The JCAH mandates several basic monitoring activities that, taken together, serve as a basic review of the quality of care rendered by the members of the medical staff. These review functions may be performed by standing committees, or by committees of the whole in small medical staffs. The JCAH recommendations apply only to member hospitals, but the basic review functions they outline would be equally valuable in a group practice or HMO.
The central problem in implementing the JCAH review procedures whether in a hospital or other medical practice environment, is in ensuring the impartiality of the reviewers. The problem of impartiality is most severe when a single physician group has significant control over the entity conducting the review function. This control may be manifested in many ways. The most direct control can be exercised when a member of the medical staff is a major stockholder in the hospital. A physician in this position may block action directly through selection of the governing body members or may interfere indirectly with the review process through pressure on the physicians conducting the review. Fortunately, this majority stockholder position arises only in smaller private hospitals and in private group practice situations.
A more common situation arises when a single physician or a single group practice accounts for a substantial part of a hospital's income. This is often the case in hospitals and always the case in HMO settings. Even in the largest hospitals, it is not unusual to find a single physician group accounting for 10 to 20 percent of the hospital's revenue. The governing body will be reluctant to lose this revenue and will be reticent to revoke or limit the privileges of members of the group. In all but the largest HMOs, there is only one physician group delivering care. While such a group has a duty to screen and monitor physicians who are employed by the group, there will be significant pressure to exclude the more senior members of the group from this monitoring. The most difficult quality control problems arise in the small rural hospital with one or two medical staff members. In this situation, the revocation or limitation of one physician's privileges may be tantamount to a decision to close the facility. In all of these situations, there are strong pressures on the physician reviewers and the governing body to overlook patterns of bad practice. This pressure must be balanced against the legal duty to monitor medical staff performance and the legal liability that can result if this duty is not met.
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