What to Do if You Have a Concern About the Quality of Care from a South Carolina Doctor

Advice and resources for dealing with quality concerns

For many of us, our doctor is one of the most important people in our lives. We trust him or her to help keep us well or care for us when we're sick. There are over 10,000 doctors actively practicing in South Carolina, and most provide high-quality care to their patients. There are times, however, when people have concerns about the quality of care received from a doctor. If this happens to you or a loved one, this tip sheet can help. It gives you:

• Practical advice about what to do and who to talk with, including phone numbers and addresses
• Links to resources that can help

This tip sheet explains steps you can take in your doctor's office to deal with your concerns about quality. It also tells you how to contact places that regulate or oversee doctors.

Is it worth it to pursue a concern about quality?

For many of us, it's not easy to act on a concern about the quality of physician care that we or our loved ones receive. It's even harder if we try to talk with a doctor or their staff about our concerns, but don't feel we're getting anywhere. The process can be stressful, frustrating and take a long time. In the end, it's possible that others may not agree with the way we see the situation.

Is it worth the time and energy to take action about the quality of a doctor? Only you or your loved one can decide. In making the decision, think about the continued harm that might take place if you do nothing—and think about how the actions you take might lead to better care for future patients and their families.

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What is quality of care?

Quality health care is doing the right thing, at the right time, in the right way, for the right person and with the best possible results. Generally, care delivered by doctors and other health professionals must meet a "standard of care." That standard is the expected level and type of care provided by the average competent health professional in a given situation. A standard of care is based on good scientific studies or agreement among experts.

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What can you expect as a patient regarding the quality of care from a doctor?

To become a doctor, students have to go through a long training process. This includes hands-on learning in hospitals and other health settings. When they finish training, doctors promise to "do no harm" to their patients.

As professionals, doctors voluntarily follow codes of ethics that lay out the way they are to behave. For example, the American Medical Association Code of Ethics notes some patient rights in the patient-physician relationship:

• The patient has the right to receive information from physicians and to discuss the benefits, risks and costs of treatment options.
• The patient has the right to make decisions regarding health care recommended by his or her physician and may refuse any recommended treatment.
• The patient has the right to courtesy, respect, dignity, and timely attention to his or her needs.

The American Board of Internal Medicine Foundation and other partners have published a new physician code or charter. The Foundation works with an organization that certifies physicians who care for adults. This document specifically addresses quality and competence in what is expected of doctors:

• Physicians must be committed to lifelong learning and be responsible for maintaining the medical knowledge and clinical and team skills necessary for the provision of quality care.
• Physicians must be dedicated to continuous improvement in the quality of health care. This commitment means not only keeping their skills up-to-date, but also working with other professionals to reduce medical error, increase patient safety, keep an eye on costs and make sure patients are getting the best possible care.
• Physicians are required to provide care that is based on the wise and cost-effective management of limited resources. This includes avoiding unneeded tests and procedures that expose patients to avoidable harm and expense.

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What are examples of quality concerns you might experience?

Health care quality concerns could arise for a variety of reasons while you are under a doctor's care. Some concerns are the result of a specific action a doctor or staff member takes (or doesn't take) as they treat you or a family member. This includes misdiagnosing a condition or prescribing a drug that you shouldn't take.

Other quality concerns result from how well the doctor's staff work together to safely care for you—for example, making sure that the right medical chart goes with the right patient or that patient messages are delivered on time.

Some of these actions in a doctor's office may not affect your health at all; some may cause inconvenience or pain; others may cause serious harm.

The most common complaints received by organizations that oversee or regulate doctors nationwide are:

• Overprescribing drugs or prescribing the wrong drug
• Failing to diagnose a medical problem that is found later
• Misreading x-rays to identify a medical problem
• Failing to get back to a patient with medical results in a timely manner, which leads to harm to that patient
• Failing to provide appropriate care after a surgical procedure

What should concern patients the most—and what concerns organizations that oversee doctors— is when there is a pattern of problems with a doctor. If something happens once, it is usually a mistake. If it happens again and again, it may indicate a larger problem of competence or quality that could hurt any patient.

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What steps should you take if you have a concern about quality?

Depending on what kind of problem you have and your relationship with your doctor, you might talk directly to him or her or to another office staff member about your concern. For example, if your concern relates to the way the doctor's office is organized, the doctor and staff may not know how it feels to be a patient in their office. They might be particularly interested if you thought mistakes could result from what you see. Speaking honestly about your concerns gives your doctor or another staff member the opportunity to explain why things happen the way they do. It may also lead to changes in the office.

If your concern is more medical in nature—for example, getting the wrong prescription, the wrong dose, or the wrong referral—you should speak with the doctor directly to correct the problem. Then think about whether this has happened before and be alert to whether it happens again.

If your concern is with a doctor that you've been referred to for specialty care, share your concerns about that physician with your personal doctor. It will help your doctor decide whether to refer other patients to that physician. Or, if your concern is with a doctor you're seeing while in the hospital or another health organization, again, let your personal doctor know. He or she may be able to tell you who in the facility can help you.

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If you continue to have concerns about the quality of a doctor and their staff, you have the option to leave the practice and go to another doctor. Remember to check with your health insurance plan to see which doctors work with your plan and which are taking new patients.

You do not need to tell your doctor why you are leaving, but you might consider writing a note with your concerns. The more specific you are, the more he or she might be able to understand your views and possibly take action on them.

If you leave the practice, you should request copies of your medical records to take with you. Under the law, you have the right to request a copy of your records. The doctor can charge you a reasonable fee for locating, copying and mailing your records. In South Carolina, that fee can't be more than sixty-five cents per page for the first 30 pages and fifty cents per page for all other pages. The office can also charge a clerical fee of up to $15 plus postage and sales tax. A recent law in the state limits how much you can be charged for your medical records to $150 for an electronic copy and $200 for a paper copy.

For more information about your medical records in South Carolina, see the Physicians' Patients Records Act:

http://www.llr.state.sc.us/pol/medical/index.asp?file=Pdf/Laws/MERECACT.HTM

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If you feel you should take action to protect yourself and other patients from a doctor who you think poses a safety threat, you can file a complaint with the South Carolina Board of Medical Examiners. The mission of the Board is to protect the public. The Board licenses doctors and other health professionals (including physician assistants and respiratory care practitioners) to practice in the state. It also investigates and disciplines doctors and other health professionals when there are concerns about them. The 12-member Board is made up of nine doctors and three lay members (i.e., people who are not doctors) and is supported by a staff of state employees.

Be aware that if the Board pursues your case, the process can take a long time and involve many steps before any action, if needed, is taken against a doctor. And if it goes forward, your concerns will become the Board's concerns. That means that you will not be able to decide what happens with the case. State lawyers will present the case before the Board on behalf of the public. They do not represent you personally.

The Board received over 363 complaints about doctors in 2011. Only a small number (37) resulted in some type of action being taken against a doctor's license.

Filing the Complaint: The Board has a consumer complaint form that you should use to file your complaint. It is available online to print out, fill in and mail, or you can call them and have them mail you a copy: 803-896-4470.

Board of Medical Examiners Complaint Form
http://www.llr.state.sc.us/POL/Medical/PDF/ApplicationsForms/ComplaintForm.pdf

Mail to: SC Department of Labor, Licensing and Regulation
Office of Investigations and Enforcement
P. O. Box 11329
Columbia, SC 29211

Or Fax to: 803-896-4656.

The investigation:  When your complaint has been received by the Board, it is logged in and assigned to an investigator. You should receive a letter saying that the complaint has been received.

The investigator reviews the complaint to see if it violates the state law that addresses how doctors practice medicine in the state. If the complaint indicates an immediate threat to the health and safety of patients, the Board can take action right away to stop the doctor from practicing until an investigation occurs.

Examples of state law violations include:

• Lacking the professional or ethical competence to practice medicine
• Excessive use of drugs, alcohol or other substances that impair ability
• Engaging in disruptive behavior that could impact patient quality of care
• Failing to provide medical records when lawfully requested to do so by a patient

After reviewing your information, the investigator decides whether or not to open a case based on the law. You will be notified if your case is not opened and given the reasons why. Or, you may be asked to provide additional information. If a case is not opened, a copy of the complaint is still kept on file by the Board so if others complain about this doctor, there is evidence of your concern in the records.

If the complaint is found to be legitimate and reveals a violation of state law, an investigation begins. Many times, this includes an expert medical review by a South Carolina medical doctor who is not an employee of the Board of Medical Examiners.

After the investigation is complete, the investigator presents the case to an Investigative Review Committee (IRC). This committee includes legal staff, two outside doctors who are not members of the Board, and the head staff person, or administrator, of the Board. The IRC reviews the completed investigation and makes a recommendation to the Board to:

• Dismiss the complaint.
• Issue a formal complaint that charges the doctor with breaking the law.
• Issue a letter of caution. This means that the case is dismissed, but the doctor receives a letter of caution about his or her conduct. This letter, however, is not considered a form of discipline and can't be considered in a future proceeding against the doctor, unless it relates to the previous complaint.
• Investigate further.

If the Board dismisses the complaint, the case is closed and you are notified. Again, the complaint is kept in the doctor's file.

Next Steps: If the IRC recommends a formal complaint, by law, the doctor is allowed to have an informal conference. This meeting is with the Board legal staff and an outside doctor chosen by the Board. The doctor in question can have a lawyer present. You cannot attend this meeting and anything said during the meeting is confidential. It is possible that the case could be resolved during this meeting, though the resolution will need to be reviewed by the full Medical Examiners Board.

If the case continues, the doctor can decide whether to sign a "Memorandum of Agreement" or "consent agreement". This is a document in which he or she admits that they broke the law. Or, the doctor can choose to have a hearing before a Medical Disciplinary Panel. This panel includes at least three doctors and one layperson. In some cases, you may be asked to testify in this meeting. The hearing is open to the public, though sometimes a motion, or request, may be made to close it to the public. The panel then reports its recommendations to the Medical Examiners Board, which makes the final decision.

The Board also decides what sanction, or punishment, to give. They can take away or limit a doctor's license to practice in South Carolina—or they can require that the doctor get additional training or education. They can also fine the doctor up to $25,000. The doctor can appeal the case to the South Carolina Administrative Law Court.

If the Board decides to take action on a doctor's license, that information is available to the public on the Board's website. (See Alphabetical Listing of Orders and Board Actions website information below).

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How long does this process take?  On average, it took about 386 days to go through the entire process in 2012.

Can I remain anonymous when I file a complaint?  A complaint can be filed anonymously—that is, you don't give your name or contact information. Remember that if you do so, you will not be able to receive any follow-up information about what happened.

If you do provide your name, you can ask the board to withhold it.

Additional information about the South Carolina Board of Medical Examiners:
http://www.llr.state.sc.us/pol/medical/

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Where else can you go with a concern about the quality of a South Carolina doctor?

Medicare: If Medicare (the federal health insurance program for people over age 65 or people under 65 who are disabled) pays for the care you're receiving from a doctor, you have an additional place to go with a quality concern. Medicare pays a Quality Improvement Organization (QIO) to take complaints from Medicare patients. Be advised up front, however, that these organizations primarily help doctors improve the care they provide. They do not punish doctors.

In South Carolina, the QIO is called KEPRO. You can call KEPRO at the following number: 844-455-8708

Explain to the person who answers the phone what your concerns are. Depending on the type of problem you are having, they may be able to help you right away. For example, with your permission, they may be able to call the doctor's office to see if they can help solve your problem. In other cases, they may ask you to send your complaint in writing using a complaint form.

After you file a complaint with KEPRO and allow release of your medical records, a doctor will review your records. After the review, you will get a letter indicating whether the standard of care was met in your case or not—that is, whether the expected level and type of care was provided.

For more information about the KEPRO complaint system and to access an online complaint form:  https://www.keproqio.com/bene/qualityofcarecomp.aspx

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Other Health Organizations

Doctors often practice as part of larger organizations such as a medical group, hospital or managed care plan or HMO. Each of these organizations might have a process that patients can use to express concern about the quality of a doctor. Generally, these organizations will review a concern about a particular doctor's quality through a process called "peer review." This means that other doctors in the same field review the practices of a doctor in question.

If the health organization confirms that there's a quality concern with your doctor, they can limit the doctor's ability to practice in a hospital or HMO. Under certain circumstances, the organization must report its actions to the South Carolina Board of Medical Examiners. As noted above, that office can then conduct an investigation.

A health organization may also be required to report its actions against a doctor to the federal National Practitioner Data Bank. The data bank keeps information on doctors who have a record of unprofessional behavior or malpractice. The public does not have access to the data bank, but hospitals or health plans where that doctor might try to work should be checking it.

If you're a patient of a large medical group:  Look on the website of your medical group for any information about voicing a complaint. It might be in a section on "Member Rights" or in the "Customer Service" or "Contact Us" section. You can also ask an administrative staff member whether there is a number to call or a process to follow.

Your health insurance plan or HMO:   Doctors usually work with a health insurance plan or HMO. Call your health plan's customer service number, explain the problem and ask whether you can file a complaint about the care provided by a doctor affiliated with their health plan. Or look in the section of the HMO's website that is devoted to complaints, appeals or grievances for information or forms to file.

 

Physician Organizations

The physician's specialty society:  A few physician specialty societies (the professional association affiliated with the physician's type of practice—for example, pediatrics or orthopedics) accept and have a process to review complaints against their members. For example, the American College of Physicians (ACP), an association of internal medicine doctors who generally treat adult patients, has a process for addressing "ethical complaints" from patients against their physician members. For more information about the ACP process:

http://www.acponline.org/running_practice/ethics/complaints

 

Consumer Organizations

South Carolina Voices for Patient Safety is a nonprofit organization that promotes patient safety in South Carolina. It can also help when there are care problems between patients and doctors or hospitals. Their phone number is 843-910-7677; e-mail: SCVoicesforpatientsafety@yahoo.com; and website: http://www.scvps.org/

Mothers Against Medical Error is a South Carolina non-profit that works with patients and victims of medical harm to improve patient safety in South Carolina. They help inform and educate patients on navigating the healthcare system and can also help when patients suffer problems in their medical care. Their phone number is 803-254-8804 ; email: mamemoms@gmail.com; and website: www.advocatedirectory.org.

The Safe Patient Project (SPP) is a project of Consumers Union (the publishers of Consumer Reports magazine) that seeks to end medical harm in the health system. The Project is also collecting stories about patients' experiences and concerns with their care in hospitals and from doctors across the nation, including South Carolina. While they can't help with your specific complaint, the collective power of stories from patients and families can help pass laws and create other changes to make the health care system safer.

http://safepatientproject.org/

In a joint effort with the Empowered Patient Coalition, the Safe Patient Project is conducting a survey about medical events from the perspective of the patient. For more information about the survey:
http://www.advocatedirectory.org/

ProPublica is a nonprofit investigative journalism organization. They have an online patient harm questionnaire that asks for details about your concern. They write articles about people's experience of patient harm to bring public attention to these issues. The organization won't publish any information that would identify you without your permission. ProPublica also sponsors a Facebook group that can connect you with other patients who have been harmed.

Here is a link to their patient harm questionnaire:
http://www.propublica.org/getinvolved/item/have-you-been-harmed-in-a-medical-facility-share-your-story

On Facebook, search for: ProPublica Patient Harm Community

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Where can you find out information about doctors in South Carolina?

South Carolina Board of Medical Examiners Look-Up:  Once you enter the name of the doctor, you can find out whether the doctor is in good standing with the board, where they went to medical school and other information.
https://verify.llronline.com/LicLookup/Med/Med.aspx?div=16

Alphabetical Listing of Orders and Board Actions 2001-Present: A list of doctors and other health professionals who have been disciplined by the South Carolina Board of Medical Examiners:
http://www.llronline.com/POL/Medical/index.asp?file=finalorders.htm

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Other useful information

If you're concerned about the quality of care in a South Carolina hospital, managed care plan or HMO, nursing home, or the care provided by registered nurses, here's where to go for more information:

IPI Hospital Tips Sheet:
What to Do if You Have a Concern about Quality in a South Carolina Hospital
http://www.informedpatientinstitute.org/HOSQuality-SC.php

Managed Care or HMO:
South Carolina Department of Insurance
https://online.doi.sc.gov/Eng/Public/Consumer/Complaint.aspx

IPI Nursing Home Tip Sheet:
What to Do if You Have a Concern about Quality in a South Carolina Nursing Home
http://www.informedpatientinstitute.org/NUHQuality-SC.php

Registered Nurses:
South Carolina Board of Nursing
http://www.llr.state.sc.us/pol/nursing/index.asp?file=boncomplaintproc.htm