Executive Summary - Report of the Special Investigative Commission

Executive Summary Report of the Special Investigative Commission

Following the arrest of Earl Bradley, a pediatrician charged with sexually abusing children in our community, Beebe Medical Center ("Beebe") established a Special Investigative Commission to look at how Beebe might strengthen its internal procedures and practices to best ensure the care and safety of the most vulnerable members of our community (children and infirm adults of any age). In arriving at our final report, the Commission reviewed the existing practices and procedures of the Medical Center and its staff. We considered the twenty-eight (28) recommendations contained in Dean Linda Ammons' report, the sixty-seven (67) recommendations contained in the Solicitor General's report, and the Hospital System Trust Agenda adopted by all Delaware acute care hospitals.

The report of the Commission makes sixteen (16) recommendations to improve Beebe Medical Center and staff practices. The recommendations are also available in the Commission's full report on Beebe's website. The recommendations focused on three (3) concerns: reporting; identification of individuals suspected of being a safety risk to patients; and monitoring our progress.

Reporting

Our first concern was to review Beebe's reporting procedures. What more could be done to educate Medical Staff and employees about Delaware's mandatory "Duty to Report" reasonable beliefs of unsafe or unprofessional conduct of doctors and other healthcare professionals? We sought to ensure compliance with Delaware's requirements concerning the duty to report, as well as all new legislation passed by the General Assembly. The following actions were implemented:

A standardized educational program emphasizing the duty to report unprofessional and unsafe conduct of physicians and all other healthcare professionals regulated by the Delaware Division of Professional Regulations has been developed. Beebe also requires internal reporting of any unprofessional and unsafe conduct by any employee, Medical Staff member, or volunteer. This program began on August 3, 2010. Instructions on how to report unsafe and/or unprofessional conduct are now available on Beebe's internal intranet. Examples of misconduct are provided. Beebe has established a dual reporting requirement procedure with all Medical Center employees required to report unprofessional or unsafe conduct to both the Corporate Compliance Hotline and to their immediate supervisor. All physicians must also report professional misconduct to the Hotline, and to the Chief of their respective Medical Staff Department, which is ultimately reported to peer review and the Board of Directors. This internal reporting mechanism is in addition to the responsibilities that doctors or health practitioners now have to report to the state. All healthcare providers are also required to report unprofessional or unsafe conduct to Delaware's Division of Professional Regulation. "Whistleblower" protection is provided by Beebe to any individual who in good faith reports an incident or suspicion of unsafe or unprofessional behavior. Beebe will provide the general public with information on how to report unprofessional or unsafe conduct on its website and in its Patient Handbook.

Investigation

The Commission next sought to expand Beebe's ability to identify individuals who could pose a safety risk to patients. The following actions were implemented:

All internal reports of unprofessional or unsafe conduct must be made to Corporate Compliance, who then must also report to the Board of Directors within seven (7) days. The Corporate Compliance Officer will document all calls that are made. The current requirement of criminal background checks made during the pre-employment process for Medical Center physicians and staff will now also take place every two years for employees and at time of physician reappointment. Random drug testing of all Beebe employees is now mandatory. Annually, employees and physicians are required to disclose to Beebe whether they have been convicted of any crime or been the subject of any formal complaints regarding unethical or unprofessional behavior. Companies that provide contract and/or temporary employees who work at Beebe must provide background checks going back ten (10) years for any individuals scheduled to work at Beebe.

Monitoring

The Special Investigative Commission is committed to ongoing progress. The Commission retained Robert J. Marder, M.D., a peer review expert, to provide an overview of "best practices" across the country. Dr. Marder has reviewed Beebe's peer review activities and has made some suggestions for improving these processes. We have taken the following additional actions:

A management "best practice" to follow up on safety concerns will address employee and physician issues through education and/or discipline to ensure that such safety concerns or problems do not recur. A new Chaperone Policy was approved on September 24, 2010, for both Beebe and the Beebe Physician Network. This policy identifies those situations when chaperones are needed, the roles and responsibilities of a chaperone, and the patient's rights to have a chaperone. Signage and brochures have been developed to educate the public about Beebe's revised Chaperone Policy. Beebe is drafting a "Guide for Parents" to advise parents on what they can/should expect during the examination of a pediatric patient. The Medical Staff made these changes regarding peer review: The Vice or Assistant Chief in each Medical Staff Department is now responsible for the review of the performance of each practitioner within that department. A Peer Review Committee has been established to review issues identified by the Clinical Departments and the Medical Executive Committee. A report on the Medical Staff's peer review activities is now made on a quarterly basis to the Quality and Safety Committee of the Board of Directors.

Although the Commission has made numerous recommendations that will strengthen our internal processes, policies, and procedures, its work is not completed. The Commission will continue to meet at least twice a year to review the progress that has been made, to ensure the changes that have been implemented continue to be followed, and to identify additional opportunities to provide a safe environment for our patients. In addition, the Commission will have oversight of the Medical Center's outreach efforts for educating professionals, parents, and the general public with respect to identifying abused individuals, behaviors, and conduct. We will continue to do everything possible to provide a safe, compassionate, and caring environment for all who seek our care.

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