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Reporting Processes Investigative Processes Monitoring Processes

Additional Information:

Membership of the Special Investigative Commission Mission Statement of the Special Investigative Commission Healthcare System Trust Agenda Community Focus Group – Membership and Issues Raised Summary of Bills and Legislation Passed by the General Assembly Bio — Robert J. Marder, M.D., CMSL Chaperone Policy (PDF)

Beebe Medical Center ("Beebe") established a Special Investigative Commission (the “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 Healthcare System Trust Agenda adopted by all Delaware acute care hospitals. Assisting the Commission with its work was a Community Focus Group. The Community Focus Group was comprised of individuals from different vocations and geographic areas within Sussex County. The group met twice with the Commission and raised a number of issues for the Commission to address.

Reporting Processes

The purpose of reviewing our current policies and processes for reporting issues was to determine: 1) What Beebe currently does to educate employees, affiliated Medical Staff, and the Board of Directors about Delaware's mandatory Duty to Report unprofessional and unsafe conduct of physicians and other healthcare professionals; 2) changes that were needed both immediately and for the longer term to ensure that Beebe Medical Center continues to receive current and complete education; and 3) that Beebe Medical Center is compliant with Delaware's requirements for the Duty to Report, as well as all new legislation passed by the General Assembly.

The Commission determined that many policies and procedures existed to address unethical practices, impaired practitioners, privacy rights, and actions that undermined patient safety and breaches of state and federal laws. There was, however, no current standardized and consistent education process that defined unprofessional or unsafe conduct and behavior. Similarly, there was no current standardized and consistent process that gave direction on how to report such conduct and behavior. As a result, the Commission initiated a plan to ensure that all members of the Beebe Medical Center family would recognize and report unprofessional or unsafe conduct and behavior. The following actions were implemented by the Commission:

A standardized education program was developed and deployed regarding the mandatory duty to report unprofessional and unsafe conduct of not just physicians, but also of other healthcare professionals regulated by the Delaware Division of Professional Regulations. In addition, Beebe requires internal reporting of any unprofessional and unsafe conduct by any employee or volunteer. This education is an annual mandatory requirement and is monitored by both the Human Resources Department and the Medical Staff Office to ensure compliance. Education on the Duty to Report began for Beebe Medical Center on August 3, 2010. Employees, contract staff, and doctors have completed and attested to the fact that they have received training on the Duty to Report and understand their reporting requirements under this regulation. Everyone is required to acknowledge in writing that they understand and will comply with Beebe's and the State of Delaware's "Duty to Report" requirements. Examples of unprofessional and unsafe conduct as well as instructions on how to report those behaviors are available on Beebe's intranet as a resource. Beebe has established a new dual reporting requirement policy to make certain that a consistent reporting process is utilized. This applies to both Beebe Medical Center employees and Beebe Medical Staff physicians. All Beebe employees are required to report unprofessional or unsafe conduct and behavior to both Beebe's Corporate Compliance Hotline and to their immediate supervisor. In addition, all physicians and practitioners are required to report unprofessional or unsafe conduct and behavior to both Beebe's Corporate Compliance Hotline and to the Chief of their respective Medical Staff Department (e.g., Medicine, Surgery, Pediatrics, etc.). All licensed, certified, and registered healthcare providers, regulated by the Delaware Division of Professional Regulations, are required to report unprofessional or unsafe conduct and behavior to Delaware's Division of Professional Regulation. A direct link to the website of Delaware's Division of Professional Regulation is available at A process is in place to investigate and address any issue that may impact the care of patients (see later in this report). Beebe procedures have been updated to require appropriate documentation of reports of unprofessional or unsafe conduct and behavior. To ensure that all Beebe personnel are not deterred in any way from reporting unprofessional or unsafe conduct and behavior, Beebe strengthened its policies regarding retaliation and retribution by ensuring "whistleblower" protection to any individual who reports an incident or suspicion. Effective immediately, Beebe is providing the general public with information on how to report unprofessional or unsafe conduct and behavior both on the Beebe Medical Center website and in the Patient Handbook.

Investigative Processes

The Commission made a comprehensive determination of policies and practices currently in place. It reviewed those policies and practices for opportunities to strengthen our capacity to identify those individuals who are or may be a safety risk to patients. The following actions were implemented by the Commission:

All reports made to the Corporate Compliance Office through the Corporate Compliance Hotline, concerning unprofessional or unsafe conduct are also reported in writing to the Chair, Quality & Safety Committee of the Board of Directors, by the Chief Compliance Officer within seven (7) days. This additional level of reporting is required to ensure that investigations are thoroughly documented, handled appropriately by the responsible parties, and addressed as expediently as possible. In addition to the current requirement of criminal background checks made during the pre-employment process for Beebe Medical Center employees and the initial appointment process of physicians to the Medical Staff, criminal background checks will now be completed every two (2) years for employees or at the time of reappointment for physicians and practitioners. Effective October 1, 2010, Beebe implemented a new policy for random drug testing which requires all Beebe employees and all employees and physicians of the Beebe Physician Network to undergo random drug testing. All Beebe employees and physicians are required to disclose to the Medical Center, annually and at the time mandatory education takes place, whether or not they have been convicted of any crime or have been the subject of any formal complaints regarding unethical or unprofessional behavior filed against them with a licensing agency or board, regardless of whether or not that complaint was followed by an investigation. All companies or organizations that provide contract and/or temporary employees who work at Beebe continue to be required to provide background checks going back ten (10) years for any individuals who are scheduled to work any shifts or hours at Beebe.

Monitoring Processes

In addition to reviewing those processes, procedures, and practices that relate to reporting and investigation, the Commission also looked at those processes, procedures, and practices that address the monitoring of employee and physician performance. These processes are designed to ensure that mechanisms are in place to identify immediately any situations and/or individuals that present a safety concern to our patients, and that intervention can take place as swiftly as possible.

Besides the review that was done internally by the Special Investigative Commission, Robert J. Marder, M.D., a nationally recognized expert in the field of peer review, was invited to Beebe in September to conduct an educational session, during which he presented an overview of "best practices" for peer review activities. Peer review is defined as the evaluation of a physician's professional performance for all defined competency areas using multiple data sources. Dr. Marder also reviewed Beebe Medical Center and Beebe Medical Staff peer review activities and processes, and made recommendations for improving those processes. The following actions were implemented by the Commission:

A management "best practice" to follow up on safety concerns was adopted and implemented for use at Beebe. This practice is designed to investigate any safety issues that are identified internally, and to determine whether or not the safety issue identified is a process breakdown or an avoidable and/or reckless act by an individual. The Medical Center will strive to fix any processes that do not work effectively. It will address employee and physician issues either 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 Medical Center 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 Medical Center's revised Chaperone Policy. Beebe has created the brochure "Your Child's Doctor Visit" to advise parents on what they can/should expect during the examination of a pediatric patient. The Medical Staff took the initiative to make several constructive changes regarding peer review, even before the Special Investigative Commission was formed, as follows: 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. Data is now collected, reviewed, and analyzed on a continuous basis to ensure that practitioner competency and performance is continually monitored. A multidisciplinary Peer Review Committee has been established by the Medical Staff to review any concerns or issues that have been identified by the Clinical Departments and the Medical Executive Committee. The multidisciplinary peer review group has been formed to review practitioner performance to eliminate potential bias and conflicts of interest that could interfere with effective peer review. As the Board of Directors is ultimately responsible for the quality of care of the practitioners it approves for membership on the Medical Staff, 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. The purpose of this review is to assure members of the Board that an effective peer review system is in place.

Membership of the Special Investigative Commission

Janet B. McCarty — Chair of the Special Investigative Commission and Chair, Board of Directors, Beebe Medical Center

Gregory A. Bahtiarian, D.O. — Physician, Department of Family Practice, and Member of the Board of Directors, Beebe Medical Foundation

Vikas K. Batra, M.D. — Physician (Pulmonology/Critical Care) and Immediate Past-Chief, Department of Medicine, and Treasurer, Beebe Medical Staff

Paul T. Cowan, Jr., D.O. — Physician, Department of Emergency Medicine, and Member, Board of Directors, Beebe Medical Center

Emilie Crosser — Customer Service Coordinator, Department of Diagnostic Imaging

Jackye Emory — Chief Compliance Officer, Beebe Medical Center

Frances S. Esposito, M.D. — Physician (Radiology) and Chief, Department of Diagnostic Imaging, and Chair, Credentials Committee, Beebe Medical Staff

Jeffrey M. Fried — President/CEO

Bradley J. Goewert, Esq. — Legal Counsel, Beebe Medical Center, member of the law firm of Marshall Dennehey Warner Coleman, Wilmington, Del.

Reverend Keith Goheen — Chaplain, Beebe Medical Center

Cheryl Graf — Director, Employment & Development

Jeffrey E. Hawtof, M.D. — Physician, Department of Family Practice, and Vice President, Medical Staff

David A. Herbert — Community Representative, Member, Quality & Safety Committee, Board of Directors, Beebe Medical Center

Wallace E. Hudson, Jr. — Vice President, Corporate Affairs

Marcy Jack, Esq., BSN, CPHRM — Director, Risk Management

The Honorable William Swain Lee — Vice Chair, Board of Directors, Beebe Medical Center

Paul Minnick, RN — Vice President, Patient Care Services (effective 08-30-10)

Michael M. Mustokoff, Esq. — Legal Counsel, Beebe Medical Center, member and Senior Partner of the law firm of Duane Morris, Philadelphia, Pa.

Paul H. Mylander — Treasurer, Board of Directors, Beebe Medical Center, and Chair, Board of Directors, Beebe Medical Foundation

Fran Needham, RN — Director, Emergency Services/Women’s Health

Paul C. Peet, M.D. — Physician (Neurology), Department of Medicine, and President, Beebe Medical Staff

Alexander J. Pires, Esq. — Member, Board of Directors, Beebe Medical Foundation

Margaret Porter, RN — Nurse Manager, 3-Medical/Surgical Unit

Thomas L. Shreeve, M.D. — Physician, Department of Emergency Medicine, and Secretary, Medical Staff

Andrejs V. Strauss, M.D. — Vice President, Medical Affairs

Thomas K. Steiner — Executive Vice President/COO

Joan Thomas, RN — Interim Vice President, Patient Care Services (through 08-27-10)

Preachess Vellah, M.D. — Physician (Hospitalist), Department of Medicine

Michael L. Wilgus — Member, Board of Directors, Beebe Medical Center

Cheri Will, RN — Sexual Assault Nurse Examiner (SANE Nurse)

Mission Statement of the Special Investigative Commission

With the goals of providing the highest-possible levels of patient safety and restoring trust with the communities we serve, this Commission will examine all Administrative, Medical Staff, and Board policies and procedures regulating the professional conduct, behavior, and legal accountability of persons caring for our patients. Our work will include:

Identifying desirable nationwide “best practices” and legal standards as defined by Delaware law; Comparing current policies to these practices and standards and identifying opportunities to improve; Formulating recommendations for achieving "best practices" and standards in all areas; Establishing implementation timelines and methods to assure compliance; Presenting the recommendations to appropriate change agents; Recommending the means for hospital leadership to ascertain implementation, ongoing compliance, and proactive innovation; Reporting the findings of this Commission to the general public; and Monitoring the implementation process to assess the institution's progress and the efficacy of the changes.

Bio — Robert J. Marder, M.D., CMSL

Robert J. Marder, M.D., CMSL, is vice president with The Greeley Company, a division of HCPro, Inc., in Marblehead, Mass. He brings more than 25 years of healthcare leadership and management experience to his work with physicians, hospitals, and healthcare organizations across the country.

Dr. Marder's many roles in senior hospital medical administration and operations management in academic and community hospital settings make him uniquely qualified to assist physicians and hospitals in developing solutions for complex medical staff and hospital performance issues. He consults, authors, and presents on a wide range of healthcare leadership issues, including effective and efficient peer review, physician performance measurement and improvement, hospital quality measurement systems and performance improvement, patient safety/error reduction, and utilization management.

Dr. Marder is one of The Greeley Company's leading national speakers and is also the author or coauthor of many HCPro/Greeley books, including:

The Top 40 Medical Staff Policies and Procedures, Fourth Edition (2010) Peer Review Best Practices: Case Studies and Lessons Learned (2008) Measuring Physician Competency: How to Collect, Assess, and Provide Performance Data, Second Edition (2007) Effective Peer Review: A Practical Guide to Contemporary Design, Second Edition (2007) Proctoring and Focused Professional Practice Evaluation: Practical Approaches to Verifying Physician Competence (2006)

Prior to joining The Greeley Company, Dr. Marder served as assistant vice president for quality management at Rush-Presbyterian-St. Luke's Medical Center and vice president for medical affairs at Holy Cross Hospital. He also served as the national project director for indicator development and use at The Joint Commission from 1988 to 1991. Dr. Marder was assistant director of laboratories and director of clinical immunology at Northwestern Memorial Hospital and associate clinical professor at Northwestern University Medical School.

Dr. Marder is a graduate of Rush Medical College and completed his residency training at Rush-Presbyterian-St. Luke's Medical Center in pathology with a fellowship in microbiology/immunology. He is a Board Certified pathologist.