neal b. kauder, president visualresearch, inc. elizabeth carter, ph.d, executive director, virginia...
TRANSCRIPT
Neal B. Kauder, PresidentVisualResearch, Inc.
Elizabeth Carter, Ph.D, Executive Director,Virginia Board of Health Professions
SanctioningReferencePoints
Presented at the 2004 CLEAR Annual ConferenceSeptember 30 – October 2 Kansas City, Missouri
Sanctioning StudyVirginia Department of Health Professions
• Questions raised relating to consistency, neutrality,
and appropriateness of Health Regulatory Board
sanctions
• Only anecdotal information previously available
• Hard data unavailable on factors that relate to sanction
decisions – aggravating or mitigating factors, etc.
Virginia Board of Health Professions, Work plan, Spring 2001
Need for Study
Purpose
“…to provide an empirical, systematic analysis of board
sanctions for offenses and, based upon this systematic
analysis, to derive reference points for board members
and an educational tool for respondents and the public”
Virginia Board of Health Professions, Work plan, Spring 2001
Sanctioning StudyVirginia Department of Health Professions
Guiding Principle
“ … for any sanction reference system to be successful,
it must be developed with complete board oversight
(representatives from various boards), be value-neutral
and grounded in sound data analysis, and be totally
voluntary…”
DHP Internal Committee & Staff, Fall 2001
Sanctioning StudyVirginia Department of Health Professions
Medicine (selected as first board)
• Large number of cases
• Good variation in case type
• Eagerness to participate
13 Boards, Each with Different Case Types and Sanctioning Process…How to Get Started?
Sanctioning StudyVirginia Department of Health Professions
32 personal interviews and various committee meetings---
Medicine develops “Blueprint”
• Overall sanctioning goals
• Purpose of reference points
• Analytical approach
• Measuring case complexity & factors to collect
• Key features of reference system
Theoretical Framework
Sanctioning StudyVirginia Department of Health Professions
Purposes of SRPs
• Make sanctioning more predictable
• Education tool for new board members
• Add empirical element to a process
• A resource for staff and attorneys
• “Neutralize” unwarranted inconsistencies
• Validate board member recall of past cases
• Help ‘predict’ future caseloads (need for services, terms)
From Blueprint:
Sanctioning StudyVirginia Department of Health Professions
Key Features
• Voluntary - maintain complete discretion
• Accommodate full array of mitigating and aggravating
factors
• Operate within existing statutes and regulations
• Not too specific or narrow
• Allow multiple sanctioning goals to be considered
From Blueprint:
Sanctioning StudyVirginia Department of Health Professions
Analytical Approach
Descriptive model: Answers “What is?”
• Historical data analysis of relevant factors
Descriptive model/normative adjustment: Answers “What
ought to be?”
• Data serves as baseline, boards modify to serve goals
From Blueprint:
Sanctioning StudyVirginia Department of Health Professions
Method - Steps
• Conduct personal interviews
• Review literature/profile states
• Build consensus for theoretical framework & methods
• Identify sample & collect data
• Identify “historically relevant factors”
• Translate factors into usable reference system
• Implement, get board feedback, evaluate usefulness
Sanctioning StudyVirginia Department of Health Professions
Study Sample
• All violations going back 6 years
• 6 year period captures 447 “cases”
• Event based analysis -- “cases” vs. “orders”
Sanctioning StudyVirginia Department of Health Professions
Data Collection Sources
• Case file presented to board
• Practitioner Information website
• Microfiche
• Minutes of hearings
• Freedom of Information Act (FOIA) files
• Staff
• Ad hoc data reports
Sanctioning StudyVirginia Department of Health Professions
Descriptive & Multivariate Analysis
Descriptive – describes cases in a basic way
• What sanctions do respondents receive (by offense)
• How may respondents have prior record?
• How many respondents have ongoing substance
problems?
• What injury levels occur?
Sanctioning StudyVirginia Department of Health Professions
• Statistical models help explain how similarly situated cases
have been handled in the past
• How much weight have boards assigned to factors?
• How influential is prior history, injury level, etc.
• What respondent or offense factors predict to suspension?
Sanctioning StudyVirginia Department of Health Professions
Multivariate – Tests the Influence of Factors Simultaneously
Descriptive & Multivariate Analysis
Treatment/Monitoring
What are we trying to predict ?
Revocation XSurrender license or privilege to renew XSuspension XStayed suspension - immediate XContinue on terms XMental or physical evaluation XMonetary Penalty XNo sanction XProbation XReprimand XTERMS:Competency - continuing education XCompetency - audit of practice XCompetency - special examine (SPEX) XPrescribing - log XPractice probation/fulfill criminal probation XImpairment - evaluation XImpairment - HPIP XPractice restriction - chart/record review XPractice restriction - oversight by monitor XPractice restriction - specific XPrescribing - restrictions XSexual misconduct - chaperone XSexual misconduct - evaluation XSexual misconduct - supervised practice XSexual misconduct - therapy X
Sanction Groupings
Loss of license Reprimand
No Sanction
Sanctioning StudyVirginia Department of Health Professions
Sanctioning StudyVirginia Department of Health Professions
Patient death + High
Impaired/Obtain by Fraud + High
Consent order signed + High
Standards of Care + High
Past mental health/capacity problems + High
Past sexual boundaries/deviance problems + Med
Past difficulties with drugs/alcohol + Med
One or more prior board orders/decisions + Med
Attorney present - Med
Respondent impaired during incident + Med
Respondent receiving treatment - Low
Respondent female + Low
Past treatment -- alcohol related - Low
Years practicing + Low
Days in Board Stage - Low
(suspension, revocation, surrender)
Direction of influence
( + ) more ( - ) less
Degree of
Influence
Loss of License – Significant factors
Provided input on factors that should continue to play a role
in sanctioning
• Case type - seriousness
• Patient injury
• Past substance abuse/mental illness
What other factors should be normatively added?
• Multiple patients involved
• Prior violations (not prior cases or orders)
Make factors as consistent as possible on worksheets
BOM Committee
Sanctioning StudyVirginia Department of Health Professions
Creating Sanction Reference Points
• Place historically important factors on 5 offense
worksheets
• Add other factors that should play a role
• Score all persons in database on worksheets –
determine where they would have fallen on grid
Sanctioning StudyVirginia Department of Health Professions
Wide Sanctioning Ranges
• 70% accuracy on average across 5 worksheets
• 30% of sanctions fall above or below
recommendations
Intent is to model the most “typical” cases – not the
most aggravated or mitigated types
Sanctioning StudyVirginia Department of Health Professions
SRP Steps:
Determine if violation occurred
1) Determine case type
2) Locate appropriate worksheet
3) Score offense and respondent
factors
4) View the sanction grid result
5) Complete coversheet
6) May cite reason for departure, if
applicable
no
No worksheet completed
yes
Sanctioning StudyVirginia Department of Health Professions
1) Determine case type
2) Locate appropriate worksheet
3) Score offense and respondent
factors
4) View the sanction grid result
5) Complete coversheet
6) Cite reason for departure, if
applicable
Manual, page 9
SRP Steps:
Caspian
010100000
1) Determine case type
2) Locate appropriate worksheet
3) Score offense and respondent
factors
4) View the sanction grid result
5) Complete coversheet
6) Cite reason for departure, if
applicable
Manual, page 15Sanctioning StudyVirginia Department of Health Professions
SRP Steps:
1) Determine case type
2) Locate appropriate worksheet
3) Score offense and respondent factors
4) View the sanction grid result
5) Complete coversheet
6) Cite reason for departure, if applicable
Manual, page 20
SRP Steps:
Caspian
010100000
1) Determine case type
2) Locate appropriate worksheet
3) Score offense and respondent factors
4) View the sanction grid result
5) Complete coversheet
6) Cite reason for departure, if applicable
Sanctioning StudyVirginia Department of Health Professions
Manual, page 15
SRP Steps:
1) Determine case type
2) Locate appropriate worksheet
3) Score offense and respondent
factors
4) View the sanction grid result
5) Complete coversheet
6) Cite reason for departure, if
applicable
Manual, page 12Sanctioning StudyVirginia Department of Health Professions
SRP Steps:
Existing Sanctions
Fit into 4 Sanction
Groups
Sanctioning StudyVirginia Department of Health Professions
Manual, page 11
Prior History Scoring
• Cases ending in a violation
• Similar past violations – in same offense group
• Score past cases regardless of age
Sanctioning StudyVirginia Department of Health Professions
Cases to Exclude
• Mandatory Suspensions
• Formal Hearings
• Compliance/Reinstatement
• Actions by Other Boards
Sanctioning StudyVirginia Department of Health Professions
Sample Case
Sanctioning StudyVirginia Department of Health Professions
Sample Case
Respondent: Rebecca Sparrow
License Number: 010199999
Case Number: 22222
Case Type: Relationship Inappropriate
Circumstances Surrounding Event
Dr. Sparrow treated Patient A, a 35 year old man, for pain management. During the course of
said treatment, Dr. Sparrow failed to maintain appropriate professional boundaries. The
respondent, on several occasions, walked Patient A to his residence after pain management
treatment. Patient A reported that Dr. Sparrow took him to dinner on no less than three separate
occasions and that he accepted gifts totaling $200. On one occasion the patient took care of the
respondent’s seven-year-old son, in the respondent’s home, while the respondent was away.
Patient A reported having no sexual relationship with the respondent. Patient A did become
emotionally and psychologically dependent on Dr. Sparrow requiring treatment from a
psychologist, Dr. Hawthorne. Dr. Sparrow showed little insight into understanding the
maintenance of professional boundaries.
Respondent’s Background Information
Dr. Sparrow has one prior Board violation for standard of care issues.
Information Needed to Complete Worksheet
Offense scoring • Case does not involve sexual abuse (Circumstances)• Patient is not a juvenile, elderly, or handicapped
(Circumstances)• Only one patient associated with the case
(Circumstances)• Mental Injury (Injury Level) • Priority C (Priority Level)Respondent scoring• No concurrent actions exist (Circumstances)• No past problems are reported (Circumstances)• One prior violation, not similar (Prior Violations)
Sanctioning StudyVirginia Department of Health Professions
Sample Case
Sparrow 010199999
60
30
80
60
WorksheetSample Case
50
Sanctioning StudyVirginia Department of Health Professions
Sparrow
010199999
Rebecca MD
Relationship Inappropriate
2 2 2 2 2
X
X
CoversheetSample Case
Sanctioning StudyVirginia Department of Health Professions
Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
2002 20032001
Literature review & summation, report preparation
Data collection/coding
In-depth interviews
Building consensus
Identify sample
Develop instrument
= Project meeting/presentation
Profile other state systems
A Comprehensive Study…
Compile databases
Data analysis
ReferenceSystem developed
Sanction Reference Points Adopted
The Long Term…
• Evaluate SRP system
• What sanctions work?
• Reduce recidivism, provide benefit vs. cost, etc?
• What factors can predict success given various
sanction types?
Sanctioning StudyVirginia Department of Health Professions
Speaker contact info
Elizabeth Carter, Ph.D., Executive DirectorVirginia Board Of Health Professions6603 West Broad Street, 5th Floor Richmond, VA [email protected]
Neal Kauder, PresidentVisualResearch, Inc.P.O. Box 1025Midlothian, VA [email protected]