Are providers pumping up the volume and putting your patients at risk?
Recent cases raise question: Should you draw a line?
By Joy Daughtery Dickinson
Multiple malpractice lawsuits have been filed against a New York orthopedic surgeon who reportedly performed as many operations in two days as the typical orthopedic surgeon averages in one month. The law firm representing about 150 of the 250 former patients who are suing says that two hospitals and a surgery center will be included in some of the lawsuits.1A published news report questions the administrative oversight and patient safety in these cases.2
The physician was terminated by his medical group, and he voluntarily surrendered his medical privileges at both of the hospitals.
The role that fatigue might have played in these cases isn’t certain. However, in The Joint Commission’s examination of harmful and sentinel events, "We think we can conclude that fatigue is in fact a factor, more than an incidental finding," says Ronald M. Wyatt, MD, medical director in the Division of Healthcare Improvement at The Joint Commission (TJC).
Outpatient surgery providers and others need to recognize this area as one that needs improvement, Wyatt says. "This is the message that we need to get out the word [by saying], Organizations, this is a major patient safety issue,’" he says.
Indeed, some providers are performing too many procedures in a limited time period, says Lynn Reede, CRNA, DNP, MBA, senior director of professional practice at the American Association of Nurse Anesthetists. "Many of these surgeons are going to many facilities," Reede says. "One insurance carrier may be at one or another facility, so they’re packing in the volume on a given day."
Another contributing factor is that advances in technology mean more procedures can be performed in shorter timespan, says Marsha Wallander, RN, associate director of the Accreditation Association for Ambulatory Health Care (AAAHC).
At the same time, outpatient providers don’t normally dictate how many procedures can be performed because it depends on the type of case, Reede points out. "Some procedures take minutes, and others take hours," she says. Also, it’s not unusual for surgeons to use two operating rooms and two teams in order to be efficient, she says.
And there are other factors, Wallander says. She recently was involved in a discussion about an endoscopic surgeon who has cases that run 2-3 minutes longer than the average time. "My response was, is that the person getting all the difficult cases?" Wallander says. "There’s sometimes a reason, so look at the reasons before you jump to conclusions." For example, one provider may be doing all of the diagnostic endoscopy for patients who are post cancer surgery. "I want him to slow down and take longer," Wallander says.
Consider these suggestions for tackling the complex issue of physician caseload:
• Ensure providers are paying attention to their own level of fatigue.
In small facilities there might not be additional staff to relieve the surgical team, Reede points out. A fatigued staff member should be comfortable suggesting a break of 15 to 30 minutes, Reede says. "The anesthetist is responsible for their patient’s safety," Reede says. "Part of that responsibility if to be aware of their fatigue level and ability to focus. They may request a break or even relief."
Also, it is the responsibility of the nurse clinical manager or the OR nurse supervisor to make sure that the nursing staff have breaks and meal coverage, sources say.
The Joint Commission advises healthcare providers to involve employees in designing work schedules that minimize fatigue. The agency issued a Sentinel Event Alert on fatigue risks last year. (For more information, see "TJC gives wake-up call on fatigue risks," Same-Day Surgery, May 2012)
• Offer options to surgeons.
An interdisciplinary team can meet to address the issues of volume and fatigue. The group can include the medical director and facility leaders, Reede says. This group can approach the person responsible for risk management to discuss options.
"Administration should work with the surgeon to offer a schedule that may be more amendable to their practice and lifestyle," Reede says. For example, the surgeon can be told, "We’re doing more cases. We’re stretching ourselves thin here. Can we open another day in the schedule for you so you have more hours in the OR in your block? We can work around your office hours," she suggests.
• Have policies in place to address surgeon fatigue, and ensure compliance.
In some hospitals, surgeons may be on call the night before elective surgery and might be covering multiple hospitals, Wyatt says. Surgeons should be able to say, "I’m too fatigued to come in" and have it not seen as a blow against their reputation or against the facility’s revenue stream, he says.
Invite your staff to help you establish another system and a policy that addresses this type of unexpected situation, Wyatt says. "We’re seeing more and more emphasis in healthcare around patient safety and how you become more highly reliable," he says. "That is the way the organization becomes more highly reliable."
Changes can be built into the informed consent process, he says. For example, patients can be notified that the surgeon was up all night and asked if they want the surgeon to proceed with their elective case. "Eighty percent of the time, the patient says no," Wyatt says. "If they say no, there should be a process for another surgeon to take the case, or efficiency mechanisms in place for that patient to be rescheduled, based on internal processes," he says.
If TJC receives information indicating a surgeon was impaired, from fatigue for example, and there is a poor outcome, the agency will approach the facility to determine if it has policies in place that address issues such as surgeons being on call the night before, and it will determine whether those policies were followed, Wyatt says. (For more information, see package of stories on sleep-deprived surgeons in March 2011 SDS.)
• Track and report patient outcomes.
Facilities should be monitoring patient outcomes as part of the ongoing professional performance evaluation (OPPE) program at their facility. Deviation from the standard of care can be addressed through a focused professional performance evaluation (FPPE), also known as an action plan, Reede says.
For example, organizations should have metrics, such as return to the OR or readmissions, that are measured consistently and communicated to the department, surgeon, and the governing board, Wyatt says. If a sentinel event occurs, the TJC staff would ask if there was anything in the ongoing evaluation that indicated to the organization that a surgeon should be on a focused review for three to nine months. After that period of time, the decision might be made to continue the surgeon on focused review, drop it, or take away or suspend a surgeon’s privileges, Wyatt says. If additional mentoring or training is needed, that need should be documented, he says.
The OPPE process can address whether surgeons be limited in the number of procedures they perform in a given time period and how such limitations should be established, Wyatt says. "The TJC won’t take a stand on how many or how often, but it’s expected that as part of the OPPE process, the organization and governing board will look at those issues, monitor them in an ongoing way, and have a way to address those deficiencies," he says. "Or if a person exceeds a measure, they should have a system in place to say, `It’s not safe for you to operate at this point, based on your data and our analysis of that data.’"
AAAHC looks to members of the governing body and the administrator of a facility to ensure patient safety and to take steps when they have a concern, Wallander says. "We don’t say, if someone is doing X number of procedures, you must do Y and Z,’ but if they have a concern, we expect ongoing monitoring," she says. "If a concern appears, we expect that they take action." (Editor’s note: The AAAHC Institute for Quality Improvement provides benchmarks, including procedures times. See "AAAHC Institute releases benchmarks — Knee arthro, cataract, back injection & colonoscopy reported," Same-Day Surgery, June 2013.)
- Wisell & McGee. Wisell & McGee represents former patients of Dr Syros Panos in medical malpractice suits. Dec. 2, 2011. Accessed at http://bit.ly/14QcnxE
- Bradshaw S. Records: Spyros Panos averaged 17 surgeries per day. Lawyers ask why hospitals didn’t take action earlier. Poughkeepsie (NY) Journal. July 21, 2013. Accessed at http://pojonews.co/12jwpDL