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Sanctioning Reference Points. Elizabeth Carter, Ph.D, Executive Director, Virginia Board of Health Professions. Neal B. Kauder, President VisualResearch, Inc. Presented at the 2004 CLEAR Annual Conference September 30 – October 2 Kansas City, Missouri. Need for Study.

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Sanctioning

Reference

Points

Elizabeth Carter, Ph.D, Executive Director,

Virginia Board of Health Professions

Neal B. Kauder, President

VisualResearch, Inc.

Presented at the 2004 CLEAR Annual Conference

September 30 – October 2 Kansas City, Missouri


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Need for Study

  • 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

Sanctioning Study

Virginia Department of Health Professions


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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 Study

Virginia Department of Health Professions


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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 Study

Virginia Department of Health Professions


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13 Boards, Each with Different Case Types and Sanctioning Process…

How to Get Started?

  • Medicine (selected as first board)

    • Large number of cases

    • Good variation in case type

    • Eagerness to participate

Sanctioning Study

Virginia Department of Health Professions


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Theoretical Framework

  • 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

Sanctioning Study

Virginia Department of Health Professions


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From Blueprint:

  • 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) 

Sanctioning Study

Virginia Department of Health Professions


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From Blueprint:

  • 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

Sanctioning Study

Virginia Department of Health Professions


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From Blueprint:

  • 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

Sanctioning Study

Virginia Department of Health Professions


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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 Study

Virginia Department of Health Professions


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Study Sample

  • All violations going back 6 years

  • 6 year period captures 447 “cases”

  • Event based analysis -- “cases” vs. “orders”

Sanctioning Study

Virginia Department of Health Professions


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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 Study

Virginia Department of Health Professions


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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 Study

Virginia Department of Health Professions


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Descriptive & Multivariate Analysis

  • 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?

Multivariate – Tests the Influence of Factors Simultaneously

Sanctioning Study

Virginia Department of Health Professions


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Treatment/Monitoring

Sanction Groupings

What are we trying to predict ?

No

Sanction

Reprimand

Loss of license

RevocationX

Surrender license or privilege to renewX

SuspensionX

Stayed suspension - immediateX

Continue on termsX

Mental or physical evaluationX

Monetary PenaltyX

No sanctionX

ProbationX

ReprimandX

TERMS:

Competency - continuing educationX

Competency - audit of practiceX

Competency - special examine (SPEX)X

Prescribing - logX

Practice probation/fulfill criminal probationX

Impairment - evaluationX

Impairment - HPIPX

Practice restriction - chart/record reviewX

Practice restriction - oversight by monitorX

Practice restriction - specificX

Prescribing - restrictionsX

Sexual misconduct - chaperoneX

Sexual misconduct - evaluationX

Sexual misconduct - supervised practice X

Sexual misconduct - therapyX

Sanctioning Study

Virginia Department of Health Professions


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Loss of License – Significant factors

(suspension, revocation, surrender)

Direction of influence

( + ) more ( - ) less

Degree of Influence

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

Sanctioning Study

Virginia Department of Health Professions


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BOM Committee

  • 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

Sanctioning Study

Virginia Department of Health Professions


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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 Study

Virginia Department of Health Professions


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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 Study

Virginia Department of Health Professions


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SRP Steps:

Determine if violation occurred

no

yes

  • Determine case type

  • Locate appropriate worksheet

  • Score offense and respondent factors

  • View the sanction grid result

  • Complete coversheet

  • May cite reason for departure, if applicable

No worksheet completed

Sanctioning Study

Virginia Department of Health Professions


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SRP Steps:

  • Determine case type

  • Locate appropriate worksheet

  • Score offense and respondent factors

  • View the sanction grid result

  • Complete coversheet

  • Cite reason for departure, if applicable

Manual, page 9


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SRP Steps:

  • Determine case type

  • Locate appropriate worksheet

  • Score offense and respondent factors

  • View the sanction grid result

  • Complete coversheet

  • Cite reason for departure, if applicable

Caspian

010100000

Sanctioning Study

Virginia Department of Health Professions

Manual, page 15


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SRP Steps:

  • Determine case type

  • Locate appropriate worksheet

  • Score offense and respondent factors

  • View the sanction grid result

  • Complete coversheet

  • Cite reason for departure, if applicable

Manual, page 20


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SRP Steps:

  • Determine case type

  • Locate appropriate worksheet

  • Score offense and respondent factors

  • View the sanction grid result

  • Complete coversheet

  • Cite reason for departure, if applicable

Caspian

010100000

Sanctioning Study

Virginia Department of Health Professions

Manual, page 15


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SRP Steps:

  • Determine case type

  • Locate appropriate worksheet

  • Score offense and respondent factors

  • View the sanction grid result

  • Complete coversheet

  • Cite reason for departure, if applicable

Sanctioning Study

Virginia Department of Health Professions

Manual, page 12


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Existing Sanctions

Fit into 4 Sanction

Groups

Manual, page 11

Sanctioning Study

Virginia Department of Health Professions


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Prior History Scoring

  • Cases ending in a violation

  • Similar past violations – in same offense group

  • Score past cases regardless of age

Sanctioning Study

Virginia Department of Health Professions


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Cases to Exclude

  • Mandatory Suspensions

  • Formal Hearings

  • Compliance/Reinstatement

  • Actions by Other Boards

Sanctioning Study

Virginia Department of Health Professions


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Sample Case

Sanctioning Study

Virginia Department of Health Professions


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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.

Sample Case


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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)

Sample Case

Sanctioning Study

Virginia Department of Health Professions


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Worksheet

Sample Case

50

30

80

60

60

Sparrow

010199999

Sanctioning Study

Virginia Department of Health Professions


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Coversheet

Sample Case

2 2 2 2 2

Sparrow

Rebecca

MD

010199999

X

Relationship Inappropriate

X

Sanctioning Study

Virginia Department of Health Professions


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A Comprehensive Study…

= Project meeting/presentation

2002

2003

2001

NovDecJanFebMarAprMayJunJulAugSepOctNovDecJanFebMarAprMayJun Jul Aug Sep Oct Nov Dec

Literature review & summation, report preparation

Profile other state systems

Building consensus

Sanction Reference Points Adopted

In-depth interviews

Identify sample

Compile databases

Develop instrument

Data analysis

Data collection/coding

Reference

System developed


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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 Study

Virginia Department of Health Professions


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Elizabeth Carter, Ph.D., Executive Director

Virginia Board Of Health Professions

6603 West Broad Street, 5th Floor Richmond, VA 23230

804.662.7691

[email protected]

Neal Kauder, President

VisualResearch, Inc.

P.O. Box 1025

Midlothian, VA 23113

804.794.3144

[email protected]

Speaker contact info


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