AUDITOR GENECZAL
kEnER REPORT
September 20, 1991 Letter Report No. 91- L1
Members of the Arizona Legislature
The Honorable F i f e Symington, Governor A R j Z O N ~ STATE LlDr~ q~ y
ARCHIVES & P i i o i / < ; , ; C ( j l ; ~ ~
Dr. Nicholas J. Soldo, Chairman
Board of Medical Examiners
MPiQ i ? >? lj!
SUBJECT :
Board of Medical Examiners STATE DOCUMENTS
Performance Audit/ Sunset Review
This l e t t e r presents the results o f our review of the Board of Medical
Examiners ( BOMEX). This review was conducted in response to the
requirements of a June 14, 1989, resolution of the Joint Legislative
Oversight Committee. The audit was conducted under the authority vested
in the Auditor General by A. R. S. § § 41- 2351 through 41- 2379.
Because of p rob l ems we encountered i n conduct i ng the aud i t and changes i n
recordkeeping and automation the Board i s currently implementing, the
audit work we were able to perform a t t h i s time was l i m i ted. Therefore,
we are summarizing the results of our work in t h i s l e t t e r .
Backaround
The Board of Medical Examiners, established in 1913, i s responsible for
examining and licensing medical doctors in Arizona and protecting the
public from incompetent and harmful practitioners. The Board consists of
12 members: 9 l icensed physicians, 2 lay members, and a l icensed
professional nurse from the Arizona State Board of Nursing.
The Board i s responsible for regulating more than 10,000 licensees.
During f i s c a l year 1990- 91, the Board issued 562 new l icenses, and
received 856 complaints and malpractice claims. The Board's standard
operating procedures require them to take formal action on every complaint
2700 NURl- H CENTRAL. AVENlJE SlJlTE YOC? PI- iOENEX, ARIZONA 85004 ( 602) 255 4365
they receive . Board act ions can i nc l ude d i sm i ssa I, suspens ion, l i cense
revocation, a decree of censure, a l e t t e r of concern, a stipulation
agreement, probation, or an administrative penalty.
Scope And Methodolouy
The audit was conducted as a Sunset Review as defined by A. R. S.
$ 41- 2352. The purpose of the audit was to determine whether the Board of
Medical Examiners i s needed and the extent to which i t has accomplished
i t s statutory goals.
BOMEX i s the State's largest medical licensing board and has two
principal statutory functions: to ensure applicants for licensure meet
a l l specified requirements and to enforce the standards o f practice. We
reviewed the Board's a c t i v i t i e s i n the area of licensing and found no
s i g n i f i c a n t problems. However, since we were unable to adequately review
the Board's enforcement a c t i v i t i e s ( as noted on pages 3 and 41, which are
central to i t s mission, we could not respond as to whether the Board has
accomplished one of i t s major statutory goals - the enforcement of
medical practice law and standards.
Further, during our preliminary survey, our Office received several
complaints from doctors regarding what was termed as questionable actions
by the Board or i t s Executive Director regarding complaint handling. Our
preliminary review did not uncover any inappropriate actions by the Board
or i t s Executive Director. In addition, some allegations dated back
several years. For example, three complaints we reviewed were more than
f i v e years old. These complaints had already been investigated by BOMEX
and a formal disposition had occurred. While the doctors involved in
these cases were not s a t i s f i e d w i t h the results, they did not provide any
additional, up- to- date information to permit us to pursue these cases.
BOMEX's Reaulatory Responsibilities
BOMEX has two primary responsibilities: licensing and enforcement. We
were able to review the Board's licensing functions, and i t s a c t i v i t i e s
appear adequate. However, because we encountered significant problems in
the enforcement area, we could not complete the necessary audit work.
Licensina a c t i v i t i e s - The Board appears to be performing well in the
licensing area. We reviewed 46 license application f i l e s for the period
March 1990 through June 1991 to determine whether licensing requirements
were being met and documented. A l l 46 applicants met statutory
requirements for licensure and f i l e s contained adequate documentation.
For example, f i l e s contained copies of a l l applicant test scores, records
of medical training c e r t i f i c a t i o n , school education transcripts,
employment history, and personal data. In performing our review, we also
noted that the Board appears to be processing applications for licensure
in a timely manner.
Enforcement function - The Board's manual complaint tracking and f i l i n g
system i s i n such disarray a t t h i s time that the enforcement function
cannot be audited. BOMEX has been aware of the problem for some time and
i s i n the process of implementing a new automated system that is intended
to remedy many of the problems of the manual system.
When we last audited the Board in 1982, a complaint logging system was
being used, and the Board's f i l e s were in good order. This is no longer
the case. According to the Board's Executive Director, personnel changes
and a dramatic increase in the volume of complaints received annually
accounts for poor condition of the f i l i n g system.
We encountered several problems that precluded us from performing an
adequate review of the Board's complaint f i l e s . For example, the Board
does not maintain a comprehensive log for recording incoming complaints
and indicating the date of receipt, nor does i t assign complaints a
unique case number. As a result, i t is impossible to determine how many
complaints are received in a given period for audit sampling purposes.
In our efforts to perform an analysis of the Board's complaint and
enforcement function, we considered alternate sampling methods, but
determined that none of the alternatives provide a means of accounting
for a l l complaints received. Further, compounding this problem, the
Board has no formal written guidelines or procedures for handling
complaints. As a result, i t was d i f f i c u l t to determine how the Board
handled complaints, whether a l l complaints were processed in the same
manner, and whether the Board or i t s staff used standardized methods or
procedures for handling a l l complaints.
In addition, once a complaint is identified, f i l e s are d i f f i c u l t to
locate. Files may be in any one of four separate sets of f i l e cabinets.
Further, the f i l e s in the cabinets do not necessarily contain a l l
information pertaining to a complaint. Adding to the d i f f i c u l t y , many
complaint f i l e s are not in the f i l e cabinets. We identified f i l e drawers
where there were more " outcards" than f i les. Worse yet, i t appears that
outcards are frequently not used at a l l .
To determine whether f i l e s would be accessible for review, we attempted
to locate fourteen complaint f i l e s . Of the fourteen, only five could be
located.
W E X i s automatina i t s com~ laint handlina function - BOMEX is automating
i t s complaint handling function. Due to the increased volume and
complexity sf i t s complaint handling process, BOMEX recognized the need
for system automation in 1989. With the assistance of the Department of
Administration, BOMEX staff identified and purchased a computer and
software system to address i t s automation needs. As a result, some of
the problems we encountered in identifying complaints and locating f i les
w i l l be remedied i f this e f f o r t is successful. For example, the
automated system w i l l provide for the logging and tracking of
complaints. In addition, a major e f f o r t to organize and improve the
manual f i le system w i l l be initiated in the next few months. According
to BOMEX, both the automated system and the new manual f i l e system should
be f u l l y implemented by April 1, 1992.
It is important to note that the new automated system w i l l not be a
panacea for a l l of the Board's current problems, nor w i l l i t f u l l y enable
us to audit the Board's enforcement a c t i v i t i e s . BOMEX has an extensive
backlog of complaint and malpractice investigations, and i t i s our
understanding that only new cases w i l l be entered on the system. Older
cases may s t i l l be quite d i f f i c u l t to locate and track. Ideally, there
w i l l need to be some period of time for complaints to be handled under
the new system before an audit would be feasible. We estimate that at
least one year of complaint processing under the new system would be
needed.
I f delays in the implementation of the automated system are anticipated,
BOMEX w i l l need, at the very least, to i n s t i t u t e a manual logging system
that w i l l assign each incoming complaint a unique case number or
i d e n t i f i e r . A logging and tracking system, whether automated or manual,
is needed to manage and control BOMEX's enforcement function e f f e c t i v e l y .
The Board of Medical Examiners has reviewed t h i s report and their
response i s attached.
My s t a f f and I w i l l be pleased to discuss and c l a r i f y any items in this
report.
This report w i l l be released to the public on September 23, 1991.
was R. Norton
Auditor General
cc: Douglas N. Cerf, Executive Director
Board of Medical Examiners
(; I><\,! if,,,
F~ feS ym~ iipton THE ARIZONA BOARD OF MEDICAL EXAMINERS E u ' l u f i ' ' ' L1i"'( rl"
DousI,~\ N. Cert
C'huii. nluit 2001 West Camelback Road, Suite 300 Phoenix, Arizona 85015 $,. D i ! . c l i i J l+., ,,
N~ cholas J. Soido, M. D.
Telephone ( 602) 255- 3751 L1c C i I \ l ( i <' llt!< I
C'cc. r Ci~ uit. mun A ~ / ~ I I I Z I . \ ~ ~ ~ ~ I I I ~ ~ ~
Barry A. Friedman. M. D. Mark R. Speichi> r
--. Burton N. Druckrr
September 17, 1991
Douglas R. Norton
Office of the Auditor General
State of Arizona
2700 North Central Avenue, Suite 700
Phoenix, Arizona 85004
Re: Board o f Medical E x a m i n e r s
P e r f o r m a n c e A u d i t / S u n s e t R e v i e w
Dear Mr. Norton:
This letter serves as the formal response of the Board of
Medical Examiners to the letter report of the Auditor
General's Office regarding the Performance AuditISunset
Review of the Arizona Board of Medical Examiners.
The letter report indicates that the changes in
recordkeeping and automation that the Board is currently
implementing prevented an audit of the enforcement
activities of the Board. We believe that one additional
factor leading to the inability to accomplish an audit of
the enforcement area ( please see below) is the fact that the
time the auditors spent at the offices of the Board of
Medical Examiners was limited to a period of four weeks
( June 11, 1991 through July 8, 1991), the fact that the
Board held a five day meeting from June 18 through June 22,
1991 in Tucson, Arizona, which required the presence of all
the Board's executive and medical consultant staff, and the
fact that the auditors did not spend their full time on the
days that they were in the office of the Board of Medical
Examiners on the BOMEX audit, as they were concluding the
sunset audit of the Board of Regents which required a great
deal of time.
Under the section " Scope and Methodology,'' it is indicated
that the Office of the Auditor General received " several
complaintsw regarding questionable actions by the Board or
its executive director, from physicians, evidently regarding
whom these actions had been taken. Your report does not
clarify that the Board of Medical Examiners never received a
list of physicians presenting these questions or a list of
cases to which we could respond; we have no idea even to the
number of complaints, as the office of the Auditor General
was previously informed. Additionally, the report indicates
Douglas R. Norton
September 17, 1991
Page - 2-
" some allegations" dated back several years. The Board had
acted on these particular cases already and the doctors were
not satisfied with the results. The Board does not know,
from the " several" complaints from doctors received by the
Auditor General's office, how many allegations dated back
several years, nor how many were made by the same physician.
The Auditor General's office is aware that there is an
individual physician who misrepresented himself as the head
of a group of physicians unhappy with the activities of the
Board. When the Auditor General's staff contacted a
physician named in this group by the complaining physician,
he disallowed any membership in the group. The failure of
the Auditor General's office to provide any specifics
regarding the allegations from wseveral" physicians,
prevents the Board or its staff the opportunity to respond
in any fashion. In fact, one could wonder what purpose is
even served by bringing these matters up if we cannot be
provided the basic facts necessary to address the
complaints.
Under the section " Regulatory Responsibilities1', the Board
would like to specifically address the following points:
You indicate that the filing system is in such poor
condition that it cannot be audited. Our filing system
clearly suffers from an overload of complaint files, and you
have recognized that we began taking the necessary steps in
1989 to correct this problem. Prior to 1989, the Board had
requested in 3 different annual budget requests, funds and
authorization for a records librarian since we process more
patient records than most hospitals in the state. It should
be clarified that none of the files reviewed were found to
have been investigated improperly, or to have been
incomplete.
Additionally, you indicate that the complaint log I1does not
exist". There is a log kept of each and every incoming
complaint before that complaint is acknowledged and
investigated. Copies of the patient complaint summary
sheets were made available to the auditors. Clearly it
would have been possible to count the summary sheets on the
complaints and balanced them with the number of complaints
the Board reports in its annual report each year as having
been received.
Your staff balked at counting the summary sheets as a valid
approach to determine an actual tally of cases to be
Douglas R. Norton
September 17, 1991
Page - 3-
investigated. They advised the Board's staff during a
meeting to discuss the preliminary letter report draft that
folders with each months1 summary sheets had a number
written on the folder which was 3 to 5 cases more than the
actual number of summary sheets. Your staff, therefore,
concluded it could not adequately audit the Board's
investigation process. In reality the difference in these
numbers was a result of cases being set up which were
already malpractice claims being investigated, where the
patient also wrote us a complaint letter because his/ her
attorney withdrew from the case or it was dismissed in
court. ( The patient did not understand that we investigate
a malpractice claim independent of decisions made by the
judicial system or the patient's lawyer to terminate
representation). In addition, summary sheets are routinely
set up on Board- ordered office practice or pharmacy surveys.
After a case has been resolved, these surveys allow the
Board to determine if the physician was in compliance with
the Boardls previous concerns or directives.
The summary sheets on the above two types of cases are
created to make sure nothing is overlooked and then removed
and filed in the current active investigative files. To
leave them in the file of summary sheets would distort the
activities and statistics of the Board while creating double
files on the same cases.
Additionally, as an alternative, the license files of the
physicians are clearly delineated as to which license files
contain references to a complaint file ( e . which
physicians have ever had a complaint filed against them),
and those that do not contain references to complaint files.
Certainly in order to find each open complaint, the
physician files so designated to indicate that a reference
to a complaint file was within, could have been pulled and
reviewed in order to determine whether or not an open
complaint existed, as all the complaint resolutions are also
recorded on this same page in the physicians' license files.
Each and every malpractice claim and complaint received is
tagged in the respective physician's license file.
While there is no written procedure in place, the Board does
investigate each and every complaint and malpractice claim
it receives; additionally, each complaint or malpractice is
investigated in the same way. The case comes in, is
acknowledged, the physician is notified of the case and a
response and records are requested from the physician, the
case is reviewed by a medical consultant to the Board and
Douglas R. Norton
September 17, 1991
Page - 4-
then by a lead Board member, following which the case is
reviewed by the full Board. Certain types of cases go
through other steps which may include investigational
interviews, subpoena of records from physicians or
hospitals, interviews of patient, evaluations of the
physician, etc. and these are all delineated on the summary
sheet of the complaint, and the records for each of these
activities are in the complaint file. While no written
procedure exists for this system, the system was discussed
in detail with the Auditor General's staff and the
procedures do not appear to be too difficult to comprehend.
It is certainly true that some files in the office of the
Board of Medical Examiners are difficult to locate. For
example, files could be in a file cabinet for an upcoming
agenda, with an attorney, with a staff physici, an, or with an
investigator. They could also be with the executive
director or the assistant director or the verification clerk
responding to other states, lawyers, hospitals, HMO's,
insurance companies and citizens. However, it is possible
to find files in our office, and the Board of Medical
Examiners' clerical staff has a great deal of expertise in
locating such files. It was the decision of the staff of
the Auditor General's office not to use the Board's clerical
staff in order to locate the 15 files for which they
identified in their letter report. No doubt if a BOMEX
staff member walked into the Auditor General's office, they
would have difficulty locating some files without a solid
knowledge of the intricacies of the filing system.
Following the Auditor General's verbal comments after the
audit, and in preparation for the conversion of the current
paper filing system to a new, end tab system ( which was
begun in April 1991), the BOMEX staff made a list of every
file inside the BOMEX office. This was done in a period of
approximately three days.
Additionally, it is no doubt true that in some cases someone
takes a file out of the file room without leaving an
outguide. However, if this were true in most cases, the
Auditor General would not have found that " some file drawers
contained more outguides than files."
As the Auditor General indicated, the Board of Medical
Examiners has, since 1989, been attempting to computerize
its physician data base and document management system. The
computerization of the office, included a 4 year phase- in
effort as represented in the Board's annual budget and
appropriation as a " below the linet' expenditure. In fact, a
Douglas R. Norton
September 17, 1991
Page - 5-
request for a Request for Proposals from DOA for a physician
data base and complaint tracking system was made in 1990,
and then again in April of 1991. The Department of
Administration was able to go out to bid on this matter in
June of 1991, and the bid was awarded in July of 1991. The
successful bidder has met with the BOMEX staff and has begun
development of this system.
As outlined above, in April of 1991 we determined funds were
available to convert our current filing system to a new, end
tabbed color- coded filing system on shelves in order to
increase the capacity of our current file room. A request
was made in April of 1991, and the Department of
Administration developed an RFP in July of 1991.
As you can see from the above, our time tables for the
installation of these two systems were severely impacted by
the ability of the Department of Administration to develop
our requests and specifications into a Request for
Proposals.
Obviously, no state agency operates independently from the
Department of Administration including BOMEX, and,
unfortunately, agencies sometimes encounter difficulties
which can hold up important system improvements.
The Board and its staff believe that the new automated
system will allow the state to audit the Board's activities
completely. While only new cases will be entered onto the
document management system from the beginning, each
physician in the data base who has ever had a complaint or
malpractice claim filed against him will be so tagged, and
we will have a list of all previous cases ( by patient name
or complainant name and type), the disposition of those
cases ( if closed), and the date of disposition, kept as
confidential information in the electronic file.
Information which is currently in the paper license file
which corresponds to this electronic information was viewed
by the representatives of the Auditor General's office.
This means that every case received by the Board will be
entered into the computer system.
What will not be entered into the computer system regarding
previous cases will be the detail ( i. e. each document
generated during the investigation) on the cases. However,
the above- referenced information clearly will allow the
Auditor General's office to obtain an appropriate sample of
complaints both open and closed.
Douglas R. Norton
September 17, 1991
Page - 6-
Arizona State Library and ,+ hives
20016615 9
We do, of course, concur with the Auditor General's
indication that if a re- audit is to be done, giving this
agency the chance to operate with our new filing system and
our new computer system in place for one year will clearly
enable us to " get the bugs outn so that we may ensure that
we are able to fully cooperate with the Auditor General's
office during the next audit.
And, finally, no mention was made in your report of an
attempt to audit the Board's rehabilitation program for
physicians with drug or alcohol problems. However, files in
this area were reviewed by individuals of the Auditor
General's off ice. It is the Board's view that these files
are in good order, that they are complete, and that they
demonstrate that the Board has a rehabilitation program
which protects the public and supports physician compliance
with a stringent monitoring program and with participating
physicians maintaining a chemical free lifestyle that has a
proven success rate of over 90%.
The Board and its staff appreciate the opportunity you have
provided us to respond to your draft report. We also wish
to note our recognition of your staff Is efforts in reducing
all the information they gathered to a concise summary. We
hope our suggestions and clarifications will add to the
validity of their report.
Sincerely,
BOARD OF MEDICAL EXAMINERS
STATE OF ARIZONA fl
~ icholas J. ~ dldo, M. D., Chairman
NJS : dls
cc: Douglas N. Cerf, Executive Director
Mark Speicher, Assistant Director, Administration, BOMEX
Arizona State Government Publications
