Reference no: EM133176394

You are supervisor for the operating room at ABC Hospital, a critical care access hospital located in northern Minnesota.  Given the remote location, the medical staff includes only five (5) physicians, all of whom are employed by the Hospital, with privileges to admit and treat patients.  Two older physicians have privileges to perform certain surgical procedures in the operating room. 

Dr. Whip is one of the two surgeons.  He is 68 years old and has been on the ABC Hospital Medical Staff for the duration of his career.  He performs frequent surgical procedures in the operating room yet his complications, especially his patient mortality and morbidity rates, are beginning to increase in the past year.  You learned from the Hospital's administrator that the Quality Improvement Committee recently began to conduct focused reviews of his surgical outcomes, especially his post-surgical infection rates, return to surgery and re-hospitalization rates.  The chief of the medical staff, Dr. Risk, plays golf with Dr. Whip every Wednesday afternoon and he has made it clear to everyone that he thinks the Committee's focused reviews of Dr. Whip are unnecessary, if not unfair. 

One afternoon, one of the surgical scrub nurses came to your office and closed the door.   He reported that the sponge count in one of yesterday's surgical procedures performed by Dr. Whip was not correct and he fears that the sponge remains in the patient's abdominal cavity.  You learn that the patient was discharged this morning and has returned home to recuperate following surgery.  You phone Dr. Whip's office and leave a message for him to call you back at his earliest convenience to talk about a question involving one of his discharged patients.

The next morning, Dr. Whip comes to your office and closes the door.  You tell him about the discharged patient and the surgical sponge count discrepancy.  He asks to see the patient's medical record and the surgical sponge count records that were created by the surgical scrub team.  He pauses for several minutes before he says, "I see no issue.  That sponge can't possibly hurt the patient and she likely will never know it is there.  I suggest we sit on this and only deal with any issues if and when they arise, which will probably be never."    In response, you suggest a call to Dr. Risk to bring him into the discussion, given his role as chief if the medical staff.  Dr. Whip responds that he will take it up with Dr. Risk directly, physician to physician, and warns you to "stay out of it!" 

You are familiar with the many Hospital policies governing surgical services, risk management and quality improvement, not to mention the Medical Staff Bylaws, all of which are catalogued in the many notebooks on your office shelf.   You decide to call the Hospital administrator and report the sponge count discrepancy involving Dr. Whip.  The administrator asks you to wrap up your investigation and submit a completed copy of the hospital-approved incident report with supporting documentation to her office by the end of the business day. 

Issues. List and describe at least three (3) of the key issues that concern you, in your role as supervisor, and why.  

Requirements. List and summarize the various applicable requirements - including but not limited to ethical principles, laws, regulations, Hospital accreditation standards, Medical Staff bylaws, ethical principles - that need to be consulted to address these issues.   What peer review policies and procedures in the medical staff bylaws govern here? 

Action Plan. What are the essential actions that need to be initiated by the Hospital, its CEO and chief of medical staff, in order to address these issues and requirements?