Monitoring Physician Conduct

There is both a legal and a voluntary (JCAH) duty to monitor the competence of members of the medical staff. The goal of this monitoring is to ensure the competence of the members. A secondary goal is to document adequately the review process to demonstrate that the duty to review was properly performed. This is necessary because it is impossible to anticipate all negligent behavior. The hospital is not responsible for individual negligent acts. It is responsible only for patterns of negligent behavior. If the review committee minutes are complete, and if they do not show a history of questionable behavior, the hospital will have complied with its duty to the patient even if the physician was negligent.

The medical staff is usually charged with the task of monitoring the practice of the individual physicians. Since the board is composed chiefly of laymen, it is not well-suited to evaluating the exercise of independent medical judgment. This does not mean that board members cannot judge any of the actions of the medical staff members. They are able to evaluate deviations from the staff rules and hospital bylaws. They are also able to evaluate gross deviations from acceptable medical practice. In these types of issues, the monitoring committees should document the rules in question, the violation complained of, and the potential consequences of the violation. This will give the governing body a clear, understandable basis for its decision on whether to limit or revoke a medical staff member's privileges. If the incident involves more subtle problems of bad judgment, the monitoring committee should be prepared to document both the mistakes and the usual standards of practice. All of this documentation should be part of the usual course of the committee's activities and should be incorporated in the committee minutes.

• JCAH Review Procedures
• Role of the Governing Body
• Monitoring Functions