By James Anliot, Esq.

Internal oversight is essential for any business today, but it is especially important in the healthcare industry, where even a simple mistake can cost a person's life and result in a multi-million dollar verdict.

In today's regulatory environment, hospitals and other healthcare facilities must increasingly take responsibility for the actions of practitioners working within their walls, even if they are not employees. Confronted with increased patient-care demands, reimbursement issues and staff shortages, they also find it difficult to ensure that necessary preventative or corrective measures are being implemented.

Licensing boards and other regulators increasingly are using monitoring services to handle disciplinary issues. Professional monitors observe healthcare professionals and help them comply with regulations in lieu of other disciplinary action. Instead of fining practitioners or taking away their right to practice, monitoring can help correct problems, keep talented people practicing and relieve the burden on regulatory agencies.

But external monitoring can also be useful for internal compliance within a healthcare facility. Advantages external monitoring provides include:

• Monitoring can address a broad range of issues, from internal disciplinary sanctions to operational or financial improvements.
  
  
• Monitoring can provide an impartial third-party look at how you do business; monitors are unlikely to be influenced by internal organizational tensions.
  
  
• Monitor qualifications can be custom-tailored to the issues involved; third-party monitors can provide expertise that may not be available internally.
  
  
• Outsourcing saves money. Instead of using fulltime internal staff, healthcare organizations can retain monitors only when they need them.
  
  
• Outsourcing enables healthcare organizations to focus on their core business of providing quality healthcare.

The Monitor's Internal Role

One area where monitoring can help is when a credentialed physician is brought before a peer review committee or internal disciplinary panel because of a behavioral problem or clinical performance issue. Suspension of staff privileges or dismissal is often undesirable, because the practitioners' skills are needed and because dismissal can cause other problems, including lawsuits.

Consider, for example, a case where an internal disciplinary panel has convened to consider action against a physician based on a complaint from a nurse about what she views as a "near miss" involving a patient. A review shows that the incident was insignificant and resulted in no harm. Yet it reflects a pattern in which the nurse and her colleagues repeatedly had to ask the physician for clarification, because documentation is often incomplete, illegible or based on a shorthand that no one but the physician understands.

The nursing staff finds it difficult to develop appropriate care plans and is worried about possible medication errors. Despite repeated efforts to address the issue with the physician, nothing changes and the nurses become increasingly frustrated. The small hospital has not yet implemented a fully electronic record-keeping system. The physician in question is considered an excellent clinician, but patient safety considerations require that something be done.

Dismissal of the physician, even temporarily, is too severe an outcome and is undesirable to the hospital. However, correcting documentation issues requires re-education of the physician, along with ongoing oversight to ensure that permanent changes are made. This can pose a challenge for in-house staff, because of the volume of other concerns they must address.

An independent monitor with an appropriate clinical background, however, could provide the ongoing presence and consistent oversight needed to re-train the physician to make permanent improvements. Such an approach is more effective than the traditional solution of additional continuing education courses. Short-term improvements derived from such courses often succumb to day-to-day pressures and the temptation to return to old habits. The monitor is available to provide not just continuing oversight, but advice and one-on-one training, which can help the sanctioned professional avoid backsliding.

In addition, the sanctioned professional learns from a fellow professional, chosen precisely because of the specific expertise the sanctioned professional needs.

The monitor can provide the peer review committee with neutral, objective reports about whether progress is being made, and share information about situations in which documentation deficiencies recur. The monitor can also relieve the overburdened quality improvement staff of a labor-intensive task.

An independent monitor is also helpful for handling behavioral issues. With no vested interest in the outcome, the monitor can offer an objective evaluation and may identify factors contributing to difficult workplace conditions. If further incidents occur, the monitor can conduct an objective inquiry, and provide an unbiased assessment of what happened and why. The monitor may also suggest changes to reduce conflict. The monitor's neutral, detached perspective may encourage both sides to develop innovative ideas that differ from the hospital's usual procedures.

Other Uses

Independent monitoring can be applied to any matter in which oversight is needed. Implementation of recommendations from a patient safety committee, for example, can be monitored to ensure that they are fully carried out. The use of a qualified, but neutral monitor can help resolve or avoid tensions that sometimes interfere with the execution of such improvements. Similarly, monitoring can be used to ensure that changes in credentialing procedures are carried out. The monitor can conduct independent reviews of personnel files and credentialing activities, and inform senior managers of any deficiencies.

Monitoring can also be used to ensure the implementation of other compliance programs. A qualified monitor can conduct financial and operational audits of particular departments or service units and identify deficiencies. Once recommendations for improvement are made, the monitor can oversee implementation.

How the Monitor Works

The monitor must, of course, have skills appropriate to the situation being monitored. A physician or supervising nurse may be used for monitoring clinical issues, while someone with a business or financial background may monitor conformance with specific policies.

The monitoring process is flexible. The monitor gathers the information needed to evaluate the individual through direct observation, review of clinical or business records, and contact with patients, colleagues or others. Depending on the situation, the monitor's activities can be scheduled, unannounced or a combination of the two. The reporting process can be specifically tailored to the particular circumstances of the situation and management's preferences. The monitor can also provide direct advice to the individual.

Perhaps best of all, monitoring can be cost-effective, since a healthcare facility can engage a monitor only when needed.

James Anliot, Esq. is the Director of Healthcare Compliance Services for Affiliated Monitors, Inc. (AMI), a consulting corporation that provides compliance programs to chiropractors and other healthcare professionals. He can be reached at (866)201-0903 or janliot@affiliatedmonitors.com.