Reference no: EM132219676

You are the Chairperson of the Department of Surgery and you attend the quality committee meetings. You do not have a vote on the quality committee because you need to carry out the recommendations of that committee. The committee is reviewing several cases of Dr. Monitor, one of the busiest surgeons on staff. These cases have had bad outcomes and the committee is concerned about Dr. Monitor’s surgical judgment. When each case is reviewed individually, it appears the issues are minor. However, upon detailed review of many of Dr. Monitor’s cases, a devastating pattern of events has emerged and the committee feels his practice patterns are not safe for the patients at this hospital. The committee has several choices; all choices are, however, only recommendations to you, the department Chairperson. The surgeon under scrutiny is not known to be arrogant or malicious and is, in fact, well liked. When you discuss these events with the partners in his practice, you find they are also concerned about Dr. Monitor’s practice patterns. You ask the committee to hold off on a recommendation giving you the opportunity to discuss the situation with the surgeon. After a very open discussion with Dr. Monitor and one of his partners, the Division Chief, you ask Dr. Monitor to voluntarily give up his privileges to perform the procedures that are in question. After being informed that he can only assist one of his partners in the procedures of concern, Dr. Monitor cordially agrees to comply with this recommendation. At the next quality committee meeting, you announce Dr. Monitor has volunteered to reduce his privileges

Discussion Questions

1. What are the facts in this situation?

2. Dr. Monitor volunteered to reduce his privileges. Does this event constitute a disciplinary action? Is this required to be reported to the physician licensing board?

3. What obligations, if any, does the Chairperson have to report this to other hospitals where Dr. Monitor has privileges?

4. If Dr. Monitor had been a difficult personality to deal with, do you think the Chairperson of surgery would have proceeded in the same manner? What type of communications do you think might have occurred in that scenario? Provide your reflections and personal opinions as well as your rationale for your responses.

5. Physician credentialing and privileging is a duty of the hospital Board of Trustees (BOT). The BOT delegates this responsibility to physician experts on the hospital staff. If the quality committee and the Chairperson of surgery had not done their jobs, what might the repercussions have been for patients and for the hospital? Provide your reflections and personal opinions as well as your rationale for your responses.