1. LA / NY / SF / DC / arentfox.com WAMSS Annual Educational Meeting May 4-6, 2016 CORRECTIVE ACTION: Strategies for Avoiding Necessary Action Erin L. Muellenberg

2. Where we are going…… Identifying When Actions are Necessary Why Actions Must be Done Phases of Corrective Action Overcoming Barriers to Action Clinical Problems All Other Problems Immunities and Protections 2

3. When are Actions Necessary? NEVER!!! “My medical staff is perfect” Pollyanna 3

4. “If we don’t look, there isn’t a problem.” 4

5. CORRECTIVE ACTION DONE RIGHT: Progressive Discipline Rationale: Least restrictive means to protect patients and practitioners 5

6. When are Actions Necessary Initial Application Reappointment Privileges: New & Existing Patterns Single Event Skill deterioration Cognitive Decline Impairment 6

7. Why corrective action must be done - Patient safety Provider remediation ACA/Value Based Payments Avoid enforcement activity 7

8. No Action: Patient, Family & Staff 8

9. Impact of Action on Practitioner Remorse Remediation Ruin career –Medical Board reporting –NPDB reporting 9

10. Value Based Payment Fully implemented by 2018 Quality based Enforcement will follow –Reasonable and necessary –Worthless services –Difference in medical opinion does not mean fraud 10

11. Footer Text 11

12. Enforcement Focus Trends Patterns Agendas 12

13. Corrective Action Bylaws define Summary suspension or restriction Least restrictive thing that can be done which will protect patients Hearing rights Simplify the corrective action process 13

14. Corrective Action Simplified Mediation Arbitration Dedicated hearing panels Stipulated facts 14

15. Informed Decisions - Employment – –Wrongful termination Contract –Breach of contract HCQIA –Immunities 15

16. Breaking Down the Barriers 16

17. Why are Disciplinary Actions Avoided? Leave it for the next chief of staff It will ruin a career He/she is not hurting anyone Mistakes happen to everyone It’s biased (only competitors or partners are involved) It’s expensive in time and money Unreliable data 17

18. Removing the Barriers Reliable data –Good quality program Leadership selection and training –Review selection criteria –Payment? Leadership operational support –Administrative commitment to staff Governing body support 18

19. Clinical Problems OPPE FPPE External Review Patterns 19

20. Health Care Quality Improvement Act Protects Peer Review bodies and all participants Protects communications to other peer review bodies Immunity provided if standards are met 20

21. HCQIA Standards Reasonable belief in the furtherance of quality care Reasonable effort to obtain the facts Adequate notice and hearing procedures Reasonable belief the action was warranted by the facts 21

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23. Practitioner Health Aging Mental Health Impairment Illness Disruptive Behavior Well-Being Committee 23

24. Cura te ipsum – Physician Heal Thyself 24

25. Estimates Continued Projected number of active physicians in 2020 AMA Masterfile: AMA = 1,050,000 65+ = 189,000 (18%) 55+ = 409,500 (39%)

26. MILD COGNITIVE IMPAIRMENT NEJM 2011; 364: 2227-34 In persons older than 65 in the general population the prevalence of mild cognitive impairment (MCI) is about 10% and perhaps slightly more In the population with MCI the annual progression to dementia, most commonly Alzheimer’s disease, is about 5% to 10%

27. Hospital/GroupScreening Commences at Frequency of assessment Areas assessed Stanford Lucile Packard Children’s Hospital Age 75 Every 2 years Peer assessment of clinical performance History & physical Cognitive screening University of Virginia Health System Age 70 Every year after age 75 Physical and mental capacity (not defined further) Driscoll Children’s Hospital Age 70 At reappointment Physical and mental examinations (described elsewhere) Proctoring of clinical performance if deemed appropriate What can we do? – 3 Policies

28. MENTAL HEALTH: Recognizing and Addressing the Signs and Symptoms Before It Is Too Late 28