Background Statement

Describe what is going on in the case as it relates to the identified major problem. What are (only) the key points the reader needs to know in order to understand how you will solve the case? Summarize the scenario in your own words; do not simply regurgitate the case. Briefly describe the organization, setting, situation, who is involved, who decides what, etc.

Major Problems and Secondary Issues

Specifically identify the major and secondary problems. What are the real issues? What are the differences? Can secondary issues become major problems? Present analysis of the causes and effects. Fully explain your reasoning.

Your Role

For purposes of completing the case analysis, identify your role either as an outside observer or consultant, member of senior leadership in the organization, or a specific participant identified in the case (unless the role has already been designated in case specific instructions). The selection may impact your perspective on the case.

Organizational Strengths and Weaknesses

Identify the strengths and weaknesses that exist in relation to the major problem. Again, your focus should be in describing what the organization is capable and not capable of doing with respect to addressing the major problem. Thus, the identified strengths and weaknesses should include those at the managerial level of the problem.

Alternatives and Recommended Solution with Evaluation Methodology

Describe the two to three alternative solutions you came up with. What feasible strategies would you recommend? What are the pros and cons? State what should be done, why, how and by whom? Be specific.

You are the Chief Medical Officer (CMO) at Sunnyside Memorial Medical Center (SMMC). It has been brought to your attention that one of your surgeons, Dr. Kutall, is doing an extraordinary amount of carotid artery surgery. Your first impression is that this is good for the institution. He has developed a large referral practice, been a member of the staff for many years, and always supported the hospital. Drs. Smith and Boyle have requested a meeting with you because they are concerned about this extraordinary number of procedures and have reviewed some of the preoperative indications. Dr. Smith is Chief of Vascular Surgery and chairs the quality assurance committee for the department. It is his job to examine the indications for these procedures. The surgeon in question, Dr. Kutall, has been operating on the basis of duplex ultrasound testing obtained primarily from his laboratory, which he operates independently of the hospital. A few patients had their workups done elsewhere. Drs. Smith and Boyle reviewed those studies and felt the results did not warrant surgical intervention. The quality assurance committee has asked Dr. Kutall to provide the workup and diagnostic information for his last 50 carotid surgeries. The committee reviewed the reports from Dr. Kutall's vascular laboratory. According to his reports, all signed by Dr. Kutall, the patients met the criteria for surgery. However, when Drs. Smith and Boyle reviewed the scans, they felt that these were grossly overread. What Dr. Kutall considered a greater than 70% blockage, the other surgeons read as no greater than 50% blockage. operates independently of the hospital. A few patients had their workups done elsewhere. Drs. Smith and Boyle reviewed those studies and felt the results did not warrant surgical intervention. The quality assurance committee has asked Dr. Kutall to provide the workup and diagnostic information for his last 50 carotid surgeries. The committee reviewed the reports from Dr. Kutall's vascular laboratory. According to his reports, all signed by Dr. Kutall, the patients met the criteria for surgery. However, when Drs. Smith and Boyle reviewed the scans, they felt that these were grossly overread. What Dr. Kutall considered a greater than 70% blockage, the other surgeons read as no greater than 50% blockage. The gold standard indication for carotid surgery is an arterial blockage of 70% or greater. Dr. Kutall's procedures on patients with no greater than 50% blockage were definitely not indicated or appropriate. Upon further review, the success rate for Dr. Kutall's surgery seemed to be in the acceptable range, which would be one reason Dr. Kutall's practice variation had not appeared on the hospital quality assurance radar in the past. His results were not bad, but the surgeries were not indicated. Inappropriate surgery puts patients at risk unnecessarily, to say nothing about resulting in excessive expenditures for unnecessary procedures. As the CMO, it is your job to ensure appropriate medical care and patient safety. The report on Dr. Kutall and his dubious practices was forwarded to the medical executive board for review. It is now up to them to decide if Dr. Kutall should be disciplined