Neal B. Kauder, President VisualResearch, Inc. Elizabeth Carter, Ph.D, Executive Director, Virginia Board of Health Professions Sanctioning Reference Points

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


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


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?


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


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:


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:


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:


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


Study Sample

• All violations going back 6 years

• 6 year period captures 447 “cases”

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


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


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?


• 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

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



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


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


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


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





factors



6) Cite reason for departure, if

applicable

Manual, page 9

SRP Steps:

Caspian

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factors




applicable

Manual, page 15Sanctioning StudyVirginia Department of Health Professions

SRP Steps:



3) Score offense and respondent factors



6) Cite reason for departure, if applicable

Manual, page 20

SRP Steps:

Caspian

010100000



3) Score offense and respondent factors



6) Cite reason for departure, if applicable


Manual, page 15

SRP Steps:




factors




applicable

Manual, page 12Sanctioning StudyVirginia Department of Health Professions

SRP Steps:

Existing Sanctions

Fit into 4 Sanction

Groups


Manual, page 11

Prior History Scoring

• Cases ending in a violation

• Similar past violations – in same offense group

• Score past cases regardless of age


Cases to Exclude

• Mandatory Suspensions

• Formal Hearings

• Compliance/Reinstatement

• Actions by Other Boards


Sample Case


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)


Sample Case

Sparrow 010199999

60

30

80

60

WorksheetSample Case

50


Sparrow

010199999

Rebecca MD

Relationship Inappropriate

2 2 2 2 2

X

X

CoversheetSample Case


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?


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]

Documents

Neal B. Kauder, President VisualResearch, Inc. Elizabeth Carter, Ph.D, Executive Director, Virginia Board of Health Professions Sanctioning Reference Points