گزارش حسابرسی عملکرد(عملیاتی) آمریکا-لاتین
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Board of Medicine Progress Report

September 10, 2008

 

Performance Audit of April 2008


Observations that Have Been Acted Upon:

2. Hiring of Family Members: The LBA’s recommendations on this observation are primarily directed to the Legislature and the Division of Personnel.  The Board has determined that it will exert more oversight of the hiring process. 

3. Improve Compliance with Filing Financial Statements: In 2007, the Board adopted new procedures for ensuring Board and MRSC members’ compliance. The Board and the MRSC had 100% compliance for this year.

16.  Adhere to Relicensing Statutes: The Board does act to comply with its statutes.  The Board has articulated that where a request for an exception to its laws and rules is made, the Board will only grant such in conformance with its laws and rules.

25. System Letters: The Board has begun to issue its systems letters to the Bureau of Health Facilities Administration (BHFA) where appropriate, in addition to issuing such letters to the facilities directly whether or not they are regulated by the BHFA.  The Board has determined that its role in promoting public safety justifies continuing to issue “system letters” to facilities that are not regulated by the Department of Health and Human Services where the Board has learned of system failures or errors that jeopardize patient safety.


Observations that Do Not Require Board Action:

4. Clarify Statutory Eligibility Requirements: The Board believes that all members have complied with statutory eligibility requirements.  There is disagreement between the LBA and the Board over the proper interpretation of the applicable statutes.  The LBA’s recommendations regarding this observation were addressed exclusively to the Legislature.  The Board will propose that the legislature modify RSA 329.

5. Improve Adherence to Quorum: This audit finding was in significant part functionally a duplication of the prior observations regarding filing of financial affidavits and terms of office.  The audit report considered members who did not file financial affidavit reports as not counting towards the quorum.  The Board (and its legal counsel) disagree that such members do not count towards the quorum.  The Board will propose that the legislature modify RSA 329.

The Board has implemented a new policy to ensure filing compliance.  The audit report did not question the physical presence of Board or MRSC members.  Nonetheless, the
Board has adopted a policy regarding repeated non-attendance for such members.  The
audit report did question the physical presence of Physician Assistant Advisory Committee (“PAAC”) members; however, the Legislature has repealed the PAAC statute so this entity no longer exists.  The Board has relied in part on administrative rule Med 105.02, which sets the quorum at a smaller number for specific purposes.  The LBA’s observation, in effect, concluded that the Legislative JLCAR committee approval of the rule was in error.  The Board intends to rely on JLCAR’s determination that the rule is permitted by law.  The Board will propose that the legislature modify RSA 329.

7. Improve Management of PAAC: The Legislature has repealed the PAAC statute so this entity no longer exists.

13. Quorum: The Board cannot unilaterally disregard a validly promulgated administrative rule, Med 105.02.  The Board will request legislative affirmation of the authority of the Board to adopt a quorum requirement for the purposes of hearings and receiving information that requires fewer members than a meeting to conduct regular business.  The Board will propose that the legislature modify RSA 329.

20. Anonymous Complaints: The Board has the statutory authority to review anonymous complaints.  Whereas all other complaints are routed through the Board’s investigator to the MRSC for investigation, the Board voted to change the automatic routing for anonymous complaints to first be reviewed by the Board, and, if there is a possibility of a physician’s violation of the Board’s statutes and/or rules, the complaint is routed through the Board’s investigator to the MRSC for investigation.

31. Physician Effectiveness Program Fund Administration: Within the next 6 months, the Board will develop and implement a policy and procedure to govern Fund accounting.

Observations that the Board Is Acting/Will Act Upon:

1.  Broader Control Daily Operations: The Board will be including funding for an Executive Director position or its equivalent. The Board is also in the process of drafting possible statutory language for an ED position as well as drafting a job description for the ED. The Board will be seeking funding for a third party to formulate a plan for “conducting a risk assessment and implementing risk mitigation efforts to control State assets,” as the current measures taken by the Board have been deemed insufficient in the audit report.

6.  Expand Control Over the MRSC: While the Board deems it improper and unlawful to expand control over the MRSC, in the upcoming fiscal year the Board will draft and submit rules better defining the MRSC’s investigatory process.

8. Exercise Independent Board Authority: The Board will promulgate detailed administrative rules for the investigatory process.  The Board is planning implementation of an enhanced records management system to be better able to track the time required to complete each step a complaint goes through.  This will provide data on the timeliness of the APU’s completion of its duties.
The Board’s relationship with its legal counsel, who is an attorney in the Civil Bureau of the Department, is codified in RSA 21-M.  Furthermore, last fiscal year, the Board entered into a Memorandum of Understanding with the Department of Justice to pay for additional legal counsel services that includes Board Counsel attending the entire board meetings and its adjudicative hearings. 

9. Right-to-Know Law: The Board complies with RSA 91-A, the Right-to-Know law.  Additionally, the Board acts to comply not only with the intent but also the spirit of the law.

All matters before the MRSC are exempt from the Right-to-Know law by statute.  The Board will request legislative clarification that the MRSC is exempt from the Right-to-Know law. 

The observations and recommendations concerning the PAAC are moot as the statutes creating this entity have been legislatively repealed and the PAAC no longer exists.

10. Polling Members:  The Board will avoid the necessity of telephone polls regarding procedural decisions by delegating authority to make procedural decisions to a member.  Changes to the Right-to-Know law, effective July 1, 2008, address the participation in meetings via telephone.  The Board will comply with the new requirements of the Right-to-Know law.  The Board will propose that the legislature modify RSA 329.

11. Administrative Rules: Once statutory changes are implemented, the Board will seek changes to its administrative rules: to correct erroneous references, to better conform to state and federal statutory requirements regarding social security numbers and criminal background checks, and to delineate the MRSC’s investigatory process.  As above, the

Board will seek funding for an Executive Director or its equivalent, whose duties will include regularly reviewing the administrative rules to ensure the rules are current and reflect best operating practices.

12. Additional Administrative Rules: In the next legislative session, the Board will seek statutory amendment to delete outdated rule requirements.

14. Administration of License Applications: In the next legislative session, the Board will review whether (1) the statutory timeframe for applicants/licensees to report adverse actions needs to be sooner than the subsequent renewal application; and (2) whether training licenses should be issued on a biennial renewal cycle. Upon completion of such review, the Board will seek legislative changes accordingly. As discussed in number 33, the Board’s new database will help streamline and unify the application processes. As discussed above, the Board will seek funding for an Executive Director or its equivalent, whose duties will include regularly reviewing the current practices of the Board to ensure the application forms reflect the Board’s statutes and rules.

15. Licensing Physicians: To the extent that the Board chooses to make conditional approvals, delegating the ministerial task of confirming completion of an objectively determined condition to its administrative staff, the Board will ensure that its minutes reflect this decision. 

17. Continuing Medical Education Oversight: The legislature has recently delegated the responsibility to verify physicians’ continuing medical education (CME) to the New Hampshire Medical Society (NHMS).  The Board attended a legislative hearing on August 19, 2008 on this subject.

18. Physician Assistant License Renewals (with Termination of Supervision):  The Board will seek changes to its administrative rules to include systematic reporting and review of PAs whose supervision is terminated.

19. Physician License Renewals (with Reportable Misconduct): The Board will seek changes to its administrative rules to include systematic reporting and review of physicians who have engaged in reportable misconduct.  If necessary, the Board will also seek statutory modifications to compel this reporting and review.

21. Clarify and Codify Investigative Process: The Board will seek changes to its administrative rules to delineate the MRSC’s investigatory process.

22. Subpoenas: Since March 2008, the Board has added an agenda item to its regularly scheduled monthly meetings delegating its subpoena authority to the Board’s investigator.  The Board will propose that the legislature modify RSA 329.

23. Timeliness of Complaint Resolution: Within the next biennium the Board will seek funding and OIT assistance in modifying and improving the tracking mechanism to follow complaints, including the lengths of investigations and the lengths of adjudicative proceedings.

24. Discipline Consistency:  The Board has already created categories and subcategories of discipline in its records system to more comprehensively track Board actions.  Within the next biennium the Board will seek funding and OIT assistance in modifying and improving the computerized records management system with the capacity to categorize past Board actions to ensure future consistency.  The Board will seek funding for an Executive Director or its equivalent, whose duties will include regularly updating this database.

26. Closing Cases: As stated in number 23, the Board will modify and improve the tracking mechanism to follow complaints, including verifying the closure of all cases. (Note: The Board has provided a letter to Director Mahoney detailing the error in the report concerning the 21% and proved that this number is less than 2% of the auditors samplings).

27. Revenue Controls: The Board has adopted an interim policy on the regular deposits of incoming funds.  Within the next six months, the Board will review this policy to ensure that it conforms with all applicable statutes and rules.  In the next two months, the Board and its administrator will develop a budget to correspond to the permitted 125%.

28. Procurement Practices: Within the next 9 months, the Board will schedule a meeting with the Department of Administrative Service to create, develop and implement a policy and process to procure expert medical services for difficult cases.

29. Technology: The Board has recently begun, and expects to continue, to work in cooperation with the Office of Information Technology.  We are dependent upon OIT to support our current or future database system.

30. Physician Health Program:  The Board will request legislative changes to RSA 329:13-b, V(b) and RSA 6:12-e in accordance with the auditors recommendations.  The Board will propose that the legislature modify RSA 329.

32. Information Management: As stated in numbers 23 and 24, the Board will seek budgetary authority for funding and support to create a more comprehensive records management system for the board.  That process will prioritize establishing a tracking mechanism to follow complaints and another to track prior board actions to create a reference database to assess consistency in disciplinary actions.

33. Information Technology Management: The Board is heavily dependent on the Office of Information Technology.  In the past, the Board was unable to satisfy our requirements from OIT.  It appears that OIT will be assisting the Board achieve its goals.  The Board will seek to have OIT help the Board comply with this observation as soon as possible.  The Board is dependent upon OIT’s assistance to support our Microsoft Access program.  This assistance is presently not available.  A designated person through OIT to support Microsoft Access would be helpful.

34. Business Continuity and Contingency Plan: The Board will develop a business continuity and contingency plan.  The plan will be developed in accord with the process currently underway being lead by the Department of Safety, Division of Homeland Security and Emergency Management.
Observations that Have Been Acted Upon:

2. Hiring of Family Members: The LBA’s recommendations on this observation are primarily directed to the Legislature and the Division of Personnel.  The Board has determined that it will exert more oversight of the hiring process. 

3. Improve Compliance with Filing Financial Statements: In 2007, the Board adopted new procedures for ensuring Board and MRSC members’ compliance. The Board and the MRSC had 100% compliance for this year.

16.  Adhere to Relicensing Statutes: The Board does act to comply with its statutes.  The Board has articulated that where a request for an exception to its laws and rules is made, the Board will only grant such in conformance with its laws and rules.

25. System Letters: The Board has begun to issue its systems letters to the Bureau of Health Facilities Administration (BHFA) where appropriate, in addition to issuing such letters to the facilities directly whether or not they are regulated by the BHFA.  The Board has determined that its role in promoting public safety justifies continuing to issue “system letters” to facilities that are not regulated by the Department of Health and Human Services where the Board has learned of system failures or errors that jeopardize patient safety.


Observations that Do Not Require Board Action:

4. Clarify Statutory Eligibility Requirements: The Board believes that all members have complied with statutory eligibility requirements.  There is disagreement between the LBA and the Board over the proper interpretation of the applicable statutes.  The LBA’s recommendations regarding this observation were addressed exclusively to the Legislature.  The Board will propose that the legislature modify RSA 329.

5. Improve Adherence to Quorum: This audit finding was in significant part functionally a duplication of the prior observations regarding filing of financial affidavits and terms of office.  The audit report considered members who did not file financial affidavit reports as not counting towards the quorum.  The Board (and its legal counsel) disagree that such members do not count towards the quorum.  The Board will propose that the legislature modify RSA 329.

The Board has implemented a new policy to ensure filing compliance.  The audit report did not question the physical presence of Board or MRSC members.  Nonetheless, the
Board has adopted a policy regarding repeated non-attendance for such members.  The
audit report did question the physical presence of Physician Assistant Advisory Committee (“PAAC”) members; however, the Legislature has repealed the PAAC statute so this entity no longer exists.  The Board has relied in part on administrative rule Med 105.02, which sets the quorum at a smaller number for specific purposes.  The LBA’s observation, in effect, concluded that the Legislative JLCAR committee approval of the rule was in error.  The Board intends to rely on JLCAR’s determination that the rule is permitted by law.  The Board will propose that the legislature modify RSA 329.

7. Improve Management of PAAC: The Legislature has repealed the PAAC statute so this entity no longer exists.

13. Quorum: The Board cannot unilaterally disregard a validly promulgated administrative rule, Med 105.02.  The Board will request legislative affirmation of the authority of the Board to adopt a quorum requirement for the purposes of hearings and receiving information that requires fewer members than a meeting to conduct regular business.  The Board will propose that the legislature modify RSA 329.

20. Anonymous Complaints: The Board has the statutory authority to review anonymous complaints.  Whereas all other complaints are routed through the Board’s investigator to the MRSC for investigation, the Board voted to change the automatic routing for anonymous complaints to first be reviewed by the Board, and, if there is a possibility of a physician’s violation of the Board’s statutes and/or rules, the complaint is routed through the Board’s investigator to the MRSC for investigation.

31. Physician Effectiveness Program Fund Administration: Within the next 6 months, the Board will develop and implement a policy and procedure to govern Fund accounting.

Observations that the Board Is Acting/Will Act Upon:

1.  Broader Control Daily Operations: The Board will be including funding for an Executive Director position or its equivalent. The Board is also in the process of drafting possible statutory language for an ED position as well as drafting a job description for the ED. The Board will be seeking funding for a third party to formulate a plan for “conducting a risk assessment and implementing risk mitigation efforts to control State assets,” as the current measures taken by the Board have been deemed insufficient in the audit report.

6.  Expand Control Over the MRSC: While the Board deems it improper and unlawful to expand control over the MRSC, in the upcoming fiscal year the Board will draft and submit rules better defining the MRSC’s investigatory process.

8. Exercise Independent Board Authority: The Board will promulgate detailed administrative rules for the investigatory process.  The Board is planning implementation of an enhanced records management system to be better able to track the time required to complete each step a complaint goes through.  This will provide data on the timeliness of the APU’s completion of its duties.
The Board’s relationship with its legal counsel, who is an attorney in the Civil Bureau of the Department, is codified in RSA 21-M.  Furthermore, last fiscal year, the Board entered into a Memorandum of Understanding with the Department of Justice to pay for additional legal counsel services that includes Board Counsel attending the entire board meetings and its adjudicative hearings. 

9. Right-to-Know Law: The Board complies with RSA 91-A, the Right-to-Know law.  Additionally, the Board acts to comply not only with the intent but also the spirit of the law.

All matters before the MRSC are exempt from the Right-to-Know law by statute.  The Board will request legislative clarification that the MRSC is exempt from the Right-to-Know law. 

The observations and recommendations concerning the PAAC are moot as the statutes creating this entity have been legislatively repealed and the PAAC no longer exists.

10. Polling Members:  The Board will avoid the necessity of telephone polls regarding procedural decisions by delegating authority to make procedural decisions to a member.  Changes to the Right-to-Know law, effective July 1, 2008, address the participation in meetings via telephone.  The Board will comply with the new requirements of the Right-to-Know law.  The Board will propose that the legislature modify RSA 329.

11. Administrative Rules: Once statutory changes are implemented, the Board will seek changes to its administrative rules: to correct erroneous references, to better conform to state and federal statutory requirements regarding social security numbers and criminal background checks, and to delineate the MRSC’s investigatory process.  As above, the

Board will seek funding for an Executive Director or its equivalent, whose duties will include regularly reviewing the administrative rules to ensure the rules are current and reflect best operating practices.

12. Additional Administrative Rules: In the next legislative session, the Board will seek statutory amendment to delete outdated rule requirements.

14. Administration of License Applications: In the next legislative session, the Board will review whether (1) the statutory timeframe for applicants/licensees to report adverse actions needs to be sooner than the subsequent renewal application; and (2) whether training licenses should be issued on a biennial renewal cycle. Upon completion of such review, the Board will seek legislative changes accordingly. As discussed in number 33, the Board’s new database will help streamline and unify the application processes. As discussed above, the Board will seek funding for an Executive Director or its equivalent, whose duties will include regularly reviewing the current practices of the Board to ensure the application forms reflect the Board’s statutes and rules.

15. Licensing Physicians: To the extent that the Board chooses to make conditional approvals, delegating the ministerial task of confirming completion of an objectively determined condition to its administrative staff, the Board will ensure that its minutes reflect this decision. 

17. Continuing Medical Education Oversight: The legislature has recently delegated the responsibility to verify physicians’ continuing medical education (CME) to the New Hampshire Medical Society (NHMS).  The Board attended a legislative hearing on August 19, 2008 on this subject.

18. Physician Assistant License Renewals (with Termination of Supervision):  The Board will seek changes to its administrative rules to include systematic reporting and review of PAs whose supervision is terminated.

19. Physician License Renewals (with Reportable Misconduct): The Board will seek changes to its administrative rules to include systematic reporting and review of physicians who have engaged in reportable misconduct.  If necessary, the Board will also seek statutory modifications to compel this reporting and review.

21. Clarify and Codify Investigative Process: The Board will seek changes to its administrative rules to delineate the MRSC’s investigatory process.

22. Subpoenas: Since March 2008, the Board has added an agenda item to its regularly scheduled monthly meetings delegating its subpoena authority to the Board’s investigator.  The Board will propose that the legislature modify RSA 329.

23. Timeliness of Complaint Resolution: Within the next biennium the Board will seek funding and OIT assistance in modifying and improving the tracking mechanism to follow complaints, including the lengths of investigations and the lengths of adjudicative proceedings.

24. Discipline Consistency:  The Board has already created categories and subcategories of discipline in its records system to more comprehensively track Board actions.  Within the next biennium the Board will seek funding and OIT assistance in modifying and improving the computerized records management system with the capacity to categorize past Board actions to ensure future consistency.  The Board will seek funding for an Executive Director or its equivalent, whose duties will include regularly updating this database.

26. Closing Cases: As stated in number 23, the Board will modify and improve the tracking mechanism to follow complaints, including verifying the closure of all cases. (Note: The Board has provided a letter to Director Mahoney detailing the error in the report concerning the 21% and proved that this number is less than 2% of the auditors samplings).

27. Revenue Controls: The Board has adopted an interim policy on the regular deposits of incoming funds.  Within the next six months, the Board will review this policy to ensure that it conforms with all applicable statutes and rules.  In the next two months, the Board and its administrator will develop a budget to correspond to the permitted 125%.

28. Procurement Practices: Within the next 9 months, the Board will schedule a meeting with the Department of Administrative Service to create, develop and implement a policy and process to procure expert medical services for difficult cases.

29. Technology: The Board has recently begun, and expects to continue, to work in cooperation with the Office of Information Technology.  We are dependent upon OIT to support our current or future database system.

30. Physician Health Program:  The Board will request legislative changes to RSA 329:13-b, V(b) and RSA 6:12-e in accordance with the auditors recommendations.  The Board will propose that the legislature modify RSA 329.

32. Information Management: As stated in numbers 23 and 24, the Board will seek budgetary authority for funding and support to create a more comprehensive records management system for the board.  That process will prioritize establishing a tracking mechanism to follow complaints and another to track prior board actions to create a reference database to assess consistency in disciplinary actions.

33. Information Technology Management: The Board is heavily dependent on the Office of Information Technology.  In the past, the Board was unable to satisfy our requirements from OIT.  It appears that OIT will be assisting the Board achieve its goals.  The Board will seek to have OIT help the Board comply with this observation as soon as possible.  The Board is dependent upon OIT’s assistance to support our Microsoft Access program.  This assistance is presently not available.  A designated person through OIT to support Microsoft Access would be helpful.

34. Business Continuity and Contingency Plan: The Board will develop a business continuity and contingency plan.  The plan will be developed in accord with the process currently underway being lead by the Department of Safety, Division of Homeland Security and Emergency Management.

 

 

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