Hospital Quality Bomb — behind the veil

bomb

When a headline reports a doctor did something bad at a hospital don’t you wonder what happened behind the scenes?  What was the doctor doing and what was the reaction of people at the hospital?

Case in point:   Michael Booth of the Denver Post reported on 4/11/13 about the disciplinary procedure against a local general surgeon.  According to the report the surgeon was a frequent user of robotic surgery.  But, things were not going well in the operating room.

2008 to 2010 the surgeon had several major complications including perforating the aorta while doing kidney surgery and leaving instruments and sponges inside patients.  After at least 14 such incidents the hospital suspended him for 3 months.

He went back into practice but a formal complaint was registered April 2013 by the Colorado State Medical Board.  Centura Health – Porter Adventist Hospital declined to provide details of the case citing the Colorado law protecting peer review activities from disclosure.

Were there warning signs?  The CMS Hospital Compare website shows Porter Hospital has about average quality among Colorado hospitals.  The Health Grades website entry for the surgeon is fairly unremarkable — no patient comments  and no listing of disciplinary action.  Clearly, these sources are not good for early warning.

Usual or unusual?  The course of these events seems typical for a surgeon with quality problems in the hospital setting.   Although typical,  these events causes agony in the hospital quality department.  The hospital board (mostly non-medical people) is involved and they are always  horrified.

Cost to the hospital — a lot.  The cost to the hospital in terms of staff to investigate the surgeon, due process, legal counsel, physician (peer) review, and extensive documentation is likely at least a half  million dollars.

Money down the drain.  All the hospital actions motor upstream against the current of revenue generated for the hospital by the surgeon.  In other words, it’s really hard to barbecue a cash cow.

Is the hospital hiding something?  One might wonder why the hospital peer-review process is protected (kept secret).  The answer is very simple, if there was no protection then  no quality review would ever be done.  Lawyers are sometimes accused of chasing ambulances to get clients — no hospital quality review could be done with hungry lawyers reading every word.

The trip-wire.   The main concern in this situation, and many others like it, is the extremely slow detection and subsequent resolution of the problem.  The hospital department of surgery is on the front line for spotting surgeons with quality problems.  If that department does not have a strong warning system then years can go by without other surgeons realizing bad things are happening.  Sherlock Holmes would be using his magnifying glass on that department.

The nurse knows.  Operating room nurses often know about a surgeon’s problems.  But, saying something is like reporting on your boss — not so easy.

An eye in the OR.  One simple way to check a surgeon’s technique is to video record surgery (it is especially easy to do this with robotic surgery) — then if questionable cases come to light the record can be viewed.  Surgeons hate the idea of being recorded, again due to the legal implications should such a recording land in court.

Not over yet.  It take several years before all the suits and Medical Board actions are settled.

The point:   When you read something about a hospital taking action against a physician it is just the tip of the iceberg.  The quality problem took time to find, took time to research, took time to try (unsuccessfully) to correct, and finally took time to take  disciplinary action.  Once the last step is taken the hospital tries to stay out of the news with the hope the trouble will not rub off on them.  The hope is often dashed once the state investigates the actions of the hospital.  Hindsight is 20/20, the typical state investigation concludes the final action should have been taken on day one.

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