Medical staff handling of concerns with physicians' performance.

Evaluation and management of potential physician problems need to be performed in a structured manner to provide physicians opportunities to improve performance and the organization opportunities to protect itself and the patients it serves Specific steps need to be followed in dealing with potential physician problems. Concerns, which may or may not be true problems, must be recognized. Facts regarding the circumstances of the event need to be verified. The event's severity and its relation to patient care and to previous events have to be assessed. Conclusions must be reached and actions need to be taken. Conflict and confusion result when steps occur out of sequence or are omitted.

Identifying Concerns

Medical staff officers, department chairs, and quality assurance/improvement representatives will often be notified about possible physician problems. It is important to recognize notification when it occurs. Early in the process, as identification occurs, all reports should be treated as concerns. Reports should not be considered problems until events are verified and conclusions are reached. Reports of concerns represent potential problems that need to be managed and resolved.

Potential problems can be identified from a number of sources. Most institutions have mechanisms for physicians, staff, and patients to report concerns about physicians to the administrative staff. Notification may occur by phone or in hallways. Written reports may arrive from quality improvement or other administrative staff. Concerns can be identified from a chart review process carried out for quality improvement programs or from quality assurance techniques, such as record reviews. Observations usually originate with professional staff, but any individual should be allowed to express a concern.

Identification of concerns about physician knowledge, performance, or behavior can come in a variety of forms. Invariably, the person who has observed the issue has made a judgment before reporting it. This information needs to be documented for consistent review by peers and associates. Although, in extreme or urgent situations, action may be required before documentation, it is essential that a report received for review by the medical staff be in written form. Hearsay information, while often containing a ring of truth, is gossip and should not be acted upon. All observations, reviews, and discussions should be kept within the quality management system. While legal precedents vary among the states, quality management information is often legally protected information, allowing physicians to provide peer review without excessive threat of legal entanglement.

Ensuring Accuracy

Reports of perceived concerns should be reviewed carefully by the responsible physician. If the concern appears to be a problem or a possible problem, the physician reviewer should verify the facts reported. The medical record, other participants, and the reporting individual are typical sources to be reviewed. If there have been reports in the past to other medical staff committees or medical staff officers, to quality management personnel, or to the medical staff office, they should also be reviewed. Recurrent and lesser problems may be seen in a different light when they are part of a sequence of events. Most important, after the issues raised by the report are clarified, the reported physician should be approached. This is best done in a private, informal setting where the view of the physician in question is considered and judged in the context of the medical situation. This step is one of the most important in the handling of these issues.

Assessing the Concern

When presented with a reported concern, the reviewing physician must make an initial assessment and judgment. This is not easy and should be made with care and consideration. Is there a problem? If so, what is the severity of that problem? Can the problem be handled methodically, or is prompt action required? These questions have to be answered early in the course of problem identification and resolution. Frequently, when viewed by a physician reviewer, initial reports appear inappropriate, vindictive, or frivolous. Often, it is clear that the individual reporting the incident did not understand clinical management, medical techniques, or expected physician behavior in the reported situation. Such reports are not worthy of further pursuit and should be dismissed by the responsible medical staff reviewer. Care must be taken not to dismiss reports without reason, however, and this responsibility is best handled by respected, senior medical staff members. If the question, "Is there a problem?" cannot be adequately answered by the initial reviewing physician, further medical staff review should be carried out. Further review allows for broad input and measured judgments.

If the physician reviewer feels a problem is present, the next issue is its severity. Some problems cannot await written reports or careful consideration. Intoxicated physicians, deviant behavior, or criminal violations are all causes for immediate action by the vice president for medical affairs and appropriate medical staff officers. Medical staff by-laws should address the steps to be taken in the likelihood such events may occur and should be carefully followed. Most problems with physician knowledge, performance, and behavior are not severe. They can be handled methodically, but promptness benefits all concerned. A deliberate approach is appropriate when complex issues or questionable "concerns" require multiple physicians' review and judgment.

Classifying Problems

Recognition of different types of problems may help in judging and resolving issues. The problems most often reported involve interpersonal relationships, dysfunctional behavior, or inappropriate or inadequate delivery of services. These behavioral issues can vary from minimal to severe and from a one-time occurrence to daily happenings. As with medical knowledge, the perception of appropriate behavior can vary on the basis of training and background. Despite the quandary, judgments must be made and standards applied. Sometimes, reports of concerns require the medical staff to define or formalize unwritten standards for medical staff behavior. These issues can be addressed by a broad-based group of peers, crossing specialty lines.

A deficit of medical knowledge is obviously a potential source for problems. As physicians, we often rely on our sixth sense as to what is correct and what is incorrect patient care. Unfortunately, it is impossible for any physician to be fully informed, even in his or her own field. Medical issues are often clouded by uncertainty and shades of gray. Despite uncertainties, physicians are often required to make judgments on issues of medical knowledge or practice. Suspected problems are best judged by peers, which should mean the same specialty or subspecialty. In smaller staffs or in situations where fewer peers are available, outside consultations should be considered.

Reaching Conclusions

For all concerns raised about physicians' performance, conclusions eventually must be reached. Is there a problem? Consideration should always include review by more than one physician. Consideration can be made by separate physician reviews, committee review, or other structured formats within the quality assurance/improvement system. Care must be taken to finalize the review and reach conclusions regarding the identified "concerns." Conclusions are best reached by peer consensus. Physician review must conclude whether or not the reported "concern" represents a problem with medical care, physician service, or professional behavior. If it does, action must be taken. If physician review concludes the reported "concern" does not represent a problem, the report should be closed without action.

Taking Action

Action should be recommended and overseen by the medical staff after deliberate consideration. Minor issues may be resolved by department chairs or medical staff officers. In most incidences, a problem brought to the attention of a responsible physician leads to self-correction and resolution. If the problem is important enough, actions in addition to notification of the responsible physician may be required, such as performing further monitoring, requiring educational updates, establishing expected behavior, or prescribing punitive measures. More than one type of action may be required, and all actions should follow medical staff by-laws. Flagrant problems may require action as soon as possible to protect all concerned. Medical staff by-laws have to be followed, and time may not permit extensive peer review.

The Process

The process of handling quality concern reports represents the application of the steps shown in table 1, page 17. As a report is carried through the review process, these steps can and will be applied at multiple levels by individuals and groups. Table 2, page 17, demonstrates the flow of the steps as a reported quality concern might be handled by a single physician and then a peer group. In larger organizations, several individuals might review the report before it is referred for peer review. As the number of individual physicians passing on the report increases, it is extremely important not to assume that prior reviewers have performed all the appropriate steps in the process. Each situation is unique. But, after the recognition of potential "concerns," following the steps will guide us to resolving these issues. The responsible medical staff physician can use the guidelines to keep the process on track. Knowledge and experience will allow a smooth conclusion to these potentially difficult situations.

Table 1. The Steps: Quality Concerns* with Physician Performance

* Identifying Concerns
* Ensuring Accuracy
* Classifying Problems
* Reaching Conclusions
* Taking Action

* A perceived worry, problem, or anxiety.

Table 2. The Process: Quality Concerns with Physician Performance

* Identified concern reported to medical staff

* Responsible medical staff physician reviews (officer or department
or committee chairman)
* Assures accuracy
* Classified the problem
* Judges the concern
* Reaches conclusions
- Concern is or is not a problem
- If a problem, what is degree of severity
* Takes action(s)
- Dismiss if not a problem
- Review with involved physician
* Notify of problem
* Advise of standards
* Advise of further action
- Monitoring
- Peer review
- Immediate action
* Forward for peer review
- Immediate action for serious problems

* Peer review (committee, department, or other): Each member
contributes to process as
chairman leads group through the steps to resolution
* Accuracy of report reviewed
* Type of problem clarified
* Standards for physician performance reviewed
* Problem judged
* Conclusions reached
- Problem is present or is not present
- Severity of problem present
* Takes action(s)
- Dismiss if not a problem
- Review with physician
* Advice of standard(s)
* Advice of further action(s)
- Monitor activity
- Sanctions