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Scope of Allowable Practice

The scope of allowable practice must be carefully specified if it is to be meaningful. General terms such as surgery, internal medicine, or obstetrics are not sufficiently specific to establish a reasonable definition of scope of practice. The allowable scope of practice must be defined in terms of procedures and medical conditions.

There are certain general medical skills and corresponding privileges that should be common to all members of the medical staff. These skills include such things as performing cardiopulmonary resuscitation (CPR) or doing a thorough physical examination. All members of the medical staff should be required to have these skills and should have the right to exercise them in the hospital.

Beyond the management of simple illness and injury, the hospital is required to limit the practice of medical staff members to areas of established competence. These limits serve two purposes: (1) they ensure that a staff member has demonstrated competence in the procedures that the member performs, and (2) they prevent a member from attempting procedures that the hospital is not equipped to perform. This second purpose is especially important in smaller hospitals with limited facilities. The law does not require that all hospitals be equipped equally, but it does require full equipment for all procedures for which medical staff privileges are granted. This means that a hospital does not need a heart-lung machine; but, if the hospital allows a staff member to perform heart surgery, it will be liable if the patient is injured because there was no heart-lung machine.

The medical staff should develop lists of the procedures that may be performed, the illnesses that may be treated, and the background that a physician is required to have to be granted the corresponding privileges. For example, the medical section rules may state that only a physician with special expertise in infectious diseases may treat contagious diseases without a consultant. In this case, the rule is designed to protect other patients from the spread of an infectious disease. A physician could meet this requirement by demonstrating special training or by successfully treating several cases under the supervision of the consultant. A physician who does not qualify for a specific privilege based on prior training or experience should be allowed to demonstrate the requisite skills under the supervision of a consultant. This should also be done if there is any question about the extent to which the physician's background qualifies the physician to perform a given procedure. The hospital should be less concerned with what a physician is called than what that physician is qualified to do.

The concept of a provisional status is important to both hospitals and group practices. Careful observation of a potential staff member's conduct in the hospital and management of patients is the best way to determine suitability for the permanent staff. The observations should be carried out in a systematic fashion, combining direct observation with a review of the medical records of patients the physician has treated. A written record of the observations should be prepared, and the medical staff committee should make a written report about any practices it finds questionable. The physician should be given an opportunity to meet any deficiencies delineated in the report and to explain a particular behavior or action. If the physician has not met the objections at the end of the probationary period, the probation period may be extended for a fixed time, at the discretion of the medical staff committee. The occurrence of a serious breach of medical standards should result in immediate suspension of the provisional status until a proper hearing can be held.

The results of the monitoring carried out during the probation period should be put in the physician's permanent file. If the observations are carefully recorded and documented, they will be useful evidence of the health care provider's diligence in investigating the applicant. Conversely, if serious breaches occur during the provisional period, and if they are ignored in the decision to grant the physician hospital privileges or permanent employment in a group practice, the breaches will be evidence of negligence.

The health care provider must anticipate the possible review of staffing decisions in lawsuits based on allegation of improper screening of staff members. The most effective defense against this type of lawsuit is careful documentation of the physician's performance during the probationary period. This record should demonstrate a careful monitoring program and should review any practices that the physician is asked to alter. The record will also be valuable if future problems arises and a decision is made to terminate the physician's employment or privileges. (The requirement for documenting a decision not to grant privileges or employment at the end of the probationary period will be discussed in a later section.)

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