A surgeon performed his first DaVinci system Robotic Assisted Laparoscopic Hysterectomy. The patient developed some post-op complications of pain, nausea and fluid leakage. It was eventually found that she had sustained some ureter damage with a resulting ureterovaginal fistula. She underwent corrective surgery.
The patient filed a medical malpractice complaint against the surgeon alleging improper surgical technique and against the hospital for alleged “negligent credentialing” of the surgeon.
A Medical Review Panel ruled in favor of the surgeon, finding that the injury was a known complication of the procedure made known to the patient during the pre-op “consent” process. The panel also found in favor of the hospital.
Despite the favorable panel opinion, a post-panel lawsuit was filed and discovery depositions were taken. The plaintiffs were able to obtain a copy of the hospital’s credentialing policy relative to the DaVinci system. The policy required that, before performing the procedure as the lead surgeon, doctors must:
- Observe at least one such procedure.
- Perform the procedure three (3) times with the assistance of an experienced proctor.
In this particular case, the surgeon in question had performed the three required procedures under the supervision of an experienced proctor. However, he failed to observe at least one such procedure as required by hospital policy. During deposition testimony, the surgeon conceded that he was not familiar with all of the credentialing requirements.
While it seems unlikely there would be a finding based upon the idea that the failure to observe the procedure caused or contributed to the patient’s complications, it does raise questions. What are the hospital’s responsibilities as part of the credentialing process to ensure the surgeon knows all the requirements? What are the responsibilities of the Surgery Department regarding the development of policies to verify a surgeon has met all requirements before performing a procedure, especially if the credentialing process drops the ball?
Negligent credentialing is a prime focus for liability claims at this time. It is important for hospitals to review techniques in place and evaluate current practices to avoid claims and ensure patient safety. It is the responsibility of the facility to have a standardized process in place for credentialing a physician. A checklist is an ideal resource to track a physician’s progress. Measures should be implemented to verify all appropriate information is assessed and completed. A physician orientation including a detailed explanation of information required for credentialing might be a good idea to consider. The physician’s signature confirming that all items have been reviewed and understood can assure physician acknowledgement of facility practices. Facility policy and procedures relevant to credentialing, Medical Staff Bylaws and Rules and Regulations are recommended documents to share with physicians upon application.
Medical Staff and the Board of Trustees are ultimately responsible for assuring the physician meets competency and all aspects of review have been appropriately assessed and attested according to provisions recognized by the facility. The Joint Commission recommends a focused professional practice evaluation (FPPE) that includes monitoring the care of the patient, documentation of care and review of hands on practice of the physician being evaluated. Ongoing professional practice evaluation (OPPE) is also recommended to continuously monitor of a physician’s practice habits at specified time frames determined by the organization to assure ongoing compliance. The requirements for conducting a Focused Professional Practice Evaluation (FPPE – MS.08.01.01) and an Ongoing Professional Practice Evaluation (OPPE – MS.08.01.03) apply to all practitioners and are considered a best practice. Organizational credentialing policies must comprise requirements related to the number of cases a physician observes as well as the number of procedures performed under peer review. Documentation is essential to show that the physician is notified of these requirements and meets them to continue practice within an organization.
Recommendations to mitigate risk for negligent credentialing claims include:
- Review techniques and practices currently in use.
- Implement a standardized process to credential a physician.
- Provide orientation to all applicants.
- Develop policies and procedures for credentialing.
- Review and share these protocols with all applicants.
- Implement FPPE and OPPE to mitigate risks and aim for quality care of all patients served.
- Periodically audit credentialing files to ensure compliance and report to the Board.
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