The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

Based on review of complaint files, event reports and physician file, it was determined that the provider's behavior met the criteria outlined in the hospital's policies on Medical Staff Code of Conduct and Medical Staff Quality Policy for disruptive physician behavior and the hospital failed to address his behavior until the recent complaint was received.

This physician did hold positions of authority within the hospital such as Chief of Staff. The complaint was reported anonymously and alleged that the physician's behavior made it difficult to work with him and that there was concern that this could affect patient safety.

Per the hospital re-credentialing process, every two years the hospital reviews the physician re-application. This process includes review the physician's licensure status, DEA and CDS status, Delineation of Privileges, National Practitioner Data Bank query, Office of Attorney General query, Clinical Activity and Utilization and Quality Assessment. During this process the complaint should be reviewed to determine if there are patterns of professional practice of conduct concerns. Other than a complaint log, which revealed verbal intervention with this physician, there was no further documentation of outcomes nor did the hospital track and trend the complaints to determine if there were concerns with this physician's performance.

The hospital failed to effectively use the On-going Professional Practice Evaluation (OPPE) to identify performance trends and to improve individual physician's performance prior to the re-appointment decision for this physician.
Based on the review of the physician specific complaints and the physician's file, it was determined that the complaints about a physician had been referred to the Chief of Staff and the Chief Medical Officer however, there was no written documentation on file regarding the interventions and outcomes other than the complaint log.

Complaints specific to this physician's behavior were documented as far as 3 years ago. The hospital's Medical Staff Quality Policy clearly outlines core competencies and Ongoing Professional Practice Evaluation (OPPE) section VI of the policy addresses disruptive physician behavior including examples of the types of behaviors. The hospital also has a policy entitled "Medical Staff Code of Conduct." Although the hospital has these policies in place to address disruptive physician behavior and reports were filed regarding the physicians behavior, the behavior was not addressed. It was stated that the physician was spoken to by his supervisor regarding the complaints but nothing was written regarding the intervention and outcomes. There was no evidence that the hospital had addressed the physician conduct until the current complaint was received.

The hospital's medical staff pursuant to the medical staff bylaws failed to act upon reported concerns regarding the physician's professional behavior. Failure to address the physician's behavior led to a hostile work environment and staff going outside the hospital to anonymously report concerns.