CASE STUDY #1: The Value of Objective Legal Counsel Review to Identify the Precipitant for the External Review.

The performance of a hospital employed gastroenterologist was questioned by some complaints over the past several years with little or no investigation or follow up. In February 2016 the GI Nurse Manager went to the VP of Nursing about the physician to complain that he did colonoscopies on patients with poor preps, too fast, and documented scopes to the cecum when this didn’t happen. The VP of Nursing brought this issue to the attention of the Chief Quality Officer (CQO) and the Chair of the Medical Staff Quality Committee (MSQC).

Upon the recommendation of the MSQC, the MEC required Focused Professional Practice Evaluation (FPPE) with supervision of the gastroenterologist’s next thirty colonoscopies and ten upper endoscopies. Proctoring was performed as a requirement of his employer (hospital) and involved the Department Chair and the Chief of GI. The results of the proctoring indicated no technical problems. In short, under observation his performance was acceptable.

The GI Chief was also requested by the MSQC to conduct a random review of 100 of the GI physician’s charts. The GI Chief reviewed every third chart and found the following:
- withdrawal time averaged 4-5 minutes (literature recommends 6 minutes);
- a large number of cases with inadequate bowel prep;
- overall procedure time was short and the polyp detection rate was 14% compared to the GI department average of 25%.

Random review of an additional 100 charts showed that the other GI physicians at the hospital all got better results.

The MEC concluded that there was a problem prior to the FPPE and the GI Chief’s review results led the MEC to want to pull his privileges. This may have led to a fair hearing and a NPDB report.
The Chief Quality Officer working in collaboration with the Quality Improvement Director and Legal Counsel recommended outside peer review to answer the following issues and questions:

1. Confirm the internal review findings. Prior to the FPPE was the doctor performing upper and lower endoscopies at the standard of care?
2. Does the GI physician’s performance meet a generally acceptable standard of care post FPPE?
3. What options should the hospital consider with regard to informing patients - disclosure of possible inadequate scopes, call backs for repeats, and shortened rescreening periods?
4. What are the quality/screening indicators that should have been used or should be used in the future to assure quality performance of UGIs and colonoscopies?
5. Legal Counsel asked the question: “what will we do with the results once we get the
report?”
The hospital contracted with an External Peer Review (EPR) firm who they had experience with. The external review firm agreed to be available to answer the above questions and engage in discussion on the follow up recommendations.
6. The CQO and Legal were not concerned that proctoring needed to be repeated. They were confident in the proctor’s and the GI Chief’s review. However, Legal Counsel
suggested that interviews be done with the GI nurses to establish the nature of concerns
regarding professional behavior, falsifying charting and patient communication.

Conclusion: EPR confirmed that the GI physician was not performing upper and lower endoscopies at a generally recognized acceptable standard of care prior to FPPE. The internal review results were also confirmed. Patients were protected and physician performance has improved. A fair hearing/appeal and a report to the National Practitioner Data Bank were avoided.
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The MSQC recommended to the MEC (who informed the Board) of the following actions:
- Clear performance expectations and outcome targets for withdrawal time and polyp detection rates. These targets were set consistent with the department and national averages.
- Clear performance expectations regarding professional behavior, false charting and patient communication were also set. In short, one additional occurrence of inappropriate behavior, false charting or poor patient communication would result in privileges being impacted.
- Performance will be confirmed by proctoring (at the GI physician’s expense, performed by a physician approved by the MSQC).
- Concurrent QI monitoring for the next quarter with results communicated to the MSQC.