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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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Presentation Transcript
slide1
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

slide2
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

slide3
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

slide4
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

slide5
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

slide6
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

slide7
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

slide8
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

slide9
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

slide10
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

slide11
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

slide12
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

slide13
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

slide14
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

treatment monitoring
Treatment/Monitoring

Sanction Groupings

What are we trying to predict ?

No

Sanction

Reprimand

Loss of license

Revocation X

Surrender license or privilege to renew X

Suspension X

Stayed suspension - immediate X

Continue on terms X

Mental or physical evaluation X

Monetary Penalty X

No sanction X

Probation X

ReprimandX

TERMS:

Competency - continuing education X

Competency - audit of practice X

Competency - special examine (SPEX) X

Prescribing - log X

Practice probation/fulfill criminal probation X

Impairment - evaluation X

Impairment - HPIP X

Practice restriction - chart/record review X

Practice restriction - oversight by monitor X

Practice restriction - specific X

Prescribing - restrictions X

Sexual misconduct - chaperone X

Sexual misconduct - evaluation X

Sexual misconduct - supervised practice X

Sexual misconduct - therapy X

Sanctioning Study

Virginia Department of Health Professions

slide16
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

slide17
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

slide18
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

slide19
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

slide20
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

slide21
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

slide22
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

slide23
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

slide24
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

slide25
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

slide26
Existing Sanctions

Fit into 4 Sanction

Groups

Manual, page 11

Sanctioning Study

Virginia Department of Health Professions

slide27
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

slide28
Cases to Exclude
  • Mandatory Suspensions
  • Formal Hearings
  • Compliance/Reinstatement
  • Actions by Other Boards

Sanctioning Study

Virginia Department of Health Professions

slide29
Sample Case

Sanctioning Study

Virginia 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.

Sample Case
slide31
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

slide32
Worksheet

Sample Case

50

30

80

60

60

Sparrow

010199999

Sanctioning Study

Virginia Department of Health Professions

slide33
Coversheet

Sample Case

2 2 2 2 2

Sparrow

Rebecca

MD

010199999

X

Relationship Inappropriate

X

Sanctioning Study

Virginia Department of Health Professions

slide34
A Comprehensive Study…

= Project meeting/presentation

2002

2003

2001

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

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

slide35
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

speaker contact info
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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