NH Board of Medicine Takes On System Failures

After attending the committee meeting of the audit of the NH Board of Medicine, I was stunned that this board issues confidential letters to facilities about system failures. Dr. Cervenka enlightened the committee that the board felt it was their duty to advise and alert facilities when ,in fact, it was not the error of an individual doctor but a system failure. Although I agree that systems do fail in most instances, I was stunned that this board, which rarely acts on substandard care given by physicians, felt they should send confidential letters to these facilities and had the right to do this. In fact, the Department of Health and Human Services (DHHS) administers this chapter (RSA 151) through their Bureau of Health Facilities Administration. The Board is supposed to submit their system failure concerns to the Bureau. Whether this bureau does it’s attended job will be addressed in a later blog. I sat in disbelief since this board seems stretched too far to thoroughly act on their mandated responsibilities but feels the need to advise health care facilities on their failures. All concerns by law should be submitted to the bureau. I will suggest to you that this practice does not make the people of NH safer. In a confidential letter they are alerting these facilities about complaints going forward. The people do not know anything about the “system failures” and the board is not sure of the steps these facilities take to change these failures. At the audit meetings a common theme of “transparency” has been echoed by all and I am amazed that this committee seemed to be weighing towards giving this board the authority to alert facilities with out knowledge to the public, no follow-up necessary. Superficially this may be explained as positive step toward better quality but I think it could also be looked at as a way to alert facilities that may or may not use this information in a positive way.

An example given by the board certainly missed the mark in my book. A healthcare facility was found to not give their patients a release to sign before a vaccine was given. The patient had some kind of devastating consequence after this vaccine and probably through findings from the litigation process it was uncovered. (The board receives all copies of writs submitted to the courts.) It might help the facility to avoid litigation in the future. I do not think this example makes patients any safer.

Much discussion focused on a situation where an anesthesiologist felt targeted by the board for living 30 minutes away from a hospital that does c-sections even though the hospital was fine about this arrangement. The board felt this physician, although he claimed that there was not one instance where he was negligent, was not living up to the “best practice” standard. The complaint was anonymous. Was this political? After a year the board dropped action without any explanation. I understand why obstetricians would want such a standard in place. It is not sufficient to say that this anesthesiologist had not done any thing wrong. Should we wait until something happens to a mother or baby? I clearly understand the obstetricians’ concern but what is puzzling to me is why this is not a system problem? The hospital in question has decided to not follow best practice standards. This is where the board should not have pursued the complaint against the doctor but should have questioned the facility. Why does this hospital accept this practice? These are issues that should not only go to the Bureau of Health facilities but should also be made public. For some reason the NH Board of Medicine seems to make up their own rules and in many instances does not see the need to follow the rules that are all ready in place and for me that is the biggest problem of all.