Province’s protracted peer review promise points to bigger problems

by Dermod Travis,

 

Buried among a spate of bad news announcements that the B.C. government released over the Christmas holidays was an update on a province-wide system for peer reviews of diagnostic imaging scans in B.C.

The system was to have been operational by 2014, but still isn’t in place at three of five health authorities and won’t be until mid-2016 at the earliest.

Its implementation is being overseen by the Physician Quality Assurance Steering Committee (PQASC), established in 2012 in response to Dr. Douglas Cochrane’s 2011 investigation into a series of botched CT scan readings.

While there’s a definite sense of import to PQASC’s work, there doesn’t seem to be a sense of urgency.

In a 2014 report, B.C.’s then-auditor general, Russ Jones, noted that PQASC’s “progress has been slow due to a variety of factors including the challenge of obtaining consensus with the many different entities involved, the significant cultural shift that is required to implement the initiatives, and the lack of clarity about roles and responsibilites.”

There was a toll to the CT scandal: three deaths, nine patients harmed and a second bout of stress for thousands of affected patients.

But that tally only takes into account the review period, as set out in the government’s terms of reference.

Unlike similar inquires in other provinces, the government kept a tight rein on Cochrane’s investigation. 

Four radiologists – out of 287 licensed in B.C. – were the focus and even then it was limited to part of their diagnostic work.

In the case of one radiologist 18 months of CT, x-rays and mammogram scans, in the case of another 16 months, another seven months, and one only three months.

Fourteen thousand scans were re-read in the investigation.

A similar investigation two-years earlier in Saskatchewan reviewed 70,000 studies of one radiologist going back three years.

Another investigation in New Brunswick at the same time reviewed 30,000 tests performed by one radiologist going back to 2006.

Cochrane’s report was delivered in two-parts.

Released 30-days after his appointment, the first section of Cochrane’s two-part report was accompanied by a news release headlined: “Report finds all B.C. radiologists licensed appropriately.”

Which isn’t the same as practising appropriately.

From the second-part of his report, released six months later: “The radiologist was therefore practising medicine beyond the scope allowed by his medical license.”

In January 2012, the radiologist – Dr. Mansukhlal Mavji Parmar – was reprimanded by the B.C. College of Physicians and Surgeons and ordered to pay $2,000 in costs. He relinquished his license to practise in B.C.

Another radiologist admitted that he “lacked experience working in a digital world” and hadn’t learned these skills prior to coming to Canada.

According to Cochrane, the College “was not aware of the deficiency in the radiologist’s basic education/experience.”

The four radiologists were not named in Cochrane’s report. Other provinces who undertook comparable investigations named names.

Since 2010, only two radiologists have been reprimanded by the College: Parmar and Dr. Charles William Gervais, a member of the 1981 inaugural graduating class at St. George’s University School of Medicine in Grenada.

Before practising in B.C., he worked as a radiologist in Windsor, Ontario.

In 2014, he was reprimanded by the College for practising “outside the scope of his recent experience by performing a limited number of CT studies during two short appointments (in 2010).”

In B.C., the College only posts reprimands. Dr. Parmar’s was 242-words, Dr. Gervais’s 93-words.

A 2010 disciplinary action against a Saskatchewan radiologist was accompanied by a 38-page competency hearing report and a six-page decision.

Four years after the fact, a restriction “not to practise CT without the prior consent of the College” was placed on Gervais’s license.

The same restriction was added to his Ontario license, information he didn’t share with the Arizona State Medical Board, where he’s licensed in allopathic medicine.

The Arizona board learned of the Ontario restriction from a disciplinary action report generated by the Federation of State Medical Boards last year.

After a disciplinary finding this past August – which Gervais did not contest – the same restriction is now on his license in Arizona.

Today, he is licensed to practise radiology at the B.C. Women’s Hospital in Vancouver.

Those never events

There were other events at the health authorities that should have set off alarm bells for the ministry long before 2010, including: hostile work environments, two-week crash courses in CT training, equipment no one was certified to use at one facility, and what’s called the never events.

As then-CEO of Vancouver Coastal, Dr. David Ostrow, put it in 2011: “The ball was dropped in a whole bunch of places.”

Not the least of all on patients.

Never events “are patient safety incidents that result in serious patient harm or death and are preventable using organizational checks and balances.”

They include: surgery on the wrong body part or wrong patient; wrong tissue, biological implant or blood product being given to a patient; and unintended foreign objects being left in a patient.

Before September 2015, Canada didn’t have an agreed upon list of never events. Saskatchewan and Nova Scotia did, but there was no national list or B.C. list.

As Chris Power, CEO of the Canadian Patient Safety Institute, put it: “It’s not about blaming and shaming. It’s about identifying problems and sharing solutions to prevent these incidents from happening.”

B.C. has had its fair share of possible never events, some potentially linked to the 2010 scandal, others predating it.

By keeping the terms of reference for Cochrane’s investigation tight – four radiologists, limited diagnostic reviews – many such events fell outside its scope, including two reports of misdiagnoses at St. Joseph’s Hospital in Comox, which resulted in two women each losing a breast to cancer.

One remarked that a year after getting a thumbs up from the first radiologist, a second mammogram in a different community found “two bright lights and more spiderwebs than you could ever shake a stick at.”

The other had called for an inquiry in 2008 on news of her misdiagnosis which she described at the time as “three years too late.”

Their misdiagnoses raise another concern: could the opposite occur?

In 2010, a B.C. woman underwent surgery to have half her large intestine removed due to colon cancer, only to learn after the surgery that she didn’t have cancer.

NDP MLA Nicholas Simons raised concerns in 2008 with the College of Physicians and Surgeons over a possible misdiagnosis at the Powell River Hospital.

In 2010, Simons said the College launched an investigation and found problems – but the response “obviously didn’t protect the public.”

But patients never seemed to be the first priority throughout the process.

The immediate reaction of the hospitals was the equivalent of circling the medicine wagons.

At the 241-bed St. Joseph’s General Hospital concerns were raised internally over diagnostic imaging in November 2010.

The hospital’s then 22-year veteran CEO Michael Pontus was informed in January 2011, and the ministry was advised in early February.

At the 33-bed Powell River Hospital, concerns were first raised by medical staff members as early as the spring of 2010. The ministry was notified on January 27, 2011.

Fraser Health first knew of the risk of potential issues back in 2008. Then-health minister Colin Hansen learned of the problems on February 10, 2011.

The last persons to be told? The patients affected, a delay they felt was undue. It didn’t get much better after they were told.

One received two letters, both dated February 8, 2011.

One letter advised him that no discrepancies had been found between the two readings of his scan and the other stated that a discrepancy was found that “could potentially be significant.”

That clinical approach continued when then-health minister Mike de Jong released the second part of Cochrane’s review in September 2011, with an apology: “To all of those patients and their families, I, we, are very, very sorry.”

Apology by news conference didn’t go over well.

One family reacted as might be expected – harshly – noting they were never contacted during Cochrane’s investigation.

“They never spoke to one member of our family. It was one letter from them saying we are sorry for your loss. This has been hell actually.”

Their father – who was one of those misdiagnosed – died in the family’s words “a horrible, painful death,” eight days after Christmas.

And there it might all have rested had it not been for one tiny matter: the investigations weren’t over.

When politics gets in the way of health-care delivery

With the announcement of the government’s “action plan” in September 2011, the public could be forgiven for believing it was going to be all action from thereon in.

The ministry, however, still felt a need to investigate.

Following the release of the government’s action plan, it engaged KPMG “to conduct a review of systems and processes for the licensing, credentialing, privileging and performance management of all physicians across the province.”

KPMG retained Toronto-based law firm Osborne Margo to undertake a legislative and regulatory review as well.

The two firms detailed a litany of ills ailing the system. The lay of the credentialing and privileging land as they saw it in 2012.

There was no news release or news conference with these reports, though.

KPMG didn’t pull any punches: “Stakeholders were clear that they wanted a strong ministry who advised organizations what to achieve, provided performance management frameworks and accountability frameworks, with the organizations themselves allowed to conceive and implement the necessary governance processes and delivery mechanisms.”

Those same stakeholders felt the ministry “falls short of this strong stewardship role.”

Osborne Margo’s report noted that “some existing legislative provisions impede or interfere with quality assurance and performance management functions.”

Next up was the ministry’s governance model for health authorities.

Under the Hospital Act, the board of directors of health authorities were responsible for managing and approving physician credentialing and privileging.

Appointed by the minister, each authority has six to nine board members.

They’re paid posts. One chair pulled in $30,000 last year and directors up to $20,000, depending upon their responsibilities and the number of meetings they attended.

Only one, Wynne Powell, didn’t accept his stipend.

KPMG pointed out that “Although boards receive reports and approve privileges, most directors noted that they had to have a high level of trust that the processes within the authority were being followed…(but) there is little evidence, by way of audit or similar routine checks, to give boards comfort that these processes have been followed.”

They recommended the ministry “review governance models in other jurisdictions to establish whether a case could or should be made for a different model of governance within health care to reflect commercial leading practice and allow greater levels of direct accountability for executive management.”

KPMG acknowledged that “This may be complicated as the governance model in B.C. has been established for some years and there appears to be little appetite for change.”

One possible reason for that lack of appetite?

Board members are better known for who they know than what they know about health care.

A handful have a health background, including former health minister Dr. Margaret MacDiarmid, but they’re the exception.

The rest include lawyers, accountants, foresters, a florist, a former broadcast journalist, financial advisors, civic politicians (past and present), consultants and an urban designer.

Yet, they had the final say on credentialing and privileging of physicians. It’s akin to leaving the final certification of an airline pilot to broadcaster Bill Good.

Something else most of the directors have in common? The B.C. Liberal party.

Fifty-five individuals sat on the six boards last year, including the provincial health services authority.

Since 2005, thirty-six have made personal or corporate donations to the party totalling more than $230,000. Of the 19 who didn’t, at least six have ties to the party.

At the end of the day, the accountability for health authorities rests in the hands of individuals chosen more for the party they support than their expertise.

And if few board members have a health background, it shouldn’t come as a surprise that KPMG found: “There (was) no common definition for ‘credentialing’ and ‘privileging’ within the system and they are used interchangeably, creating confusion.”

In the how not to get ahead in your career department: performance oversight was being left to nurses, with physicians relying “on nursing staff to raise red flags or file a complaint if a physician is performing outside their approved scope of practice.”

Osborne Margo’s review revealed “a lack of province-wide standards and requirements in a variety of areas relating to physician oversight and performance reviews.”

They included: “Lack of defined, clearly communicated requirements for reporting physician performance concerns to the College; lack of consistently defined and applied performance reviews as a condition for the reappointment of privileges; and a lack of requirements for the review and criteria for privilege appointments across all categories, specialties, and practice settings and the reappointment process to ensure continued competency and quality of care.”

Their concerns didn’t stop with health authorities.

Issues with the oversight of non-hospital medical surgical facilities were also flagged, including: “a lack of rigorous, province-wide standards for providers and premises to ensure patient safety.”

The two firms also pointed to “communication gaps across the system, resulting in inconsistent or poor information flows.” Gaps that extended to the public as well.

More than four years after the government set out its action plan, it’s still not fully in place. Progress, yes; slam dunks, no.

As the auditor general put it: “It is often easier to identify and address smaller, preventable issues than to try to correct broader, more deeply embedded issues.

It is essential that Government continues to examine and find ways to overcome these barriers. If it does not, it will not be able to ensure that it is providing effective oversight of physician services.”

 

Dermod Travis is the executive director of IntegrityBC. www.integritybc.ca

 

January 18, 2016