Incident 2: Miriam Hospital

The Dilemma:
In 1980, the hospital changed the analyzing machine to run blood tests from a six channel
analyzer to a twelve channel analyzer. When the insurance company (Blue Cross) was
billed for the test (only the twelve channel analyzer test was used), both tests were
unintentionally charged due to a computer programming error. This created a double-
billing situation, and Miriam hospital received funds for both the twelve channel test and
for the six channel test. In 1982, a professional standards review organization clerk
uncovered the double billing error and informed the hospital. The error was first
eliminated and then later re-instated by a “top official.” Later that year, a Blue Cross
auditor uncovered the double billing error and contacted the hospital for access to their
program. The top official instructed the manager of data processing to remove evidence
of that the error had been found, eliminated and then re-instated, thus allowing Miriam to
claim innocence of any knowledge. Eventually a indictment was brought against Miriam
for obtaining money under false pretenses, conspiracy and filing false documents. Were
these charges rightly brought against Miriam?

Analysis:
1. Almost $2.8 million was over-charged and received by Miriam.
2. Miriam claimed that they were just following a rule which stated that the same
accounting methods be used until the end of the fiscal year.
3. Two data-processing personnel were forced to quit because of allowing third
party access to Miriam’s computer system, which was a violation to hospital
policy.

Personal Opinion:
This scenario brings to light several questions: Why was evidence erased if they truly
believed they were just following procedures and that what they were doing was legal?
Why were two employees being forced to quit, unless there was a need to get rid of those
close to the situation? What would happen if they did this same thing to the government?
What would Miriam do if the tables were turned? Was the reimbursement rule that
Miriam was supposedly following meant to encourage this fraud?
I think the answer to these questions lies in one fact: that Miriam knew that if they came
clean, they would have to return the $2.8 million dollars, where as, if they could just
eliminate the error at the beginning of 1983, know one would catch the error. However,
my question is, how could Miriam believe that the error wouldn’t eventually be caught. If
there was a sudden sharp decrease in testing reimbursement, an auditor would surely have
asked why and investigated further. If they tried to continue “getting away with it,” an
auditor would surely have caught the error sooner or later, like what occurred in 1982.
This leads into the question about the reimbursement rule. This rule more in likely covers
changes in accounting methods such as switching beginning dates of the quarter,
switching to different inventory or depreciation calculation methods, or the addition of
deletion of services. However, this rule probably does not cover nor condone fraudulent
behavior. This further leads us to the preponderance of how the government would react.
Actually, we know exactly how they would react according to the False Claims Act of
1986 or to the HIPAA act of 1996. Needless to say, Miriam would be in serious trouble if
they defrauded the government instead of Blue Cross. Either way, fraudulent behavior of
this type is incorrect and should be prosecuted to the fullest extent of the law. I believe
that fraud, professional/corporate negligence and employment contract breach and
coercion should also be added to the list of charges. In-fact, to send a message to others,
all the managers involved should be fired, civilly charged and prosecuted. A system of
checks should be put in place, such as a yearly billing audit check and policies that state
if any errors or inconsistencies are found, that they be immediately reported to involved
parties so that a determination can be reached on how to proceed. This will prevent
further fraudulent behavior and allow more open and trusting communication between
HSO’s.

Incident 5: Protecting the community

The Dilemma:
Legionnella is a bacteria that causes legionnaire’s disease and one that can easily spread
through a hospital via the air conditioning system. Legionnaire’s disease is potentially
life threatening if not diagnosed and treated early, or especially in elderly people,
immuno-compromised people, or others with medical issues. Most of these types of
people are found in a hospital. In 1977, an outbreak of Legionnella occurred at University
hospital, with a cooling tower implicated as the source of the infection. It was understood
that treatment of the water system with chlorine would kill most bacteria, including
Legionnella. However, after the outbreak of 1977, no policy or standing order was
created to treat the water with chlorine. In 1982, another outbreak occurred. Chlorination
of the water was then immediately implemented; however the number of cases or deaths
resulting from this outbreak is unknown from the article. The administrator and several
others came to the decision that the outbreak should be kept from the community and that
there would be no limit on admissions to the hospital. The only communication that
occurred about this incident was a confidential letter to all the physicians stating that they
should keep in mind the potential for risk when making an admissions decision. No
emergency policy was made to prevent the admissions of those with respiratory issues or
any other issues that would make them susceptible to Legionnella. Did the hospital
administrator make the correct decision about not telling the community about the
outbreak?

Analysis:
1. In the original 1977 outbreak, a number of patients were affected and several
died.
2. Further outbreaks could have been initially avoided if the water system was
treated with chlorine.
3. University hospital acted in a negligent manner by not initially treating the water
system.
4. The administrator stated several reasons for not divulging the outbreak
a. He didn’t want to start a panic.
 b. He wanted to prevent loss of confidence in the hospital from the
community.
c. He wanted to prevent a drop in the census.
d. The medical staff created a protocol in response to the situation by stating
that any unexplained onset of acute-pneumonia was to be treated with a
potent antibiotic shown to be effective against Legionnella.

Personal Opinion:
I’m going to begin this opinion with a general description of corporate negligence.
“Corporate negligence is a doctrine under which the hospital is liable if it fails to
uphold the proper standard of care owed to the patient, which is to ensure the
patient’s safety and well-being while at the hospital.”
Several forms of corporate negligence exist including: complying with the law, providing
a safe environment, and providing all pertinent information to patients that may affect
their decision to seek treatment at the hospital. University hospital acted negligently by
breaching all of these duties owed to their patients. Firs, once an outbreak was identified,
proper agencies must be notified (for example, the CDC) and proper precautions must be
taken to prevent the spread of the disease. Also, the community should be notified about
the outbreak and that all steps are being taken to solve the crisis. Second, University
hospital acted negligently after the first outbreak by not providing the proper chlorine
treatment to the water supply to prevent future outbreaks. In-fact, this is the most serious
charge of them all; with this breach constituting gross negligence and even possibly
criminal negligence. Thirdly, patients have the right to all knowledge that would effect
their decision as to where to seek treatment. This not only is negligence, but could also be
fraudulent behavior. University hospital should have a suit brought against them with
these three charges. The administrator should also have civil charges brought against him
since it was his decisions that caused further outbreaks and by allowing pre-disposed
patients from still entering the hospital. There was no need to deceive the community,
and I highly doubt that if proper communication and notification took place, the census
would have dropped dramatically. The fall-out from this conspiracy was more
detrimental than what was trying to be prevented in the first place.

Incident 6: Decisions
The Dilemma:
A DNR (Do-Not-Resuscitate) order is an order stating that if a patient stops breathing or
if their heart stops that they do not want either be intubated or given CPR. Most people
who have these types of AMD (advanced medical directives) are terminally ill patients or
patients with extremely debilitating diseases/disorders. Mrs. Nickleby is person with
severe MS who currently lives in a nursing home. She has been having frequent asthma
attacks recently, and the nurses at the nursing home noticed that Mrs. Nickleby’s
physician ordered a DNR code in the event she has a cardiac arrest during one of her
attacks. To the knowledge of the staff, Mrs. Nickleby has not discussed this issue with
her doctor. Is this DNR valid? If so, how?

Analysis:
1. The patient is receiving care at the nursing home from her physician. A witness
was not present when the DNR was ordered.
2. The patient has been getting more depressed over the course of the past asthmatic
episodes.
3. None of the nurses have heard Mrs. Nickleby express any discontent or opinion
about not wanting to live.
4. One of the nurses has a serious problem with the order because it goes against her
professional values.
5. None of the staff members noticed the Doctor discussing this or any issue with
any of the family members.

Personal Opinion:
DNR’s and other AMD’s are not always enforceable, especially if family members have
other demands or if the staff disagrees with the order. In this case, there is a reasonable
doubt that the DNR order is completely genuine. The current DNR should be considered
null and void, and any time the issue is discussed in the future, the physician, an ethics
committee administrative representative and all involved near relatives should be present.
If the decision is finalized that a DNR is to be created, the physician, the ethics
committee member, and patient must all sign the order. Further, a policy should be
created that delineates that anytime a patient is considering a DNR, that they sign a form
to start the above process. In essence, the DNR occurs in stages: 1). Form for
consideration of a DNR. 2). Advisement with physician, ethics committee member and
family members. 3). Contemplation time of not less than 2 weeks. 4). Signing of DNR by
patient, physician and ethics committee member.