effective, ongoing peer review.
Once the applicant is working at your facility, regularly monitor surgical cases for complications, Whitney advises. Don’t limit your review to your outpatient program, but also monitor his or her inpatient privileges, she adds.
"Don’t check just every couple of years," Whitney suggests. One to two times a year is average, she adds. "Also, the grapevine will help." [Editors’ note: The state of Illinois has electronic credentialing and recredentialing forms with questions to ask about background. For a copy of the forms, go to the Same-Day Surgery web site, www.same-daysurgery.com. Your user name is your subscriber number. Your password is sds (lowercase), plus your subscriber number (no spaces). Select "toolbox" and then "credentialing."]
Reference
1. Former Hilo surgeon sued for placing screwdriver in spine. Houston Chronicle, July 16, 2003. Accessed at www.chron.com/cs/CDA/ssistory.mpl/bizarre/1996259.
Sources
For more information on credentialing surgeons, contact:
- Raymond Grundman, Senior Vice President of Development, Aspen Healthcare, Milwaukee, WI. E-mail: [email protected].
- Michelle Kelly, CMSC, Supervisor of Medical Staff Services, Ingham Regional Medical Center 401 W. Greenlawn Ave., Lansing, MI 48910. Telephone: (517) 334-2290. Fax: (517) 346-4865. E-mail: [email protected].
- Kimberly Page, BSN, JD, Associate Project Director, Division of Standards, Joint Commission on Accreditation of Healthcare Organiza-tions, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Fax: (630) 792-4926. E-mail: [email protected].
- Melinda E. Whitney, RN, MS, CPHQ, FACHE, CMSC, Director, Quality Management Consulting Group, 100 S. Third St., Columbus, OH 43215. Telephone: (614) 227-4849. E-mail: [email protected]. Web: www.qmcg.com.
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