Transcript Biomedical Ethics

Effective LTC Medical Direction:
Challenges and Opportunities
Virginia Medical Directors Association
2012 Annual Meeting
Daniel Swagerty, MD, MPH, CMD
Professor of Family Medicine and Internal Medicine
Associate Chair for Geriatric Medicine and Palliative Care,
Department of Family Medicine
Associate Director, Landon Center on Aging
University of Kansas School of Medicine
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Learning Objectives
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Define the roles and functions as they apply to long term
care (LTC) medical direction
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Describe the behavioral expectations for an active LTC
medical director in the collaborative, interdisciplinary
care of LTC residents
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Delineate the role of the medical director is assisting the
facility in complying with local, state, and federal
regulations, including the associated investigative
protocol for F501.
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LTC Medical Director Roles
and Functions
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LTC Medical Director Role
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Involved at all levels of patient care.
Serves as the clinician who oversees and
guides care.
Leader who helps define a vision of quality
improvement.
Direct supervisor of the medical practitioners.
Operations consultant for day to day issues.
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Key Roles
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Administrative Leadership: responsible
for overall care and clinical practice in
the facility.
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Clinical Leadership: applies clinical and
administrative skills to help guide facility
in providing quality care.
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Key Roles
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Quality of Care: helps the facility develop
and manage both quality and safety
initiatives.
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Education, Information and Communication:
provides information that helps others
understand and provide care.
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Functions –
The medical director…
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Pattee JJ, Otteson OJ. Medical Direction in
the Nursing Home - Principles and Concepts
for Physician Administrators. 1991.
Minneapolis, Minnesota: North Ridge Press
Participates in administrative decision making
Recommends and approves administrative policies and
procedures
Organizes and coordinates physician services and services
provided by other professionals as they relate to patient
care
Participates in the QA process to ensure the
appropriateness and quality of medical care and medicallyrelated care
Participates in the development and conduct of educational
programs
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Functions –
The medical director . . .
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Helps articulate the long-term care facility’s mission to
the community
Participates in the surveillance and promotion in the
health, safety, and welfare of employees
Participates in establishing policies and procedures for
assuring that the rights of individuals (resident, staff
members, and community members) are respected
Acquires, maintains, and applies knowledge of social,
regulatory, political, and economic factors that relate to
patient care services
Person directed care
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LTC Medical Director: Integral
Part of a System of Care
You have great influence and power in these
environments by your presence that is
derived from:
 Professional expertise
 Personality (leadership ability)
 Demonstrated interest
 Title
 Ethical behavior (or lack of it)
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LTC Medical Director: Integral
Part of a System of Care
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Your influence and power extend as far as
you wish to exert it ! For example:
Nutritional practices
 Admission standards
 Skin care protocols
 Quality assurance plan and emphasis
 Team building
 Pharmacy practices
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Medical Care Delivery Systems
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The LTC medical director should make an explicit
and deliberate effort to incorporate the principles of
systems theory and systems thinking into their
administrative practice
Systems theory should be used to
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Examine typical care delivery processes in LTC
Understand the role and functions of the Medical
Director, as well as other members of the LTC
interdisciplinary team
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The Medical Director’s Role
F 501 Tag
Medical Directors &
Federal Regulations
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Medicare regulations have required medical
directors in SNFs since 1974
OBRA ’87 extended the requirement to nursing
facilities (NFs)
Federal regulations specify only two duties
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Implementation of resident care policies
Coordination of medical care in the facility
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Importance of the Medical Director
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Improving the Quality of Long-Term Care
(Institute of Medicine report, 2001)
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Medical directors accountable for the quality of care
in LTC, but have little authority within facilities and
over attending physician
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Recommended vesting greater authority and
responsibility in medical directors for medical
services and require attending physicians and nurse
practitioners to follow facility medical policies and
procedures
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Importance of the Medical Director
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“An Insider’s View: The Role of the Nursing Home
Medical Director” (OIG Report, Feb 2003)
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Medical directors are committed
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Medical directors value role more than administrators do
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Inadequately defined regulatory role results in
underutilization
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Revised Investigative Protocol
for F-501 Tag (2005)
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No fundamental change in expectations or
requirements BUT
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Better defined the medical director’s importance
Clarifies the meaning of the original requirements
More details of essential functions and tasks
Standardized expectations for providers
Consistent with the core roles/functions identified by
medical directors themselves
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Medical Directors &
Interpretive Guidance
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Interpretive Guidance
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Clarify meaning and implementations of basic federal
regulations
Subject to periodic revision
Stakeholders can provide input
Original CMS Interpretive Guidelines defined
seven functions for medical directors
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Medical Director’s Functions
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Assuring that the facility is providing appropriate
care as required
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Monitoring and ensuring implementation of
resident care policies
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Providing oversight and supervision of physician
services and medical care of the residents
Overseeing overall clinical care of residents to
ensure to the extent possible that care is
adequate
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Medical Director’s Functions
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Evaluating possibly inadequate medical careincluding drug irregularities- identified or reported,
evaluate and try to correct the problem
If necessary, consult with resident and resident’s
physician about care and treatment
Assure the support of essential medical consultants,
as needed
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Medical Director’s Duties
OBRA : Resident Care Policies (1 of 2)
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Admissions
Treatment
Discharge
Infection Control
Use of Restraints
Physician Privileges
and Practices
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Non-MD staff
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Nursing
Rehabilitation services
Resident dietary care
Emergency care
Resident assessment
and care planning
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Medical Director’s Duties
OBRA : Resident Care Policies (2 of 2)
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Ancillary Services
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Lab
Radiology
Pharmacy
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Use of Medications
Use and Release of
Clinical Information
Overall Quality of
Care
“The medical director is responsible for ensuring that
these care policies are implemented.”
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Medical Director’s Duties
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The medical regimen must be part of an
interdisciplinary care plan designed to
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achieve highest practicable physical, mental
and social well-being
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preserve function
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minimize injury/falls
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minimize psychoactive medications/restraints
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Medical Director’s Duties
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Restraint use requires rigorous
individualized clinical assessment, should
be appropriate, and implemented only after
considering other less risky alternatives
additional functional decline may be
caused by inappropriate restraint use
 type, duration, indications, review,
revision
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Medical Director’s Duties
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The resident’s drug regimen must be
justifiable
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necessary, appropriate indications
appropriate dose, duration and monitoring
not duplicated unnecessarily
monitoring of adverse affects
attempts at drug/dose reduction, when indicated
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Medical Director’s Duties
Proactive Measures to Ensure
Year-Round Compliance
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Re-evaluate hiring and credentialing
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Ensure that attending physicians provide a
thorough, relevant, well-documented initial
examination
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Help physicians address consent-to-treatment
issues
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Medical Director’s Duties
Proactive Measures to Ensure
Year-Round Compliance
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Ensure that physicians address the broad range
of patient conditions, overall functional status, and
quality-of-life issues in the proper context.
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Ensure that physicians develop documentation
skills that reflect OBRA awareness – not OBRA
obsession.
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Medical Director’s Duties
Proactive Measures to Ensure
Year-Round Compliance
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Develop medical policies and procedures geared to
effective geriatrics and compatible with OBRA guidelines
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Help physicians in their relationships with residents and
families
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Actively help develop and implement an aggressive
quality-assurance program
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Participate in the survey process and in challenging
questionable deficiencies
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Medical Director’s Duties
Survey Participation
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Pre-Survey
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Follow proactive measures listed above
During the Survey
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Introduce yourself if possible to surveyors in the
building- business card?
Be available to administration and to surveyors
Show your presence and interaction with the staff and
administration, at least some time during the survey
Participate in exit conference, if possible
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Surveyor Investigative Protocol
Medical Director (2005)
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Objective: “To ascertain whether the medical director, in
collaboration with the facility, coordinates medical care
and the implementation of resident care policies.”
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Use this protocol when:
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The facility does not employ a licensed medical director, or the
medical director is not currently licensed by the State
Concerns with the provision of resident care or medical care or
Concerns with quality assurance related to the provision of
medical or resident care
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Surveyor Investigative Protocol
Medical Director
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During the survey process, the surveyor should attempt to
communicate with the medical director about concerns
related to:
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admission of residents whose care needs cannot be readily met by the
facility
access to or provision of physician or consultant services
identification, assessment, or provision of services to meet resident needs
capabilities and credentials of staff or other providers/contractors
facilities success in honoring residents rights and enhancing personal dignity
implementing and maintaining current standards of practice for resident care
and quality of life
effectiveness of the various committees responsible for overseeing resident
care and quality of life.
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Surveyor Investigative Protocol
Medical Director
“When concerns are identified regarding the quality of care,
quality of life, or protection and promotion of resident rights, the
surveyor should evaluate the possibility of isolated or systemic
failure of the provision of medical care in the facility.”
“If the survey process identifies the facility’s lack of a functioning
medical director or the lack of medical director involvement in
implementing resident care policies and coordinating care, use
the Medical Director Investigative Protocol.”
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Surveyor Investigative Protocol
Medical Director
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Facility/medical director responsibility for resident care
policies
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If the survey team identifies concerns related to the provision of
resident care, investigate how the medical director, in coordination
with the facility, provides input into the new development, review,
revision, and oversight of the implementation of resident care
policies.
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How was it determined that the policy reflected current standards of
practice
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If not available, interview the medical director about his/her involvement
in implementing resident policies
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Surveyor Investigative Protocol
Medical Director
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Coordination of medical care/physician leadership
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If the survey team discovers issues or concerns with resident
care/medical care, determine how the facility obtains the medical
director’s input in developing policies related to these issues and
involvement in the coordination of medical care.
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Determine how the facility has involved the medical director in establishing
and maintaining policies and procedures for credentialing physicians, nurse
practitioners, physician assistants and other licensed or certified health care
practitioners
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Determine how the facility has involved the medical director in monitoring
the provision of physician services
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Surveyor Investigative Protocol
Medical Director
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Coordination of medical care/physician leadership
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Ensuring that provisions are in place for physician services 24 hours
a day and in case of emergency.
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Ensuring that visits and orders are provided as required
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Ensure that rules and procedures are established for ongoing
coverage for physician services.
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Ensuring that practitioners, who are used to perform physician
delegated tasks, act within the regulatory requirements and within
their scope of practice as defined by State law; and ensure that they
are under a physician’s supervision.
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Whether the facility identified problems related to care that needed
her/his consultation, i.e. notification of a physician about resident
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changes.
Surveyor Investigative Protocol
Medical Director
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Once the survey team has determined that
non-compliance exists, the team will select
the appropriate level of severity
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AND they must also find a deficient practice
at another tag
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Surveyor Investigative Protocol
Medical Director
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The citation of a deficiency at F 501, Medical
Director, is a deficiency regarding the facility’s
failure to comply with this regulation
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The facility is in compliance if the medical director
has assured that the facility has adopted and
implemented relevant policies and procedures
based on current standards and if the medical
director has coordinated the provision of medical
care and services in the facility
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Surveyor Investigative Protocol
Medical Director Citation Examples
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Severity Level 4
Must have a related care tag with actual harm and the
medical director had knowledge of the issue
- timely antibiotic/medication delivery problem (widespread and known
to the medical director) in a patient with pneumonia
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Severity Level 3
The surveyor must identify the relationship between the
failed practices cited at other regulatory tags and the failure
of the medical director to perform his/her functions
- stage 2 pressure sores in a facility with no pressure sore treatment
protocols reviewed by the medical director
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Surveyor Investigative Protocol
Medical Director Citation Examples
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Severity Level 2
Must have a related care tag with no actual harm and the
potential for more than minimal harm and the medical
director had knowledge of the issue
- Repeated lack of reporting of INR levels with the result that a patient’s
anticoagulation profile is very high, but not bleeding. This is a facility
wide problem and the medical director was aware
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Severity Level 1
There is a deficient facility practice but no negative resident
outcome
- The facility is searching for a new medical director
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Survey and F-Tags
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Revision of the investigative protocol for F-501
created anxiety for many medical directors.
As it’s played out to date, this has not appeared to
add additional work or legal liability (but the legal
impact is perhaps not yet evident)
But there is always some issue rising to the top
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Summary
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Physicians need to master a basic core of
knowledge, skills and attitudes to work effectively
in long term care as administrators
Experiential learning of attitudes and skills is
needed to function effectively as a medical
director to optimize performance
Medical directors can improve the quality of care
for LTC residents
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