Answer Happy

Can some please help me answer the questions after this
case study?
BAD IMAGE RADIOLOGY:
MEDICAL IMAGING The chief of medical imaging is
Harold Goodview, M.D., a board-certified radiologist. Goodview is
the majority stockholder in Good Views Medical Imaging, LLC, the
professional corporation that has had an exclusive contract to
provide radiographic services at MacMillan for the past 15 years.
Goodview’s wife and her family are minority stockholders. Two years
ago, MacMillan and Good Views signed a 5-year extension of the
basic contract. Good Views employs all the radiologists, including
Goodview, who is both employee and owner. The department of medical
imaging is extraordinarily busy and has a volume of more than
100,000 cases per year. The hospital is paid for its work by
budgetarily apportioning part of the DRGs for Medicare and Medicaid
patients and by billing other third-party payers and the small
number of self-pay directly. Good Views has a contract billing
service that bills for the professional fee charged by the
radiologists. Part B pays for Medicare beneficiaries; Medicaid,
other third-party payers, and self-pay patients are billed
directly. Primarily because of the high volume, this basic
arrangement has been financially rewarding for both
parties. When Good Views Medical Imaging first obtained the
exclusive concession to provide radiology services, the group had
four equal partners. Over the years, Goodview bought them out when
they wanted to leave. His long-term-employed radiologists have
become fewer and fewer; currently there are only two, Drs. Banda
and Leipzig. In addition, there are several locum tenens
radiologists. The chief radiographic technologist is Sally Lebeau,
who has been employed in the department for 18 years, during half
of which she has been the chief technologist. Lebeau is well
regarded by her staff and is seen as fair and reasonable,
especially given the fast-paced and intense working environment.
Lebeau has tried to implement Deming’s quality principles and the
methods of continuous quality improvement, but neither Goodview nor
the hospital’s administration supported her efforts, and they have
come to naught. Lebeau is concerned with what she perceives to be a
decline in the quality of work in medical imaging. She has tried,
unsuccessfully, to discuss her concerns with Goodview on numerous
occasions. In the past several years she has seen other
developments that raised concerns. First, despite increased volume,
the department has fewer radiologists in total. Second, the
constant turnover of radiologists and the resulting heavy use of
locum tenens is very disruptive to the department’s work. Third,
Goodview does more and more of the work himself—both because of the
radiologist staffing problems and because of what Lebeau thinks is
an increasing obsession with money. Fourth, without the knowledge
of senior administration, Goodview ordered a cable connection so he
could follow the stock market and trade technology stocks on line.
He is often distracted from reading radiographs and other imaging
by stock market developments, especially in the volatile technology
stocks, in which he invests heavily. Lebeau’s concerns were such
that she went to see Halton. The head of maintenance
confirmed there was a cable hook-up and the hospital was paying the
fee.h When Lebeau returned to medical imaging, she saw several of
the staff standing as though transfixed outside the room where
radiologists read films. They were listening intently to a heated
conversation Goodview was having with an online broker who Goodview
alleged had failed to make a trade in time to avoid a significant
loss. The language was foul and was becoming so loud patients
waiting for procedures could hear it. Lebeau quietly shut the door
to the reading room and told the staff to go back to work.
Goodview was told the hospital had ordered the Internet service
disconnected. Goodview stormed over to “management house” to see
Gargon, who was only somewhat successful in calming him before
Goodview left his office. After talking to Halton, Gargon basically
agreed with his action, but chided him for how he had done it. In
the weeks that followed, Goodview brooded about the loss of his
cable connection; he frequently cursed out administration. Several
times he stated that if he had a bomb he’d blow up “management
house.” Goodview’s agitation was increasingly reflected in his
work. For example, he read mammograms as quickly as he could bring
them up on the monitor and dictated reports in groups. He found
virtually none that required more than a few seconds of study. When
Dr. Leipzig raised a question about the speed of his readings,
Goodview said, “Reading mammograms is so simple a one-eyed
first-year medical student could do it.” To check Goodview’s
readings, Leipzig reread 100 randomly selected mammograms and found
several that warranted follow-up studies, including repeat
mammograms and fine needle aspirations. He ordered them without
telling Goodview. Concerned about the mammograms and similar
problems, Leipzig followed Goodview’s custom and went “to the top”
to see Gargon. Gargon was initially noncommittal and told Leipzig
that he would have to undertake his own investigation. Gargon
called Halton and asked him to speak to Lebeau. When their meeting
began Halton asked Lebeau for her comments on the information
relayed from Leipzig. Her response was a torrent: poor staff
morale, low patient satisfaction, high turnover of radiologists,
and Goodview’s continuing bad behavior were causing a great deal of
stress. Alarmed, Halton met with Gargon, but they were unsure how
to proceed and the meeting produced no plan of action. The
following week, Dr. Leipzig resigned, citing in his letter the
continuing and significant quality problems in medical imaging.
This meant that Drs. Banda and Goodview were the only nontemporary
radiologists in the department. The other radiologists in the
department were locum tenens, who usually stayed only 1–3 months.
The controversy between administration and Goodview and questions
about the quality of work in medical imaging were common knowledge
in the hospital. Their extent and duration were such, however, that
admitting and referring physicians in the community were
increasingly concerned about the quality of imaging services their
patients would get at MacMillan. Gargon and several board members,
including Ms. Buchanan, had received calls from prominent active
staff physicians who said they had become uncomfortable referring
patients to MacMillan for imaging and that they would use a
competing hospital or a freestanding imaging center. In the short
term fewer referrals would reduce hospital revenue from medical
imaging; in the longer term inpatient admissions would be affected,
thus potentially affecting quality of care received by persons in
the hospital’s service area, but certainly causing a decline in
hospital revenue. Greatly concerned and prompted by a call from the
board chair, Harriet Buchanan, Gargon scheduled a meeting with
Goodview and Halton. Goodview said that radiologists were in
great demand and he was doing the best he could to recruit
additional staff. In the meantime, he, Banda, and the locum tenens
radiologists could handle the workload. After 30 minutes of heated
discussion, the meeting ended with no resolution. After Goodview
left, Gargon told Halton to contact physician search firms and
determine whether Goodview was correct about the shortage of
radiologists. A week later, in early July, Halton reported the
search firms had sent information that radiologists were available
in adequate numbers, but they were being attracted to groups that
paid better than Good Views. Goodview’s salary offers were well
known to the search firms—one even called Goodview “a cheapskate.”
A week later, in mid-July, Goodview had done nothing about hiring
more locum tenens radiologists. This prompted Halton to contact the
search firms. He asked them to send applications from the 10
radiologists whose résumés they had sent previously. Halton was
sure this would force Goodview to take action. Applications
received in administration were forwarded to Goodview, who
stubbornly ignored them.
CONTRACT TERMINATION The relevant
contract provision stated: Either party may, upon demonstration of
adequate cause, terminate the contract with a 30-day notice. Cause
is defined as either party’s: inability to meet the clinical needs
of the other; nonperformance of a significant provision of this
contract; or actions that interfere with the ability of the other
party to perform this contract. After talking to Halton, who said,
“It’s about time!” Gargon called Buchanan and told her legal
counsel had informed him there appeared to be adequate cause to
terminate the contract. Buchanan instructed him to draft a letter
advising Good Views Medical Imaging that its contract with
MacMillan would be terminated as of September 1. Consistent with
board bylaws, Buchanan polled the executive committee, which
approved the action. The letter was signed by Gargon and hand
delivered to Goodview the same day. Goodview was performing a fine
needle biopsy and he asked a technologist to read the letter to
him. On hearing the content, he became enraged.
Goodview’s attorney petitioned the court for a temporary
restraining order (TRO), arguing that contract termination would
cause irreparable economic harm to Good View’s Medical Imaging and
would also irreparably harm Goodview’s professional reputation. The
TRO was granted despite arguments by MacMillan’s lawyers that
focused on the need to provide quality imaging services and
maintain the quality of patient care. Less than a week after
the TRO was granted, Goodview filed suit against MacMillan for
breach of contract and defamation. Gargon and Halton were named
personally as having “conspired to deprive Goodview of his business
and professional livelihood and of causing irreparable harm to his
professional reputation.” In addition to economic damages for
breach of contract, the lawsuit asked that the court award punitive
damages based on the alleged conspiracy and bad faith on the parts
of Gargon and Halton, as agents of the hospital. Given the urgency
of the situation, MacMillan was successful in gaining an early
trial date on the breach of contract and defamation lawsuit. Trial
was scheduled for December 1st, even as the TRO remained in
effect.
BREAST CANCER AWARENESS MONTH As it had done
for the past 8 years, MacMillan Hospital’s “Health-Promotion
Promotion” program designated October as breast cancer awareness
month. Local radio and television stations aired public service
announcements that urged women older than age 45 to go to MacMillan
for a free screening mammogram. The continuing shortage of
radiologists and pending legal proceeding made the extra workload
seem especially burdensome this year. Cowed by the TRO and the
pending lawsuit for breach of contract and defamation and concerned
there might be charges of harassment, which could result in being
held in contempt of court or prompt another lawsuit, Gargon and
Halton stayed away from medical imaging and Goodview. Emboldened by
the initial success of obtaining the TRO, Goodview was even more
critical of administration and his behavior became increasingly
bizarre. Lebeau’s stress level was so high she sought medical
attention and was prescribed a mild tranquilizer. To the
technologists and other staff, the situation was overwhelming;
morale sank even lower and there was talk of a mass resignation.
Only the perseverance of Lebeau gave the staff some encouragement.
A MacMillan Hospital housekeeper, Amelia Tendo, presented herself
at medical imaging early one morning in October for a screening
mammogram. She said she had felt a small lump in her right breast
and was concerned about it. Goodview read the mammogram in his
usual fashion and diagnosed the lump as benign and “nothing more
than a calcium deposit in an overly anxious female.” Reassured,
Tendo asked that a copy of the report be sent to her primary care
physician.
THE FIRST TRIAL In preparing for trial,
attorneys for MacMillan and Goodview/Good Views took depositions
(questions answered under oath) of the major parties in the case.
Without exception, persons employed by the hospital, including
radiologic technologists, stated in their depositions that
Goodview’s work in managing and providing radiologic services was
well below acceptable levels and his actions that effectively
resulted in inadequate radiologist staffing had put and were
putting patients at risk. Testimony such as this was necessary
because the hospital had the burden of proving that the grounds for
termination specified in the contract had been met.The trial
commenced December 1st and lasted 5 days. The witnesses who
appeared were those who had given depositions. The jury found
in favor of the hospital and against Goodview and Good Views
Medical Imaging on both the breach of contract and the defamation
claims. The verdict caused the judge to vacate the TRO. Hospital
administration was jubilant and, with Good Views’ contract
terminating in 30 days, it immediately began to recruit a new
radiology group. Radiologists who had been part of Good Views were
contacted. Dr. Leipzig said he was interested and he set about
organizing a radiology group.
SECOND LAWSUIT Ms. Tendo, who had had the
screening mammogram in October during breast cancer awareness
month, continued to be concerned by the lump in her right breast.
When she performed her intermittent breast self-examinations over
the next several months it seemed to be growing. Whenever her
anxiety rose, she recalled Dr. Goodview’s reading and diagnosis
that it was only a calcium deposit and was reassured. Six months
later, in April she had become convinced the lump was substantially
larger and she scheduled an examination with her gynecologist. He
immediately ordered a mammogram at a freestanding imaging center,
which led to a fine needle aspiration. After other tests, the final
diagnosis was cancer of the right breast with metastases to one
lung, nearby lymph nodes, and liver. She died 3 months later.
Within a year, Ms. Tendo’s estate sued Dr. Goodview, Good Views
Medical Imaging, and MacMillan Hospital for medical negligence.
DISCUSSION QUESTIONS
1. Identify the issues in the case. Prepare a time line
of major events in the case.
2. Determine the points at which intervention by
hospital administration or the board might have prevented the
problems in medical imaging from developing as they did. For each
intervention point, outline the intervention that should have been
taken.
3. Identify points at which hospital
administration should have intervened to lessen the probability of
Dr. Goodview’s failure to diagnose Ms. Tendo’s breast
cancer.
4. What steps should be taken by MacMillan
Hospital to resolve the lawsuit brought by Ms. Tendo’s
estate?
6. What actions, if any, should be taken against
Messrs. Gargon and Halton?
7. Who should take them?