Saturday, July 05, 2008

The Patients Who Cry Wolf

If you want to find out how a hospital of emergency room works, do you send in "secret shoppers?"
"As a matter of ethics, you always have to justify why you would need to deceive someone," said Nancy Berlinger, deputy director and a research associate at The Hastings Center, a bioethics research institute in Garrison, N.Y.

Questions have also been raised about how far these undercover patients should go, because they could be exposed to procedures and medications that carry real risks.

Earlier this year, an Essex County, N.J., hospital had some of its own employees pose as secret shoppers to see whether nurses were reading back physician medication orders over the phone to ensure accuracy. Protocol also called for the nurses to record the encounter in the patient's chart

A spokesman for the hospital said employees from doctors to technicians were tapped to secretly observe the nurses, then record whether they complied with the rule.

"We discovered there was very high compliance, although it wasn't 100 percent. In those instances where the person was not complying, we just contacted them and informed them we really needed them to do this," spokesman Richard Wells said, adding that no punitive action was taken.
In a time where ER's are overcrowded, resources are in short supply, doctors and nurses are pushed to their limits, and patients' care is compromised by this fraudulent activity, this monitoring practice should be outlawed.



Ian Furst said...

That is the difference between people regulated by professional colleges and cut-throat business types. In that story, the bogus stroke patient had a CT! The Tribune should be doing a story on the ethics of that alone. What happens when she develops cataracts because she actually had 30 CT's.

Even if they mocked up the CT there are some serious ethical issues because time with the bogus patient is being diverted from others. What if there was someone else who had a slow dx of MI or stroke because there where f... around with the bogus lady.

Good link wes.

Allen said...

Amen, brother.


Anonymous said...

Not to mention the stress of thinking someone has had a stroke and them signing out AMA despite anything you say ... because they're fake. Absolutely ridiculous. Next we'll have people come in complaining of crushing substernal chest pain and then signing out AMA after they see how long it takes them to be seen.

InTheWild said...

I don't disagree. But I am curious how you'd suggest figuring out if an ER "works"? The secret shopper method has definite problems in this venue. But then, so do real patient satisfaction surveys. So do things like JCAHO visits (I've worked at hospitals that give their problem employees the week off when the Joints visit). Self-studies don't often accomplish much other than self-congratulatory navel gazing. What would work??

DrWes said...


What would work?

How about actively engaged teams of administrators and doctors working together proactively to maintain quality, as is done in most ER's in the country?

Nowhere in medicine is there more paranoia about missing the acute patient, length of stay, time to triage, follow-up, disposition of patients, and teamwork for efficient care than in ER's. For QA geeks to employ the same model of "customer service" monitoring that is employed in the hotel and airline industry totally misses the issue: unlike those industries, every ER must triage patients based on the acuity of their complaint. If a fake patient enters with a life threatening chief complaint, that fake patient will, by their very nature, delay another REAL patients' care who might just have an equally lifethreatening medical problem. Are we willing to forego a real patient's care for the sake of a such a fictitious ruse? To take it a step further: will those same QA monitoring personnel speak to the family that loses a child to an acute asthma attack because doctors were occupied caring for their employee-imposter?

This QA fishing expedition seems pretty counterproductive when we think of it that way, doesn't it?

Doctor David said...

It feels like just another example of oversight focused on enforcing rules, rather than determining if good care is being delivered. There is a culture of mistrust here that is unhealthy and changes the focus from a determination of whether or not quality care is being delivered to rote compliance with rules.

In the end, which is more important?

Anonymous said...

I am curious if somebody with a real emergency died or was hurt because of this "mistery shopper" faking a stroke, could this be a criminal case like murder? She tied up the resources while other people with real emergencies, maybe life-threatening, maybe not life-threatening but in pain were waiting because her "need" appered higher. This is so incredibly selfish and irresponsibile.

Wonder how many CT scans she had if she does it for living and what her risk of cancer is because of it. Wonder if her employees had warned her of the risks.

Anonymous said...

No offense (and I mean that), Dr. Wes, but docs don't rat out other docs... We have an incredible Quack (locally). 'Practicing' homeopathy, but he is an MD. He does not TELL his patients his 'serem' is homeopathic, he just tells them they can 'do their own injections'. Now, there is NO Allergist that I know of that will allow an individual to do their own injections (more's the pity) in this country, due to legal implications (ONE case!!! ONE!!! went bad! and it was an obviously stupid person!!!).

Well, that guy is sending people home with very expensive water and they inject it, and they 'feel better'. Or not. If not, they just go somewhere else, or tough it out... (But the initial cost is $500... You'd BETTER feel good after paying all that for medicine!)

But will any allergist in this town call him on it? Not on your life! They might get nailed and there is a 'brotherhood among thieves'.

You know there are people in your hospital that shouldn't be practicing medicine. Do you turn them in? All of them?

My father-in-law was an orthopedic surgeon. He had been forced to retire, due to age (hospital age limit). But he continued his office practice referring surgeries to his partners. Well, except he was losing his mind 'memory', and he started scheduling surgeries. NOBODY NOTICED!!!! The hospital just let it happen... We were out of state and had NO idea until we got a call from one of the nurses on the QT (after several surgeries!) that Dr. X was performing surgeries and we should get down there and do something with him, before something 'bad' happened. No effort to stop this practice by the hospital, WE had to do it. Close down our practice, go back home and get him OUT OF THERE. (Luckily his surgeries were perfect, he'd done so many hip replacements that he could do them in his sleep.) Sigh... But things could have gotten oh, so bad for one of his patients. Did any of the doctors in the hospital 'notice' this somewhat imminent physicial doing surgeries? AT THE AGE OF 82????? You bet. But...

Great, huh? And it shouldn't happen, but things happen all the time and 'we' know it. But we keep still for the most part... Only an occasional brave soul will put his head up in the firestorm of legal pot shots... You know what happens to soldiers that stick their head above the foxhole...

Strange that lawyers (those bad boys that everyone whines about) seem to do a pretty damned good job of self-administering...

Nobody likes lawyers much, but that might be because most of them are so very good at what they do.

DrWes said...

anony 11:26 AM-

No offense taken. Thanks for posing your views.

There are those who are less than skilled (or even incompetent) in every profession: be they doctors or lawyers or skilled laborers or businessmen, etc. And yes, many times we realize their incompetence and fail to act overtly. But covert diversion of referrals still occurs, since a referral to a weak individual also discredits the referrer.

In more severe cases, offenders' actions may be reported by collegues or subordiates - often through complaints to the chief of service. Usually, the complaints are reviewed and if warranted, opportunities for correcting issues are delineated. If these problems are not corrected or become recurrent, a referral to the credentials committee of the facility is made for consideration of revocation of credentials. In the most severe cases, referrals to state licensure boards are also forthcoming. Yes, legal "potshots" from those disciplined might be inevitable, but when couched in a well-documented and reasoned manner, such proceedings are very defensible and should be encouraged when warranted. To ignore unethical or incompetent behavior discredits the institution, hurts morale, and would likely result in higher malpractice rates for everyone.

Are lawyers any better at self-administration of their skills and ethics? No. In fact, one wonders if self-regulation might be worse amongst lawyers because there are no financial consequences to ignoring their collegue-offenders.

CountyRat said...

So, let's see what we have here. In an emergency department full of patients, some (we are not told if it was more than 1) nurse cut corners while filling out forms. Why does this expose not report what the nurse WAS doing? Is it possible that she was too busy to complete every line in some Joint Commission mandated piece of nonsence because she was a little bit busy, oh, I don't know, maybe doing her job by making sure a patient who might be having a stroke did not die while she dotted every "i" and crossed every "t"? And, while we are on the subject, how many other patients where in the ED who needed a nurse in their room practicing nursing more than they needed him or her behind a desk doing paperwork?

This "study" tells us that nurses may not always fill out every form they are told to fill out. What it does not tell us is whether completing the form had any relevance to the quality of patient care, or whether cutting corners on paperwork caused any bad patient outcomes.

The most useful aspect of this "study" is that the fact that it was done at all speaks volumes about what is wrong in hospital administration.