Almost every chief medical officer (CMO) that I work with in my advisory program has encountered at least one situation in the hospital every year that requires a significant intervention with a member of the medical staff. Whether the precipitating event is a disruptive physician, an incompetent provider, or simply a sensitive political situation, the leadership faces challenges as to what is the best way to provide a fair and due process that will achieve the most effective result. Having encountered many of these incidents during my tenure as a CMO and a consultant, I have found it useful to apply the following three rules to the interventions that I have had to consider. I review these rules regularly with fellow CMOs. I have discussed these previously in publications, but with the new year coming on, it is worthwhile to revisit these three simple rules:
Rule 1. Patient safety comes first- This should be self-evident, and something that is automatically assumed. We have an obligation as physicians and as health care leaders to always advocate in the best interests of our patient. When evaluating the pros and cons of any potential decision, we should always opt for the choice that offers the safest possible environment for our patients. Therefore, prior to considering any decision in these cases, I first ask myself “is the patient (or any future patients) at risk”. Patient safety is the low bar that must always be achieved. Regardless of the ultimate decision, patient safety rules!
Rule 2. Always follow your bylaws and procedures- One of the most common reasons for getting into trouble in any potential intervention is that someone did not follow the established rules. Most of us avoid reviewing the medical staff rules and regulations, and when we do look at them, they could well serve as a cure for insomnia. Having said that, we must always remember they were created for a very important purpose— and this physician intervention is specifically one of those purposes. Whoever is quarterbacking the decision process, usually the CMO, must be totally familiar with every existing rule, regulation, bylaw and precedent. The first step in the process is NOT to do a knee-jerk reaction, but rather to immediately refresh yourself with the rules. Unless you are in immediate extreme danger, and that is rarely the case, take a few moments to reacquaint yourself with those rules and bylaws up front. This review time is well spent. Also, in every step of the process, make sure that each participant, including the physician being reviewed, has a copy of those rules and understands them fully. If the situation ever goes to some form of legal review or litigation down the road, one of the first things that will be looked at is “did you follow all of your own rules and regulations?”. Do not get bit by that one. Not following the rules opens you up to all sorts of problems, all of which distract from the original offense that you are trying to manage. But rather than being negative, look at the converse- the rules are your friend during this process. Following the rules is your best protection from an adverse procedural event or adverse outcome, and your best pathway to get a reasonable remedy. Never assume you know the rules; always check them out and be sure you are comfortable with them. If there is any doubt, immediately seek legal counsel.
Rule 3. Implement the least disruptive solution that ensures Rule 1- Following these rules you have first considered the patient safety aspect, and then have followed all the rules during the process. Now it is time for the remedy. What is the most appropriate action to resolve the issue? With any intervention, there is often a continuum of potential remedies. For example, for an offending physician, it may range from a simple reprimand to summary suspension—or anywhere in between. Here is where Rule 3 is so important. I always advise clients that given a spectrum of potential responses, choose the least disruptive option that will ensure patient safety. Ensuring patient safety must trump any potential concerns for the welfare of the individual physician, or even the hospital. The sports analogy is that whether you win by 50 points or 1 point, you still win. The “win” is to maintain patient safety. Although you want to minimize the impact of the decision on the organization and on the physician, it should never sacrifice the safety of the patient.
Over the years, I have found the application of these principles to be very helpful. Even though I started doing this almost 30 years ago, I feel that the three rules are still relevant.
I welcome your feedback and thoughts.