Tag Archive for 'peer review'

SSI Names 2010 “Clean Hands Award” Recipient

26 Oct – Nashville - The Board of Directors is proud to announce that Dr. Richard Willner DPM, is the Semmelweis Society International “Clean Hands Award” recipient for 2010. Continue reading ‘SSI Names 2010 “Clean Hands Award” Recipient’

Is Healthcare Asleep at the Wheel?

Dateline: Redding California, 2002 – A jetliner carrying 700 passengers crashed into Mount Shasta killing 69 and injuring most of the remainder. Pilot error caused the crash. The FAA ignored the incident.
If this story were true, we would be outraged and demand a full government investigation of the FAA’s negligent failure to investigate. Yet the story is partially true: all the “passengers” were patients at Redding Medical Center in Redding, California between 1993 and 2002. The two “pilots” were Drs. Fidel Realyvasquez, a cardiac surgeon, and Chae Moon, a self-proclaimed cardiologist.
In late 2002, the FBI “busted” this conspiracy of negligence. The two physicians have lost their license to practice in California.  The hospital administrators who helped hide the doctors from public scrutiny have relocated to foreign countries to find work.
But “busting” the “bad guys” for unnecessary heart procedures and surgery on healthy patients was not good enough for my team, or for the people, so we set out to discover how this gross and near criminal medical negligence could possibly be tolerated for 10 years at a well respected, accredited, and licensed hospital.
Based on our investigation and report gleaned from public documents and private testimony, we found that government officials failed to enforce our laws: laws necessary to assure hospitals are safe for the public.
Both State and federal health care officials knew as early as 1999 that RMC and its medical staff could not assure patient safety for cardiac services. These officials knew the hospital and medical staff provided no oversight or review of the quality of care provided by Moon and RV. In fact, both of these physicians were in charge of their own reviews. Moreover, our main hospital accreditation organization, the Joint Commission, also knew in 1999 of the danger Moon and RV posed to patients because their patient care services were hidden from review by their peers. The JC accredited RMC anyway. The first peer review provided for Moon and RV was performed by outside medical experts hired by the FBI in 2002.
Now that we know hospital peer review requirements are not enforced, the California legislature refuses to give our enforcement agency, Licensing and Certification, the power it needs to enforce our laws.
Professional stakeholders, but not the public, oppose law enforcement penalties that would compel effective peer review. L&C does have the power to impose fines of $50,000 to $100,000 against hospitals for allowing imminent danger to patients. But the absence of peer review is not an imminent danger, even though hundreds of patients can be harmed over time.  Patients at many California hospitals are vulnerable to unmitigated medical negligence which can only be prevented by brave conscientious physicians who have the professional courage to voluntarily identify physicians who allegedly endanger patients and hold them accountable through the peer review process. In hospitals where peer review is absent or ineffective, there is no mechanism to cull out negligent physicians until after many patients are damaged.
When peer review is properly performed, suspected physician errors are discovered timely, through analysis of various triggers, such as unexpected return to the operating room or unexpected blood loss. Promoted by these triggers, specific patient cases are reviewed by other physicians at the same hospital. The care provided may be acceptable or problematic. If physician negligence is discovered, corrective action is taken. A physician may be instructed to take more education, limit performance of certain services, or could be discharged from the medical staff for egregious acts. The result is safer care for future patients.
The California Legislature ordered a report on California peer review and hired Lumetra, a private company to write it. Lumetra published its report in 2008. Lumetra found that peer review in California is unacceptable, inadequate, and ineffective: patient safety cannot be assured. RMC is the “poster child” for what goes wrong too often. Now, seven years after the FBI “busted” Moon and RV, and after the Department of Justice and CMS kicked RMC out of the Medicare Program, our peer review laws remain unenforced throughout California. 
In the 2009 legislative session, the California Legislature has taken up the peer review issue (SB 58, SB 700, AB 120, AB 245, and AB 834). But current proposals will not enact penalties L&C requires to enforce our laws. Experts believe L&C needs the power to impose intermediate sanctions against hospitals and medical staffs for repeat failure to conduct peer review. Currently, the only power L&C has is to revoke the license of the entire hospital, which the Agency rarely does. By contrast, intermediate sanctions could remove the license of a hospital for certain elective services only in those clinical departments (e.g. cardiac services) where peer review is not provided or is ineffective on repeat audit. With this power, a negligent hospital and medical staff would face huge financial losses and, therefore, would provide the missing peer review immediately. Without the enforcement power of intermediate sanctions, hospitals and medical staffs can continue to flaunt our laws knowing the State has no power to enforce them.
In other words, currently peer review is self-administered, not audited for effectiveness, and when not done, there is no power to enforce the requirement. Self-administered peer review in hospitals works as well as self-administered regulation compliance did on Wall Street in 2008. Doctors who need help are not identified, and future patients continue to suffer the consequences.
In 2009, patient safety will remain a goal, not a reality; except, perhaps, in a few self-proclaimed centers of quality. To change this unacceptable situation, you must write to your California legislator and demand enactment of intermediate sanctions to enforce the peer review laws in California.
Good luck next time you are admitted to a hospital in California. You will need it because patient safety cannot be assured. It is safer to fly.
Dr. Rogan is a family and emergency physician who served as the Medicare Medical Director in California from 1997-2003. In 2002, he assisted law enforcement with the RMC investigation. Currently, he is an
independent consultant to health services companies.
 

Peer Review in a Nutshell

Peer review is a process by which members of a hospital’s medical staff review the qualifications, medical outcomes and professional conduct of other physician members and medical staff applicants to determine whether the reviewed physicians may practice in the hospital and, if so, to determine the parameters of their practice.

To encourage peer review, almost all states have granted immunity to participants in the peer review process from certain actions and have made the deliberations and records of medical peer review privileged from judicial disclosure. These laws protect peer review participants from liability for their participation in the peer review process and keep medical peer review information privileged even if such information is relevant and probative to a judicial proceeding. In granting these protections, legislatures have determined that limiting the rights of physicians to seek damages for peer review actions and denying malpractice plaintiffs and other litigants information relevant to their lawsuits are justified in order to encourage effective peer review.

In 1986, congress enacted the Health Care Quality Improvement Act (HCQIA), a federal law that provides protection from liability to healthcare institutions and physicians involved in peer review, as long as certain conditions are met during the peer review process. The law also established the National Practitioner Data Bank, a repository of actions taken against physicians, to which healthcare institutions must report those actions. The purpose was to prevent incompetent physicians from moving between states without being detected. An entry against a physician in the Data Bank can be equivalent to a death sentence, since it makes it very difficult for a physician to obtain privileges at any other hospital, since the latter verify applicants’ credentials with the Bank prior to granting or renewing privileges. The physicians are often left with no choice but to abandon their profession and obtain unrelated jobs.

Since HCQIA went into effect in 1989, thousands of adverse reports have been filed with the Data Bank. Unfortunately, a large number of the actions reported have been taken maliciously by hospitals and their medical staff against the physicians subjects of the peer review. The motives are usually economic in nature, but also include retaliation against whistleblowers, personal spite, and even disputes over a parking space. This process has been dubbed sham peer review, has now become a powerful weapon in the hands of hospitals and those physicians who hold the political power in hospitals, and is being misused nationwide. Many lawsuits against the perpetrators have been filed by the victims, but very few of them survived a summary judgment because of the immunity provided by HCQIA and because the conditions that need to be fulfilled for a peer review to be considered adequate, as defined by HCQIA, are very vague.

The award in August 2004 of $366 million to a physician by a Federal Jury in Texas for a single bad faith peer review highlights that this practice is adding tremendous cost to healthcare.

The use of bad faith peer review as an instrument to further widespread political corruption in Georgia shows the destructive nature of bad faith peer review, and the potential terrible consequences on the public. Georgia Senator Charles Walker has been indicted on 142 felony counts for stealing from Georgia hospitals. His scheme used bad-faith peer review to silence any staff member who spoke out. The effects of this corruption on Georgia are widespread.

No one can seriously believe that bad faith peer review affects only doctors. All of society is badly harmed when huge hospitals rip off the public, silence their doctors, impair medical care and essentially destroy the system designed to protect patients.

A review of 1000 cases conducted by Verner Waite, MD, FACS, founder of the Semmelweis Society, shows that at least 80% of peer reviews are initiated for economic reasons, and are not done in good faith. This is the most comprehensive review currently known. Upon review of these cases, the officers of Semmelweis find that due process in peer review is the exception, rather than the rule. It is rare to find any hospital that uniformly applies standards of peer review to the members of their hospital staff. As a result, thousands of physicians have lost their careers without any due process.

Bad faith peer review against one physician can silence hundreds of physicians and place physicians’ livelihoods at extreme risk. It is estimated that 9 out of 10 physicians exposed to bad faith peer review never work again as physicians. It is also estimated based on extensive experience and review of the literature that 1 out of 5 physicians exposed to bad faith peer review commit suicide. Bad faith peer review is a greater challenge to the practice of ethical medicine than the malpractice crisis.

The State Boards of Medicine, which oversee physicians’ licensure, have uniformly refused to interfere or take action against the perpetrators for puzzling reasons, not considering this practice a breach of the ethics of Medicine.

Many voices have condemned this abuse of the system and have called for reforms of the HCQIA to no avail. The most prominent of those are the Semmelweis Society International, the Center for Peer Review Justice and the Association of American Physicians and Surgeons. In October 2004, both the Pennsylvania Medical Society and the Association of American Physicians and Surgeons have separately passed resolutions to investigate bad faith peer review. The two physician groups said they plan to independently look into the misuse of hospital peer review proceedings as a way to retaliate against doctors who advocate too loudly or too persistently for better patient care. In both cases, the resolutions were passed by acclamation.

The resolution of the Pennsylvania Medical Society calls on the medical society to “explore all aspects of sham (bad faith) peer review and explore ways to prevent the misuse of peer review” including looking into “applicable laws and steps that can be taken to protect physicians’ rights to advocate for quality patient care.”