Case Study: Quality vs. Communications vs. Cultural
       Fit

Situation:

• Tertiary hospital in mid sized metropolitan area
• Specialist recruited 1 1/2 years ago from previous practice site out of state
• Well qualified on "paper", board certified and fellowship trained
• Progressive clinical preferences have alarmed conservative peers (i.e. allows one family member in delivery suite, dims lights during delivery, minimizes use of draping, etc.)
• Not well accepted by peers, has not "fit in" easily
• Well received by nursing (after an initial adjustment period)
• High volume practice, no validated patient complaints noted in the 18 months of practice
• Three sentinel cases involving significant infant injury, organ perforation and unexpected death of a delivering mother on the same day recently (three separate deliveries/procedures)
• Multiple complaints from anesthesia re: inadequate communications during procedures
• Peers are becoming increasingly verbal about their discomfort with his judgment and care
• Unclear if concerns reflect quality, communications skills or cultural fit issues

QMCG Team Role: Conducted an independent onsite evaluation to facilitate appropriate and defensible decision making including:

• Physician reviewer selection and credentialling
• Study design including selection of 20 representative medical records based on practice mix and including the sentinel cases
• Direct observation of three C-Sections (two scheduled, one emergency) and patient rounds
• Interviews with the subject physician, and with anesthesia, OB/GYN, pediatrics, and referring physician peer representatives, nursing and an OR Team representative
• Review of additional records referenced within interviews of examples of concerns
• Follow-up interview with the subject physician to clarify cases in question
• Offsite review of onsite findings, data analysis and trending
• Report development including specifics supporting conclusions reached and suggested approaches for improvement
• Summary conference with medical staff leaders to discuss conclusions and assist in the development of a behavior modification and monitoring plan

Peer Review Study Conclusions: Trends demonstrating patient management quality concerns were not identified. Practice patterns vary from the local norm and those variances reflect differences in training and experience rather than quality concerns. The need for improvement in the quality and consistency of communications with other members of the team during procedures and in crises was identified. A behavioral contract for structured communications with anesthesiology staff preoperatively, intraoperatively and postoperatively was recommended.

Medical Staff/Hospital Accomplishments:

• Quality concerns were clarified and negated
• Expectations for communications have been established
• A behavior modification plan has been developed and implemented
• Monitoring is underway
• Internal evaluation of progress is planned in 6 months
• The credibility and quality of this physician's care as been reinforced
• This physician continues to have a very busy practice with full privileges
• The Medical Staff has avoided decision making which could be construed as anti-competitive