Henry Mayo Newhall Memorial Hospital (HMNMH) is a nonprofit, 501(c)3 facility required to follow governing documents for recognition of compliance, and for allowing legal accreditation. When found not to be compliant, the hospital faces sanctions that must be rectified in a timely fashion. Such has been the recent case of persistent communication problems between the Administration and Medical Executive Committee (MEC). This problem has now come full circle in a convoluted epic of power and brinksmanship, creating potential liability and putting our hospital in its greatest jeopardy since bankruptcy.
The Joint Commission (TJC) is a government agency delegated with the responsibility of assuring hospitals throughout the United States maintain consistent standards of patient care. To comply with a recent TJC sanction reciting communication problems, the hospital Administration and MEC jointly agreed to hire a Mediator who would mitigate the conflict and write a report to TJC, thus removing the hospital sanction.
Within weeks, HMNMH oddly announced creation of a new position and hiring of a hospital administrator called Chief Medical Officer (CMO), and to the surprise of the medical staff and MEC, it was the Mediator! Still with me?
Day-to-day hospital operation and function rely on committees under the auspices of the MEC, Administration, and Board of Directors. Committee members follow rules related to HIPAA and Peer Review to maintain patient confidentiality according to By-Laws, Rules & Regulations, and Hospital-Wide Policy and Procedures. The CMO position, duties, and responsibilities, are not mentioned nor defined in these HMNMH governing documents.
The hospital has demanded the CMO be allowed to sit in hospital committee meetings and peruse patient charts. The MEC has objected and feel this is a breach of HIPAA and Peer Review confidentiality. With that, every committee the CMO has attempted to attend has resulted in this objection and cancellation of the meeting, stalling hospital function and compromising patient care.
It is ironic the person hired as Mediator to improve communication has now become the source of “discommunication.”
Because I attend many HMNMH committees, I discussed this matter with my malpractice insurance Risk Management attorney. My attorney agreed that indeed, because the position of Chief Medical Officer is not defined by the hospital governing documents, physicians, Administrators, and the hospital are at risk should there be HIPAA/Peer Review litigation brought against the hospital. Additionally, governmental agencies such as TJC might sanction the hospital and jeopardize accreditation. Hospital attorneys might not agree, but I wonder what is their legal precedence?
The position of Chief Medical Officer is not new in a hospital setting, but ground work must be laid in governing hospital documents in order for the position to legally exist. This has not been done and hence the hospital may be judged to be libel.
Ultimately, the Board of Directors are responsible for this legal matter, as they voted to create the CMO position. Viability of our community hospital is at stake, so I truly hope communication is better between the Board of Directors and hospital attorneys than between Administration and the MEC.
Gene Dorio, M.D.- Commentary
Gene Dorio, M.D., is a local physician. His commentary represents his own opinions and not necessarily the views of any organization he may be affiliated with or those of the West Ranch Beacon.
The Joint Commission (TJC) is a government agency delegated with the responsibility of assuring hospitals throughout the United States maintain consistent standards of patient care. To comply with a recent TJC sanction reciting communication problems, the hospital Administration and MEC jointly agreed to hire a Mediator who would mitigate the conflict and write a report to TJC, thus removing the hospital sanction.
Within weeks, HMNMH oddly announced creation of a new position and hiring of a hospital administrator called Chief Medical Officer (CMO), and to the surprise of the medical staff and MEC, it was the Mediator! Still with me?
Day-to-day hospital operation and function rely on committees under the auspices of the MEC, Administration, and Board of Directors. Committee members follow rules related to HIPAA and Peer Review to maintain patient confidentiality according to By-Laws, Rules & Regulations, and Hospital-Wide Policy and Procedures. The CMO position, duties, and responsibilities, are not mentioned nor defined in these HMNMH governing documents.
The hospital has demanded the CMO be allowed to sit in hospital committee meetings and peruse patient charts. The MEC has objected and feel this is a breach of HIPAA and Peer Review confidentiality. With that, every committee the CMO has attempted to attend has resulted in this objection and cancellation of the meeting, stalling hospital function and compromising patient care.
It is ironic the person hired as Mediator to improve communication has now become the source of “discommunication.”
Because I attend many HMNMH committees, I discussed this matter with my malpractice insurance Risk Management attorney. My attorney agreed that indeed, because the position of Chief Medical Officer is not defined by the hospital governing documents, physicians, Administrators, and the hospital are at risk should there be HIPAA/Peer Review litigation brought against the hospital. Additionally, governmental agencies such as TJC might sanction the hospital and jeopardize accreditation. Hospital attorneys might not agree, but I wonder what is their legal precedence?
The position of Chief Medical Officer is not new in a hospital setting, but ground work must be laid in governing hospital documents in order for the position to legally exist. This has not been done and hence the hospital may be judged to be libel.
Ultimately, the Board of Directors are responsible for this legal matter, as they voted to create the CMO position. Viability of our community hospital is at stake, so I truly hope communication is better between the Board of Directors and hospital attorneys than between Administration and the MEC.
Gene Dorio, M.D.- Commentary
Gene Dorio, M.D., is a local physician. His commentary represents his own opinions and not necessarily the views of any organization he may be affiliated with or those of the West Ranch Beacon.
