Panel 5: State Coalitions and Public Policy Advocates
Testimony of James Winn, Federation of State Medical Boards of the United States, Inc.
The first National Summit on Medical Errors and Patient Safety
Research was held on September 11, 2000, in Washington, DC.
Sponsored by the Quality Interagency Coordination Task Force
(QuIC), the Summitís goal was to review the information needs of
individuals involved in reducing medical errors and improving
patient safety. More importantly, the summit set a coordinated
and usable research agenda for the future to answer these
Individuals were selected by the Agency for Healthcare Research
and Quality (AHRQ) to testify at the summit as members of the
witness panels. Each submitted written statements for the record
before the event, documenting key issues that they confront with
regard to patient safety as well as questions to be researched.
Other applicants were invited to submit written statements.
Disclaimer and Copyright Statements
I am Dr. James R. Winn, M.D., Executive Vice President of the Federation of State Medical Boards of the United States, Inc. The Federation of State Medical Boards is a national non-profit organization comprised of medical licensing and disciplinary boards of the United States and its territories. The Federationís primary mission is to improve the quality, safety, and integrity of health care by promoting high standards for physician licensure and practice, as well as supporting and assisting state medical boards in safeguarding public health, safety and welfare. The Federation is recognized as a national leader in the protection of public safety and thus is uniquely positioned to facilitate a national discussion of the role state medical boards can and should play in efforts to improve patient safety.
State medical boards receive complaints about physicians from a variety of sources, including patients, other physicians, nurses, family members, and health administrators. The contents of these complaints may be brief or very detailed. The staff of the licensing board investigates those complaints that appear to involve a violation of the medical practice act or board rules and regulation. Depending on the seriousness of the complaint, an investigation may be concluded with a single phone call, or at the other extreme, a lengthy examination of a physicianís practice involving review of his medical records, and interviews with his patients, professional colleagues, and employees. A very small percentage, 10-20 percent, of complaints and investigations will result in the licensing board taking some action against a licensed physician. This is because the mission of the boards is relatively narrow; to evaluate the professional competence and fitness of physicians, and when appropriate, sanction physicians for unprofessional conduct that violates that stateís medical practice act. Many complaints that do not warrant a formal investigation may contain information with important implications for improvements in patient safety.
Because their statutory authorization is relatively narrow and their resources are limited, state boards have not generally tried to develop strategies to reduce the incidence of patient injuries, except through the tools of denying initial licensure and monitoring practice standards after licensure. The data included in complaints made to licensing boards and the data collected during investigations conducted by those boards have generally not been systematically studied to determine if such information can be synthesized in a way that helps to identify patient safety problems within the broader healthcare system. Additionally, there may be patterns in physician conduct that can be linked to such variables as physician age, length of time since last formal education and training, site of care, workload, or family status, which would be useful in predicting quality of care deficiencies in physicians.
A few individual state boards have conducted focused studies of their licensees concerning a single variable. For instance, the licensing board in California recently conducted a study focusing on the correlation between the frequency and severity of disciplinary actions taken and the duration of a physicianís postgraduate training. The California board determined that physicians with only one year of postgraduate training were more than twice as likely to have been the subject of disciplinary actions than those who received more than one year of postgraduate training. Although disciplinary actions are occasionally meted out for conduct unrelated to patient safety, they are usually a proxy for conduct that has threatened, or may threaten patient safety.
Similarly, the Federation has conducted some preliminary studies of data concerning the correlation between
- the number of years since graduation from medical school and the type of misconduct reported to boards,
- a physicianís age and the type of misconduct reported,
- the time of initial disciplinary action taken and the site of medical school training (US schools vs. foreign schools), and
- the time of initial disciplinary action and the number of attempts required to pass the final step of the National Medical Licensing Examination.
These preliminary studies were undertaken to assist in the development of Federation policies, but were never followed up with rigorous research because of constraints on resources for research.
The Federation strongly believes that the data included in the complaints received by licensing boards as well as the data included in the investigations conducted in follow up to those complaints should be studied to determine whether they yield information that can be useful in reducing the incidence of patient injuries. We believe that the first step in studying this data is to take an inventory of the data that individual state boards have collected over the last several years. The Federation already tracks the types of mandatory reporting that states require concerning licensees. Typically reports required by virtually all states, include privilege suspensions or restrictions, voluntary surrender or restriction in privileges, and liability insurance payments made on behalf of the physician. Additionally, a number of states require reporting of a physicianís treatment for certain mental health conditions such as bipolar disorder, and conviction of substance abuse related crimes such as Driving While Intoxicated. These kinds of reports are kept in a relatively uniform manner by all the states.
The manner in which information contained in complaints and investigations is kept varies widely from state to state. One of the first steps that will have to be taken in any study of data kept by licensing boards will be to identify what data is universal to all or a substantial majority of states that can be aggregated for further analysis. Additionally, it will be important to determine to what extent data from complaints and investigations have been abstracted and how much is still only accessible through a review of records at the source of the complaint or individual physician files.
We know there has never been an in-depth study of information contained in complaints received by state boards. Although such information covers a wide variety of situations, it is only logical that complaint information can be a source for identifying problems in medical practice and health care delivery that threaten patient safety. Currently, state medical boards do not have the resources to initiate studies of complaints that do not rise to the level of a formal sanction.
With regard to predicting quality of care issues in practicing physicians, some of the larger states do a significant amount of abstracting of information so that that one can identify the number of physicians who are 65 or older who have involuntarily lost privileges at a hospital as a result of an incident involving surgery. In other states, there is much less abstracting and a researcher pursuing a hypothesis about surgical incidents and older physicians would probably have to review the individual files of all physicians who have involuntarily lost hospital privileges. Only by going through the individual files of those physicians could a researcher determine which were at least 65 and which lost their privileges as a result of an incident involving surgery. The resource requirements to wade through individual files to obtain data has been the biggest stumbling block preventing a systematic review of physician-related data kept by licensing boards.
But once hypotheses are made and the data are analyzed, we strongly believe the results will reveal patterns and causal relations that will be extremely useful in making policy interventions to improve patient safety. As you would expect, the Federation and a number of individual state boards have developed hypotheses based on anecdotal evidence that we believe should be rigorously tested. Unfortunately, state legislatures do not generally authorize licensing boards to conduct this type of research. Nor are funds appropriated for boards to conduct this type of research.
In conclusion, the Federation of State Medical Boards believes that analysis of the complaint data its member boards collect and information concerning the conduct of individual physicians will reveal a number of interventions that can be taken to improve patient safety.
Current as of September 2000
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