Kudos for putting a great deal of thought into the various complexities of medical staff credentialing, peer review and quality monitoring. Welcome to my (exceedingly convoluted) world!
With regard to your comments about communication between State Licensing Boards, there is one small bright spot. State Licensing Boards report all actions taken against a physician's license to the National Practioner Data Bank, which was created by the US Healthcare Quality Improvement Act of 1986.
The NPDB has not proven to be as useful as its founders may have envisioned, but licensing actions and malpractice payments paid on behalf of a physician are reported.
The public has no access to NPDB records, but hospitals and some healthcare plans do. Hospitals query the databank at least every two years and review the information for initial granting and renewal of privileges.
With all the thought you've put into this, I hope if you don't already serve on your hospital's Credentials Committee that you'll volunteer. We need more physician champions.
Rita Schwab, CPCS, CPMSM
Me?!? On the credentials committee? Perish the thought --- I'm, let's say, a bit too old-fashioned and politically incorrect to be allowed to sit on that type of committee. The members just occasionally ask my opinion...
When I (mostly) retired, proof that I'd been working way too hard was that my clinic ended up hiring three additional surgeons within two years to get the wait-times for appointments (etc) back to where they'd been. So they hired me to mentor each of those new surgeons. I scrubbed with them on most of their cases, day and night, for a while. As a result, I got to evaluate them quite thoroughly, and to impart a few pearls (which they actually appreciated!), along the way. Maybe it's a concept worth exporing more generally: using recently retired docs in some sort of official (and protected?) capacity as mentor/monitors for the newly minted. Given the unknown effects of the 80 hour week, it may well be essential. I'm guessing the newest of the newly will be significantly under-trained...
I enjoyed this blog, but I can't help reading a little arrogance on your part. Thats a pitty, because your ideas are otherwise good.
What do you think of this. My hospital recently denied priveledges to a young vascular surgeon because he did not due x number of carotids per year. Could this be the existing vascular guys protecting their own turf? Or perhaps it is in the interest of patient safety, hospital liability exposure etc. But I can't help seeing this as a narrow minded and provincial approach from the old guard, established surgeons. A hospital that is otherwise strapped for cash could do well to have another surgeon bringing in his elective cases, for perhpas the next 30 years.
Dr. Schoor, I apologize if I came off with a bit of arrogance; I have never sat on our facility's credendtials committee. I have similarly seen apparently well-trained physicians denied privileges to perform certain procedures by the "old guard." Not only is that stupid on the hospital's part, it is a very tenuous position for the "old guard," who may need to bring in a young physician or two of their own.
It all comes down to statistics --- how do my statistics stack up against the national averages for complications etc. When one performs fewer of any particular procedure, it is difficult to get enough statistical oomph to say that you are well within the accepted rate of complications. If the stroke rate for carotid endarterectomy is 1-2% and you only do about 10 a year, a single stroke in any given calendar year will stick out like a sore thumb.
While I agree with Schoor and disagree with you about statistics, I feel the peer review process is "old boys club". I was fresh out of residency when I was peer reviewed out of a job because my "statistics" were "out of the norm" I had two lap chole injuries out of my first 200 cases. I never had one in residency, statistically, that puts me in 0.5% I may never have had anymore injuries if I had continued to practice, in that case, my "statistics" would have dropped below "norm". Peer review is never a careful process. Statistically, it is started by one person, taken for however far it can go, and rules favor the house.
[Excerpt from PhysiciansNews]
Bias and Conflicts of Interest Immaterial
In Manzetti v. Mercy Hospital of Pittsburgh, the Pennsylvania Supreme Court held on July 18, 2001 that the hospital and reviewers were entitled to immunity under HCQIA. The Supreme Court disregarded all evidence relating to the reviewed physician
’s competitors’ involvement in the case and attacks against him. The Court stated that any self-interest, bias or conflicts of interests by the reviewers were immaterial. According to the Court, the only time HCQIA precludes an economic competitor from involvement in the internal peer review process is at the hearing panel phase of the case; however, HCQIA does not preclude economic competitors from perpetrating due process violations and inculcating bias throughout the early phases of the review process. Under most hospital bylaws, by the time the physician gets to the fair hearing panel, the burden has shifted against the physician with the requirement that the physician prove by clear and convincing evidence that all prior decisions were arbitrary and capricious or factually baseless. Practical experience demonstrates this is a virtually impossible burden to sustain and standard to satisfy.
The Supreme Court also held that the "reasonable effort" prong of the four-part HCQIA immunity test is satisfied if the review activities are "sensible," but they do not have to be "flawless." Thus, the Supreme Court has countenanced due process violations and errors in the peer review process.
Sloppy, Negligent and Wrong Peer Review Warrants Immunity
In Donnell v. HCA Health Services of Kansas, Inc., the Kansas Court of Appeals held on
July 6, 2001 that physician peer reviewers are immune from liability under HCQIA even if their investigations are sloppy, negligent, and wrong. Physicians must prove bad faith and malice to have a peer review decision overturned.
This decision, like Manzetti above, allows a hospital to make serious mistakes about the quality of a physician
’s health care. It also permits termination of the physician’s staff privileges, and the detrimental effect of a Data Bank entry, all with immunity from liability and practical impunity.
One Mistake and Done: Free Ride for Abuse
In Meyer v. Sunrise Hospital, the Nevada Supreme Court held on May 15, 2001 that a
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