Assume you are the Chief Compliance Officer for Everytown
Memorial Hospital, a not-for-profit hospital which was formed under a
Charter "To render needed healthcare services to the citizens of the
community of Everytown, and to serve the underprivileged in need of healthcare
within our community." The Board of Trustees has an upcoming board
meeting and your job is to review their agenda and determine if any legal
issues are presented by that agenda that should be referred to legal council
prior to the meeting.
Among the Agenda items for the Governing Board are the
following:
1. To grant general surgery privileges to Dr. Armstrong, a
board certified general surgeon with impeccable privileges that meets all
required credentials for the requested privileges.
2. To review the CEO's recommendation to expand the
services of the hospital by opening a cosmetic surgery center which will only
do cosmetic (not reconstructive) surgeries such as breast enlargements and
liposuction through physicians that will be employed by the
corporation. Because they are courting wealthy patients, they could make
a lot of money for the Corporation. Also, because they are only
doing such things such as breast enhancements and tummy tucks, the CEO is
recommending they waive any formal credentialing processes for the
cosmetic surgeons who will be hired based upon the CEO's review of
their resumes and interviews.
3. To grant approval for the hiring of Straight, Laced and
Ethical, CPAs, a highly reputable and skilled accounting firm to do their
annual audit. It has been confirmed that they have healthcare expertise,
have no conflicts and can perform a truly independent audit for a
reasonable fee.
4. To hire Dr. Smally, an interventional cardiologist, as
an employed physician to perform procedures, and to be the medical director of
the Corporation's newly developed Cardiac Care Center. Also, to grant Dr.
Smally full interventional cardiology privileges so he can treat patients
there. It is anticipated that Dr. Smally will generate a lot of business
since he is well known and trusted in the community and will undoubtedly bring
lots of referrals. Because the center is ready to go, the CEO and Medical
Executive Committee are recommending that we waive the requirement of full
credentialing which takes time (confirmation of licensing and board
certification and review of malpractice history) so the doctor get
the center going as soon as possible (we are losing money while it is
empty). If credentialing issues come up after he starts, we will deal
with it then.
5. To raise the CEO's salary to an amount that happens to
be 3 times the average salary for a chief executive of a hospital
corporation this size. (Unspoken reason for such salary hike is that his father
was the founder of the Corporation and still holds a lot of sway around
Everytown).
The Question
Some of the above agenda
items present legal issues, some do not. List each problematical matter you see and state what the
issue might be. Because the only the problematical
issues should be referred to counsel (referring non-issues cost us
money!), we just need to know which ones might be problematical and why ( what law, regulation or legal
doctrine they might run afoul of).
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