by Medical Justice | Mar 4, 2016 | Healthcare Reform
Doesn’t happen often. But, when it does, expect a potential s*%#storm.
Patient is anxious about the mole on his back. A dermatologist removes the mole and sends the specimen to the lab. Rule in or rule out melanoma. The lab says it never received the specimen. The dermatologist then does full excision. Then the doctor and patient discuss the pros and cons of doing a metastatic melanoma workup. Not a fun day at the OK Corral.
A urologist performs a cystoscopy on a patient with hematuria. He identifies a fungating mass, removes what he sees, then takes tissue to learn whether the mass is more invasive than expected. It’s nursing shift change and the circulator drops the ball. The specimen never makes it to the lab.
Fortunately, for many cases, the ramifications of losing a specimen are not horrific. It’s embarrassing. And it causes the patient to lose faith. But, frequently, care can still be rendered. And often, the inconvenience of obtaining another specimen is not life-altering.
Problem related to surgical specimens are not limited to getting lost. They are sometimes mislabeled. The laundry list of mislabels include:
a. No label
b. No specimen
c. Incorrect laterality
d. Incorrect tissue site
e. Incorrect patient
f. No patient name
g. No tissue site
h. No clinical history
How do you sidestep this?
Include a verification step to check-out the specimen the same way blood products are checked-in before transfusion.
The nurse reads back the patient name, specimen name, and laterality (if relevant). Surgeon confirms and documents at the end of the case. The names of all parties who participated in the “chain of custody” should be known and recorded.
What about chain of custody for specimens sent to outside labs?
Document the specifics of the specimen and to whom it was handed off and when. So, if Fed Ex or UPS pick it up, keep a record of that. Once the delivery service has picked it up, liability should transfer to them if lost.
Remember the Tom Hanks movie Castaway? If so, you’ll remember a Fed Ex plane crashes. Hanks’ character, who was overseeing the air transport, survives on an island. Eventually he makes it back to land. The movie closes with him delivering one of the packages that never made it to the intended recipient.
I’m trying to imagine a different ending. Hanks’ takes surviving lab specimens and delivers them to pathology lab. I doubt that would have been a happy ending.
by Medical Justice | Feb 26, 2016 | Healthcare Reform
I live in North Carolina. Each year I have a general physical exam. This includes the ritual known as the prostate exam. I don’t particularly look forward to it. But, it takes a few seconds and I’m reassured knowing that there are no lumps or bumps. My internist is male. And, in the exam room, it’s just the three of us – my doctor, the electronic medical record, and me.
But, if I cross the border into Georgia for the same exam, the exam room may be more crowded.
The Georgia Composite Medical Board recently proposed new rules defining “Unprofessional Behavior.” One new rule, if adopted and enforced, would redefine “unprofessional conduct” to include:
Rule 360-3-.02(12):
“Conducting a physical exam of the breast and/or genitalia of a patient without a chaperone present.”
This Rule would replace the existing Rule 360-3-.02(12) which currently reads:
“Conducting a physical exam of the breast and/or genitalia of a patient of the opposite sex without a chaperone present.”
The pre-existing rule was not perfect. If a patient does NOT want another person in the room, it should be their right to keep the traffic down – even if the examining doctor is of the opposite sex. The old rule is silent on whether the chaperone needs to the same sex as the patient. So, read literally, a male doctor could bring in another male staff-member to comply with the pre-existing rule for say, a gynecologic exam.
Now for the potential consequences of the proposed rule.
My yearly prostate exam would fill the room with yet another individual. I’m male. My internist is male. The proposed rule would add another body in the exam room. Might be male; might be female.
And, my exam is more than a prostate exam. My shirt is off and my heart and lungs are auscultated. Since the stethoscope touches my breast, does this now turn into a “breast exam?” Must the chaperone come back in?
Why not put in some bleachers?
On January 7, 2016, the Georgia Composite Medical Board referred the proposed updated rule back to the Rules Committee “to address concerns.” So, it’s not a done deal just yet.
It’s not clear from the Board’s minutes what these “concerns” were. But, my chest and my prostate can name a few.
by Medical Justice | Feb 19, 2016 | Healthcare Reform
The question is not so simple anymore.
According to the UCLA School of Law’s Williams Institute, there are approximately 700,000 transgender individuals in the United States.
In a recent Equal Employment Opportunity Commission ruling (Lusardi v. McHugh, EEOC, No. 0120133395, 4/1/15), the US government ruled that a government employee who transitioned from male to female could not be forced to use a unisex bathroom. Instead she had the right to use the woman’s bathroom.
The Equal Employment Opportunity Commission (EEOC) noted it will rely on this ruling when investigating similar charges in the private workplace. The EEOC message is that transgender employees (not the employers) pick the bathroom s/he identifies with. This is true even if other employees complain.
The other message EEOC is signaling is that while providing a unisex bathroom is reasonable, mandating its use is forbidden. The EEOC noted that directing transgender employees to a specific bathroom is a form of illegal segregation – akin to race-segregated bathrooms decades ago.
The conundrum is more challenging given that many transgender people are either choosing to avoid going through full gender reassignment surgery – or they are in the middle of transitioning.
While the EEOC has made its position clear, the matter is probably not fully settled. Still, if an employer wants to avoid litigation, they should not deny a transgender employee the bathroom of his or her choice until the legal complexities are settled. That likely will be years down the road.
In the Lisardi case, the complaints of female co-workers prompted the federal employer to mandate use of a unisex bathroom. That’s when the matter escalated into a discrimination case.
Managing the expectations of a transgender employee versus those of co-workers is an interesting balancing act. The expectation of privacy in the bathroom is well established in society and law. No court would claim that an employer did not have the right to segregate its bathrooms between men and women, even after Lusardi.
Still, if an employer wants to propel a middle-of-the road policy, this might strike a balance: employees who have not or are not fully transitioned must temporarily use the unisex bathroom as a reasonable accommodation. This argument is more persuasive than stating all transgender employees must use the unisex bathroom.
Such an argument could be strengthened by statistics which suggest that employees who have not fully transitioned are at high risk for physical or sexual assault; and harassment and bullying. Of course, if you’re making a statistical argument, you are probably in the middle of litigation.
One important point to remember. The EEOC doesn’t necessarily target the smallest of businesses. It addresses private business employee-related complaints as described on its web site:
If a complaint against a business (or some other private employer) involves race, color, religion, sex (including pregnancy), national origin, disability or genetic information, the business is covered by the laws we enforce if it has 15 or more employees who worked for the employer for at least twenty calendar weeks (in this year or last).
Final thought. Here’s another option. If you building out a bathroom, just create a collection of single person bathrooms. The multiple unisex bathroom option. The Ally McBeal option. Remember that? What do you think?
by Medical Justice | Jan 29, 2016 | Healthcare Reform
How many of us has received the dreaded notice that medical records are not complete; or worse, that records are complete but need to be signed. The absence of a “proper” signature gums up the works for getting paid.
This following is what CMS considers to be a valid signed order/record.
I won’t belabor the obvious.
If your signature is legible, you’re done.
If not, your illegible signature should be “connected” to something written or typewritten which is legible. Such as your legible printed name, letterhead, etc. If you are in a group and every doctor is listed in the letterhead, you’ll need to circle your name. Really. (Again, if your signature IS legible, you’re done and don’t need to worry about this.)
You have the alternative to submitting a signature log which gives meaning to your illegible signature.
Finally, something called an attestation will work. Here’s a sample attestation.
“I, _____ [print full name of the physician/practitioner] ___ , hereby attest that the medical record entry for _____ [date of service] ___ accurately reflects signatures/notations that I made in my capacity as _____ [insert provider credentials, e.g., M.D.] __when I treated/diagnosed the above listed Medicare beneficiary. I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.”
Guess what? An attestation has to be signed. Seems circular.
Alternatively, what about electronic signatures?
Yes, those are acceptable as long as it cannot be “tampered with” – and there’s an audit trail. EMRs typically address this just fine.
Interestingly, if you’ve ever sent a check to the IRS without your signature, legible or otherwise, the field office is instructed to submit for processing.
“Verify that an authorized signature appears on the check or money order. However, if the remittance is unsigned, and the taxpayer is not available to sign the check or money order, the unsigned check should be submitted for processing.”
Your bank may complete the transaction.
Out of our collective chicken scratches have sprung a litany of rules. Is this a self-inflicted wound? What do you think?
by Medical Justice | Jan 22, 2016 | Healthcare Reform
We’ve heard plenty of horror stories where someone tried to do the right thing – and got screwed.
Everyone knows the saying, “No Good Deed Goes Unpunished.”
Still, my faith in humanity was renewed on January 10th.
(more…)
by Medical Justice | Jan 15, 2016 | Healthcare Reform
Dr. Philip Taylor was employed by Spectrum Health Primary Care Partners. He practiced as an ob-gyn. His employment agreement with Spectrum defined how they could terminate the relationship.
Summary Termination. If your employment … is terminated by its Board of Directors [the “Board”] for a serious, intentional violation of the standards of patient care (i.e., serious quality and/or safety breaches), or unethical behavior, you will automatically be deemed to have voluntarily resigned or otherwise terminated your clinical privileges or medical staff membership at any Spectrum-owned hospital facility. Termination under these circumstances will be taken only after thorough investigation and review of facts by [the Board] which includes the President of [defendant] and CEO of Spectrum. Any termination described immediately above will be referred to in this Agreement as a “Summary Termination,” and will trigger automatic resignation of Medical Staff privileges. . . .
(more…)
