SBAR: New administrative suspension process

By James R. Gengaro, DO, Regional Vice President of Medical Affairs, Main Line Health – Paoli Hospital and Riddle Hospital

S: A new administrative suspension process is now defined in the Medical Staff Rules and Regulation

B: After the CMS validation survey at Paoli Hospital resulted in several citations pertaining to a large number of incomplete charts and lack of resultant administrative suspension per the previous rules and regulations, it was recognized that the Medical Staff Rules and Regulations needed to be updated to reflect a process that can be accommodated by the current EMR.

A: The proposed amendments to the Medical Staff Rules and Regulations were approved by the Bylaws Committee, the Medical Executive Committee and by the Quality and Safety Committee of the Board on 5/31/19. These amendments reflect the following changes which will start on 6/3/19:

  • While on administrative suspension:
    • The physician will be notified by email and fax by the Medical Staff Office that they have been placed on administrative suspension
    • That physician may not see any patients in the hospital
    • All surgeries or procedures booked during the time on administrative suspension will be canceled by that department
    • It is expected that the physician’s call group will cover for rounding on patients in the hospital and cover for ED call
    • The physician may not book any new cases while on suspension
    • The responsible administrative department (for example, HIM) will notify the Medical Staff Office once the physician is back in compliance
    • The VPMA will then lift the administrative suspension once the physician’s compliance has been verified.
  • For HIM (medical records) specifically
    • Medical Record delinquencies are now defined as charts that are more than 21 days old since discharge
    • The Medical Staff Office will notify the physician of their delinquent status by fax and email and will call out the date for initiation of administrative suspension if the charts are not completed.
    • The physician will have 10 days to complete their delinquent charts
    • If charts are still delinquent after 10 days, the physician will be administratively suspendedR:
  • Please go into your inbox in Epic at least once weekly and complete charts. This will prevent charts from becoming delinquent.
  • If you become delinquent, please complete the delinquent charts in <10 days to avoid administrative suspension.
  • If you still have delinquent charts after 30 days since discharge and get placed on administrative suspension, please complete the charts ASAP and let HIM know you have completed the charts.
  • If you have questions, please reach out to your VPMA.
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