A performance audit of the Board of Podiatry Examiners

              STATE OF ARlZONA
OFFICE OF THE
AUDITOR GENERAL
A PERFORMANCE AUDIT
OF THE
BOARD OF PODIATRY EXAM1 NERS
DECEMBER 1981
A REPORT TO THE
ARIZONA STATE LEGISLATURE
REPORT 81 - 1 9
DOUGLAS 3. NORTON. CPA
AUDITOR GENERAL '
STATE OF ARIZONA
OFFICE OF THE
AUDITOR GENERAL
December 22, 1981
Members of the Arizona Legislature
The Honorable Bruce Babbitt, Governor
Dr. W i l l i a m Friedman, President
Board of Podiatry Examiners
Transmitted herewith is a report of the Auditor General, A Performance
Audit of the Board of Podiatry Examiners. This report is i n response to a
January 30, 1980, resolution of the Joint Legislative Oversight
Committee. The performance audit was conducted a s a part of the Sunset
review s e t f o r t h i n A. R. S. § $ 41- 2351 through 41- 2379.
The blue pages present a summary of t h e r e p o r t ; a response from the
President, William Friedman, D. P. M., is found on the yellow pages
preceding the appendices.
My s t a f f and I w i l l be pleased to discussqor c l a r i f y items i n t h e r e p o r t .
Respectfully submitted,
~ o u ~ y Ra. s N orton
Auditor General
Staff: Gerald A. Silva
William Thomson
Steve Thacker
Brent L. Nelson
Gloria G. Glover
Enclosure
1 1 1 WEST MONROE SUITE 600 PHOENIX. ARIZONA 85003 ( 602) 255- 4385
OFFICE OF THE AUDITOR GENERAL
A PERFORMANCE AUDIT OF THE
BOARD OF PODIATRY EXAMINERS
A REPORT TO THE
ARIZONA STATE LEGISLATURE
REPORT 81- 19
TABLE OF CONTENTS
INTROEUC TIOB AND BACKGROUXD
SUNSET FACTORS
FINDINGS
FINDING I
The Board of P o d i a t r y Examiners h a s n o t resolved
complaints i n a t i m e l y manner. I n a d d i t i o n , t h e Board
h a s n o t r e c e i v e d medical m a l p r a c t i c e i n f o r m a t i o n ,
as p r e s c r i b e d by s t a t u t e .
CONCLUSION
FINDING I1
Procedures regarding the preparing and
grading of the Board's w r i t t e n examination
need t o be improved.
CONCLUSION
FINDING I11
Board records a r e incomplete, d i s o r g a n i z e d and
not i n compliance with s t a t u t e s .
CONCLUSION
WRITTEN RESP0; JSE TO THE AUDITOR GENERAL REPORT
Page
i
1
5
LIST OF TABLES
TABLE 1
Board workload i n d i c a t o r s f o r f i s c a l years
1977- 78 through 1981- 82
TABLE 2
Board a c t u a l revenues and expenditures f o r f i s c a l years
1977- 78 through 1980- 81 and estimated revenues and
expenditures f o r f i s c a l year 1981- 82
TABLE 3
Regulatory s t r u c t u r e i n s t a t e s which combine the
medical and podiatry boards
TABLE 4
Comparison of current operating c o s t s with
c o s t s under combined boards
TABLE 5
Repeated use of examination questions i n exams
given by the Board from October 1975 t o May 1981
TABLE 6
Board treatment o f q u e s t i o n s missed by four o r
more of the nine a p p l i c a n t s t h a t took the
October 1979 w r i t t e n examination
TABLE 7
Page
2
Documentation i n Board minutes f o r complaints
received and disposed of since January 1, 1978
SUMMARY
I n response t o a January 30, 1980, r e s o l u t i o n of the J o i n t L e g i s l a t i v e
Oversight Committee, the Office of the Auditor General has conducted a
performance a u d i t a s p a r t of the sunset review of the S t a t e Board of
Podiatry Examiners ( ~ o a r d ) , i n accordance with A. R. S. $$ 41- 2351 through
41- 2379.
Arizona law defines podiatry a s the s u b s p e c i a l t y of medicine d e a l i n g w i t h
the "... diagnosis o r medical, s u r g i c a l , " mechanical, manipulative or
e l e c t r i c a l treatment of ailments of the human f o o t and leg ...." " Legw is
defined a s " t h a t p a r t of the lower limb between the knee and the foot."
The Board was f i r s t created a s the Board of Chiropody i n 1941 and was
renamed the Board of Podiatry Examiners i n 1964. Board d u t i e s include
examining a p p l i c a n t s f o r l i c e n s u r e , resolving complaints and promulgating
r u l e s and r e g u l a t i o n s .
Our review showed t h a t the Board has not i n v e s t i g a t e d and resolved
complaints i n a timely manner. The Board took an average of nearly e i g h t
months t o resolve the 19 complaints it received and closed between
January 1, 1978 and October 1, 1981. I n a d d i t i o n , nine complaints still
pending a s of October 1, 1981, had been pending an average of more than 11
months. Limited funding and lack of f u l l - t i m e s t a f f h a s f o r c e d the Board
t o r e l y on its own members, the Attorney General s t a f f o r volunteer
p o d i a t r i s t s f o r any i n v e s t i g a t i v e a c t i o n s needed t o resolve complaints.
In many cases the Board h a s n o t received adequate o r timely responses from
these sources. ( page 9)
* Licensed p o d i a t r i s t s i n Arizona a r e not allowed t o amputate a l e g ,
f o o t or toe o r use other than a l o c a l a n e s t h e t i c .
In addition, insurance companies are not reporting malpractice actions
involving Arizona podiatrists within the time period required by law and
the Board is not fully utilizing such information when it is received. As
a result, the Board's effectiveness in regulating the profession is
hampered. ( page 22)
We found that improvements are needed in the preparation and grading of
the Board's written examination. Specifically, the Board does not
sufficiently revise examination questions. In addition, the Board has
graded examinations in a questionable manner and incorrectly calculated
scores. Further, the Board's decisions regarding grading procedures are
not documented in its minutes. One solution to remedy these deficiencies
would be for the Board to use a nationally prepared written examination in
lieu of the written examination prepared by the Board. Currently 35
states either use the national examination instead of a state- prepared
written examination or accept the national examination in lieu of their
state- prepared written examination. ( page 27)
Finally, our review revealed that Board records have not been maintained
in an adequate manner in that 1) minutes of Board meetings do not record
all legal actions, and 2) complaint and examination files are
disorganized and incomplete. As a result, our ability to evaluate Board
activities as part of the Sunset Review process was impaired. ( page 35)
Consideration should be given to the following recommendations:
1. The Legislature adopt one of the following alternatives:
a. Transfer the responsibility for regulating podiatrists to
the Board of Kedical Examiners and provide for
representation of the podiatry profession by either
1) placing a podiatrist on the Board of Medical Examiners,
or 2) creating a small advisory cornmittee/ board of
podiatrists.
b. Increase funding of the Podiatry Board in order to support
more investigative activities.
2. The L e g i s l a t u r e amend insurance s t a t u t e s t o require i n s u r e r s to
report malpractice claims o r s e t t l e m e n t s t o the appropriate
Arizona regulatory boards and provide a penalty f o r noncompliance.
3. The Department of Insurance monitor compliance with the
malpractice reporting provisions through i t s market conduct
examinations o r other regulatory programs.
4. The Board review malpractice information a s it is reported and
take appropriate i n v e s t i g a t i v e s t e p s t o determine i f d i s c i p l i n a r y
measures a r e warranted.
I n a d d i t i o n , c o n s i d e r a t i o n should be given t o the following a l t e r n a t i v e s :
A l t e r n a t i v e 1
The L e g i s l a t u r e amend A. R. S. $$ 52- 825, subsection C , and 32- 827 t o
require the NBE ( n a t i o n a l examination) and eliminate the S t a t e w r i t t e n
examinat ion.
A l t e r n a t i v e 2
- The Board more frequently r e v i s e examination questions f o r each
examination date.
- The Board define procedures f o r determining when exam questions
a r e u n f a i r and c o n s i s t e n t l y follow these procedures f o r each exam.
- Questions determined t o be u n f a i r should not be used on
subsequent exams.
- The Board base a c a n d i d a t e ' s grade on the number of examination
q u e s t i o n s , e x c l u s i v e o f any questions determined to be u n f a i r .
- The Board e s t a b l i s h procedures t o ensure t h a t a l l examination
questions a r e graded and t h a t grades a r e c a l c u l a t e d c o r r e c t l y .
- The Board adequately document i n its minutes decisions regarding
examination grading methods and questions found to be u n f a i r .
iii
Finally, we recommend t h a t
1. ASBAO and the Attorney General's Office provide guidelines t o the
Board regarding the keeping of adequate meeting minutes.
2. ASBAO adopt and implement formal p o l i c i e s and procedures
governing the management of a l l Board records.
IRTRODUCTION AND BACKGROUND
In response t o a January 30, 1980, r e s o l u t i o n of the J o i n t L e g i s l a t i v e
Oversight Committee, t h e O f f i c e of the Auditor General has conducted a
performance a u d i t a s p a r t of the sunset review of the S t a t e Board of
Podiatry Examiners ( ~ o a r d ) , i n accordance with A. R. S. $ 541- 2351 through
41- 2379.
Arizona law d e f i n e s podiatry a s the s u b s p e c i a l t y of medicine dealing with
the "... diagnosis or medical, s u r g i c a l , * mechanical, manipulative or
e l e c t r i c a l treatment of ailments of the human foot and leg.. . ." " Leg" is
defined a s " t h a t p a r t of the lower limb between the knee and the foot."
The Board was f i r s t created a s the Board of Chiropody i n 1941 and was
renamed the Board of Podiatry Examiners i n 1964. Membership presently
c o n s i s t s of t h r e e licensed p o d i a t r i s t s and two lay members ( added i n 1977)
appointed by the Governor f o r five- year terms.
Board d u t i e s include examining a p p l i c a n t s f o r l i c e n s u r e , resolving
complaints and promulgating r u l e s and regulations. Table 1 gives a
summary of the volume of Board a c t i v i t y f o r the p a s t f o u r years.
* Licensed p o d i a t r i s t s i n the S t a t e of Arizona a r e not allowed t o
amputate a l e g , f o o t , or toe or use other than a l o c a l a n e s t h e t i c .
TABLE 1
BOARD WORKLOAD INDICATORS FOR
FISCAL YEARS 1977- 78 THROUGH 1981- 82"
Licensing:
Licensure
a p p l i c a t i o n s
New l i c e n s e s
issued
Licenses renewed
Complaint Actions:
Complaints
handled
Hearings held
Licenses revoked/
suspended
~ e n s u r e / ~ r o b a t i o n
Consent agreements
The Board d e r i v e s its revenues from examination and l i c e n s e fees. These
fees are $ 150 f o r examination, $ 75 f o r i n i t i a l l i c e n s u r e , and $ 100 f o r
l i c e n s e renewal. A l l monies are paid t o the s t a t e t r e a s u r e r , with 90%
deposited i n a podiatry fund f o r maintenance of the Board and enforcement
of the s t a t u t e s and 10% going to t h e g e n e r a l fund. Revenues and
expenditures f o r f i s c a l years 1976- 77 through 1981- 82 a r e presented i n
Table 2 .
x Sources: Budget requests f o r f i s c a l years 1977- 78 through 1981- 82 and
Board l i c e n s i n g records.
TABLE 2
BOARD ACTUAL REVEEUES AND EXPENDITURES FOR
FISCAL YEARS 1977- 78 THROUGH 1980- 81 AND ESTIYiTED REVENUES AItD EXPENDITURES
FOR FISCAL YEAR 1981- 82"
1381- 82
1977- 78 1978- 79 1979- 80 1980- 81 ( Estimated)
Revenues :
Balance from p r i o r year 3,200 2,600 4,100 2,500 ** 6,200
Ninety percent of r e c e i p t s 7,500 7, SO0 7,300 14,500 15,800 a Total revenues 10,700 10,400 11,400 17,000 22,000
Expenditures:
Personal s e r v i c e s 3,600 2,300 1,300 1,100 1,500
Professional and outside s e r v i c e s 2,100 2,500 6,600 8,000 10,600
Travel :
In S t a t e 1,000 300 500 1,000 1,700
Out of S t a t e 400 300 - - -
Other operating expenditures 1,000 900 800 700 1,100
Total expenditures 8,100 6,300 9,200 10,800 14,900
Balance forward to next year
The Board of Podiatry Examiners has no f u l l - t i m e support s t a f f . A l l
support functions a r e provided by the Department of Administration
through the Arizona S t a t e Boards Administrative Office ( ASBAO). The
ASBAO w a s created i n 1976 t o provide s e c r e t a r i a l , c l e r i c a l and other
general support functions and o f f i c e f a c i l i t i e s to 11 small s t a t e
boards and commissions. The Board of Podiatry Examiners f i r s t
contracted f o r s e r v i c e s from ASBAO i n l a t e 1977.
The Office of the Auditor General expresses its g r a t i t u d e to the
members of the Board of Podiatry Examiners and the s t a f f of the
Arizona S t a t e Boards Administrative Office f o r t h e i r cooperation and
a s s i s t a n c e during the course of our a u d i t .
* Source: Budget requests f o r f i s c a l years 1977- 78 through
1982 - 83.
** Budget documents show a discrepancy of $ 300 between the amount
c a r r i e d forward i n f i s c a l year 1979- 80 and the Balance from
p r i o r year f o r f i s c a l 1980- 81.
SUNSET FACTORS
Nine f a c t o r s a r e considered t o determine, i n p a r t , whether the Board of
Podiatry Examiners should be continued or terminated, i n accordance with
A. R. S. $$ 41- 2351 through 41- 2779.
SUNSET FACTOR: THE OBJECTIVE AND
PURPOSE I N ESTABLISHING THE BOARD
The purpose of the Board is not s t a t e d e x p l i c i t l y i n Arizona law.
According t o a statement provided by a Board member, the primary purpose
or objective of the Board is t o p r o t e c t t h e h e a l t h and well- being of the
public by 1 ) evaluating the p r o f e s s i o n a l competency of p o d i a t r i s t s
seeking t o be licensed i n Arizona, and 2) promoting continued competency
and f i t n e s s by i n v e s t i g a t i n g complaints a g a i n s t p o d i a t r i s t s and taking
d i s c i p l i n a r y measures i f needed.
SUNSET FACTOR: THE DEGREE TO WHICH THE
BOARD HAS BEEN ABLE TO RESPOND TO THE
NEEDS OF THE PUBLIC AND THE EFFICIENCY
WITH WHICH IT HAS OPERATED
The Board has f a i l e d t o resolve complaints i n a timely manner. I n
a d d i t i o n , malpractice a c t i o n s a g a i n s t p o d i a t r i s t s a r e n e i t h e r being
reported t o the Board i n a timely manner by i n s u r e r s nor f u l l y u t i l i z e d by
the Board when reported. ( page 9)
The Board has always operated under a r e l a t i v e l y small budget. Estimated
expenditures f o r f i s c a l year 1981- 82 t o t a l only $ 14,900, the l a r g e s t p a r t
of which is f o r c o n t r a c t u a l support s e r v i c e s from the S t a t e Boards
Administrative Office.
SUNSET FACTOR: THE EXTENT TO WHICH THE
BOARD HAS OPERATED WITHIN THE PUBLIC INTEREST
Complaints f i l e d with the Board generally have not been i n v e s t i g a t e d i n a
timely manner and lengthy delays have occurred before d i s c i p l i n a r y a c t i o n
was taken. I n some cases i t appears the Board's review of complaints was
not thorough enough because it lacked i n v e s t i g a t i v e resources. ( page 9)
I n a d d i t i o n , the Board's l i c e n s i n g examination needs t o be improved by
upgrading t h e q u a l i t y of its contents and by e s t a b l i s h i n g more c o n s i s t e n t
and accurate grading procedures. ( page 27)
SUNSET FACTOR: THE EXTENT TO WHICH RULES
AND REGULATIONS PROMULGATED BY THE BOARD
ARE CONSISTENT WITH LEGISLATIVE MANDATE
Administrative r u l e s and r e g u l a t i o n s promulgated by the Board a r e reviewed
f o r consistency and l e g a l i t y and approved by the Attorney General p r i o r t o
t h e i r implementation.
SUNSET FACTOR: THE EXTENT TO WHICH THE
BOARD HAS ENCOURAGED INPUT FROM THE PUBLIC
BEFORE PROMULGATING ITS RULES AND REGULATIONS
AND THE EXTENT TO WHICH I T HAS INFORMED THE
PUBLIC AS TO ITS ACTIONS AND THEIR EXPECTED
INPACT ON THE PUBLIC
The Board has h e l d p u b l i c hearings on proposed r u l e changes. P u b l i c i n p u t
a t these hearings has been minimal. According t o the Board p r e s i d e n t ,
most proposed r u l e s have not been c o n t r o v e r s i a l . The small s i z e of the
profession ( only about 100 p r a c t i c i n g p o d i a t r i s t s i n ~ r i z o n a ) and low
public awareness of the Board probably accounts f o r the l i m i t e d amount of
p u b l i c i n p u t . Only nine percent of respondents interviewed a s p a r t of a
statewide public opinion survey were aware of the Podiatry Board.
Although the Board meets the l e g a l requirements f o r posting notices of
meetings and hearings, it does not have funds f o r extensive p u b l i c i t y of
r u l e s hearings.
The Board n o t i f i e s i n d i v i d u a l complainants before holding hearings or
taking d i s c i p l i n a r y a c t i o n .
Minutes of Board meetings and t r a n s c r i p t s of formal hearings a r e a v a i l a b l e
f o r public i n s p e c t i o n a t the Board o f f i c e .
SUNSET FACTOR: THE EXTENT TO hqICH THE BOARD
HAS BEEN ABLE TO INVESTIGATE AItD RESOLVE
COMPLAINTS THAT ARE WITHIN ITS JURISDICTION
The Board receives a limited number of complaints. During the period
January 1, 1978, to July 1, 1981, the Board received 35 complaints. A s of
October 1, 1981, 19 complaints had been resolved, nine were s t i l l pending,
and seven had been r e f e r r e d t o the Arizona Podiatry Association.
The Board does not have adequate s t a f f or funds f o r i n v e s t i g a t i v e
a c t i v i t i e s . A s a r e s u l t , complaints generally are not resolved i n a
timely manner and i n some cases a r e not thoroughly i n v e s t i g a t e d . ( page 9)
SUNSET FACTOR: THE EXTENT TO WHICH THE
ATTORNEY GENERAL OR ANY OTHER APPLICABLE
AGENCY OF STATE GOVERNMENT HAS THE AUTHORITY
TO PROSECUTE ACTIONS UNDER ENABLING LEGISLATION
The podiatry s t a t u t e s do not s p e c i f i c a l l y address t h e s u b j e c t of a u t h o r i t y
to prosecute criminal a c t i o n s under the enabling l e g i s l a t i o n . In the
absence of such a statement of a u t h o r i t y , the County Attorney normally has
a u t h o r i t y to prosecute such a c t i o n s .
SUNSET FACTOR: THE EXTENT TO WHICH THE
BOARD HAS ADDRESSED DEFICIENCIES I N ITS
ENABLING STATUTES WHICH PREVENT IT FROM
FULFILLING ITS STATUTORY MANDATE
The Board has not i n i t i a t e d or openly supported l e g i s l a t i v e proposals i n
r e c e n t y e a r s . According t o the Board p r e s i d e n t , t h e Board was under the
impression t h a t such was not an appropriate r o l e f o r the Board.
Individual Board members have been involved, however, as members of the
p o d i a t r y p r o f e s s i o n i n supporting l e g i s l a t i v e changes. No changes were
made i n the podiatry s t a t u t e s i n the 1981 l e g i s l a t i v e session. During the
1978, 1979 and 1980 sessions l e g i s l a t i o n passed covering the following
topics:
- p e n a l t i e s f o r unlicensed p r a c t i t i o n e r s ,
- provisional l i c e n s e s ,
- misleading advertising,
- failure to renew licenses, and
- increases in license fees.
SUNSET FACTOR: THE EXTENT TO WHICH CHANGES
ARE NECESSARY IN THE LAWS OF THE BOARD TO
ADEQUATELY COMPLY WITH THE FACTORS LISTED
IN THIS SUBSECTION
The Legislature should consider combining the regulation of podiatrists
and medical doctors under a single board. a age 21)
In addition, insurance statutes should be amended to require insurers to
report malpractice claims or settlements to the appropriate regulatory
boards, and provide a penalty for noncompliance. ( page 22)
Finally, the Legislature should consider amending A. R. S. $$ 32- 825,
subsection C, and 32- 827 to require the National Board Examination and
eliminate the State- written examination. ( page 31)
FINDING I
THE EOARD OF PODIATRY EXAMINERS HAS NOT RESOLVED COlPLAIWTS Ih' A TIMELY
PZANNER. I N ADDITION, THE BOARD HAS NOT RECEIVED MEDICAL MALPRACTICE
- --
INFORFXTION , AS PRESCRIBED BY STATUTE.
The Board's handling of complaints is characterized by lengthy delays.
The Board took an average of nearly eight months to resolve the 19
compleints it received and closed between January 1, 1978, and October 1,
1981. In addition, nine complaints s t i l l pending as of October 1, 1981,
had been pending an average of more than eleven months.
The Board's lack of responsiveness i n resolving complaints is due to
1. Untimely i n v e s t i g a t i v e and legal services from the Attorney
General's Office;
2. The use of p o d i a t r i s t s as volunteer investigators; and
3. The f a i l u r e of the Board to i n i t i a t e i n v e s t i g a t i o n s and follow up
i n a timely manner.
In a d d i t i o n , t h e Board has not received a l l medical malpractice
infomation as prescribed i n the s t a t u t e s o r u t i l i z e d f u l l y such
infomation when it was received.
Excessive Time To Resolve Com~ laints
The Board has not investigated and resolved complaints i n a timely
manner. Since January 1, 1978, the Board has received 35 complaints
against p o d i a t r i s t s . Of these 35 complaints, seven were referred to the
Arizona Podiatry Association because they were fee disputes and thus
deemed to be o u t s i d e t h e Board's j u r i s d i c t i o n ; and as of October 1, 1981,
19 had been resolved and nine were still pending. The 19 closed
compleints were resolved i n an average of nearly eight months, including
one conplaint which remained unresolved f o r 577 days. The nine complaints
still open as of October 1, 1981, had been pending an average of more than
eleven months, including four which had been pending 15 months or longer.
By way of c o n t r a s t , the S t a t e of Arizona, Board of Medical Examiners
( BOMEX) resolves complaints i n an average of l e s s than four months.
No Staff and Limited Budget
The Board r e l i e s on the Arizona S t a t e Boards Administrative Office ( ASBAO)
f o r c l e r i c a l / s e c r e t a r i a l support services, including receiving complaints
from the public, typing Board minutes, processing license applications,
and maintaining Board f i l e s . However, no i n v e s t i g a t i v e services are
provided by the ASBAO under its present contract with the Board. The
Board has no s t a f f of its own to conduct i n v e s t i g a t i o n s and very l i t t l e
funding to acquire such services. For example, only $ 800 was budgeted to
cover i n v e s t i g a t i o n costs i n f i s c a l year 1981- 82 and only $ 300 was
budgeted f o r such purposes i n each of the f i s c a l years 1979- 80 and
1980- 81. Therefore, the Board must rely on the Attorney General's Office,
p o d i a t r i s t s who are willing to serve without compensation, or Board
members to provide i n v e s t i g a t i v e services.
Untimely Assistance From
Attorney General's Office
The Board has requested assistance from the Attorney General i n two stages
of the complaint process: 1) investigation, and 2) preparation f o r
formal hearing. Our review of complaint- related information i n Board
minutes and f i l e s revealed t h a t the Board has not received timely
assistance i n e i t h e r area as the following cases i l l u s t r a t e .
CASE I
Nature of complaint: excessive f e e s ; l a c k of informed consent.
- Date
April 12, 1979 Complaint received i n Board o f f i c e .
May 4, 1979 Discussed i n Board meeting. Board member appointed
t o investigate.
May 17, 1979 Board member met with complainant.
June 20, 1979 Board heard o r a l report of Board member's
interview. Both p a r t i e s t o be invited t o a Board
meeting and doctor's records t o be obtained and
reviewed.
Date ~ c t i o n / ~ o m m e n t
June 25, 1979
September 20, 1979
September 25, 1979
October 5, 1979
November 14, 1979
January 30, 1980
March 26, 1980
May 9, 1980
October 3, 1980
November 19, 1980
Written r e p o r t of Board member's interview received
by Board.
Board l e t t e r t o complainant requesting her
attendance at next meeting.
L e t t e r t o Board from complainant explaining t h a t she
cannot a t t e n d due t o lack of t r a n s p o r t a t i o n .
Discussed i n Board meeting. Attorney General
r e p r e s e n t a t i v e t o interview complainant and then
report t o the Board.
Discussed i n Board meeting. Attorney General
r e p r e s e n t a t i v e had not yet met with complainant due
t o p r i o r i t y of other matters.
Discussed i n Board meeting. No report yet from
Attorney General r e p r e s e n t a t i v e ; Board President t o
c o n t a c t r e p r e s e n t a t i v e about s t a t u s of matter.
Discussed i n Board meeting. Attorney General
r e p r e s e n t a t i v e had not yet met with complainant;
intends t o have interview i n near f u t u r e .
Discussed i n Board meeting. Change i n Attorney
General r e p r e s e n t a t i v e s i n c e l a s t meeting. Attorney
General i n v e s t i g a t o r t o bring complainant i n t o
Attorney G e n e r a l ' s O f f i c e f o r interview.
Discussed i n Board meeting. Board concerned t h a t
complaint is over 15 months old. Another change i n
Attorney General r e p r e s e n t a t i v e s i n c e l a s t meeting.
New r e p r e s e n t a t i v e asked t o meet with complainant
and r e p o r t t o Board. ( ~ t t o r n e ~ General
r e p r e s e n t a t i v e interviewed complainant sometime
between October 3 and November 19, 1980.)
Discussed i n Board meeting. Board dismissed
complaint on grounds t h a t no v i o l a t i o n of s t a t u t e s
had occurred.
Comment: A t its October 25, 1979, meeting the Board requested its
Attorney General r e p r e s e n t a t i v e t o interview the complainant.
Approximately - one - year- l a t e r , some time between October 3 and November 19,
1980, t h i s assignment was completed. During the i n t e r i m t h e Board's
Attorney General r e p r e s e n t a t i v e was changed twice. Total time t o resolve
complaint was nearly 19 months.
CASE I1
Nature of complaint: Unlicensed p r a c t i t i o n e r ; misleading advertising.
Date
November 30, 1979
January 30, 1980
March 26, 1980
October 3, 1980
November 19, 1980
January 21, 1981
March 18, 1981
May 13, 1981
June 5, 1981
h he Board did not
Complaint received i n Board office.
Discussed i n Board meeting. Attorney General
r e p r e s e n t a t i v e d i r e c t e d to investigate.
Discussed i n Board meeting. Attorney General
representative reported t h a t i n v e s t i g a t i o n had not
begun, but would be conducted i n near f u t u r e .
Discussed i n Board meeting. Change i n Attorney
General representative since l a s t meeting; new
representative t o investigate and report a t next
meeting .
Discussed i n Board meeting. Another change i n
Attorney General r e p r e s e n t a t i v e s i n c e l a s t meeting.
Investigation had begun, but had not yet located a
witness.
Discussed i n Board Meeting. Attorney General
i n v e s t i g a t i v e report reviewed, but not adequate.
P o d i a t r i s t to be appointed to investigate.
Discussed i n Board meeting. Additional information
still needed. Board agreed to ask a p a r t i c u l a r
p o d i a t r i s t t o investigate. ever appointed,
according t o Board President. )
Board meeting held; no mention of complaint i n
minutes.
Discussed i n Board meeting. Discrepancies noted i n
Attorney General i n v e s t i g a t i v e report; a Board
member w i l l seek c l a r i f i c a t i o n from Attorney General
investigator.
Discussed i n Board meeting. Matter still awaiting
f u r t h e r investigation; no additional information
a v a i l a b l e y e t .
meet between June and November 1981.)
Comment: A t its January 30, 1980, meeting the Board directed its Attorney
General representative t o investigate the matter. A s t a f f i n v e s t i g a t o r i n
the Attorney General's Office was assigned the i n v e s t i g a t i o n some time
between January 30 and October 3, 1980. The Board received the report and
reviewed it a t its November 19, 1980, meeting, however, the Board
determined t h a t the report was incomplete and agreed to appoint a
p o d i a t r i s t t o i n v e s t i g a t e f u r t h e r . A s of October 1, 1981, or 22 months
a f t e r the Board received the complaint, it was still pending.
The above cases, as well as others reviewed, indicate that complaints
turned over to the Attorney General staff for investigation have not
received prompt response.
In addition, lengthy delays have also been experienced when the Board
votes to hold a hearing and turns complaint- related documents over to its
Attorney General representative in order to prepare for the hearing as the
following case illustrates.
CASE 111
Nature of complaint: Unnecessary surgery; inadequate care.
Date
July 7, 1978
August 8, 1978
August 30, 1978
September 1, 1978
October 6, 1978
October 17, 1978
November 30, 1978
January 31, 1979
May 4, 1979
May 16, 1979
May 21, 1979
May 23, 1979
June 20, 1979
Complaint received in Board office.
Board letter to complainant requesting additional
information before Board can proceed.
Board meeting held; no mention of complaint in
minutes.
Second letter from complainant received in Board
off ice.
Discussed in Board meeting. Board decided to
appoint a particular podiatrist to investigate.
Board letter to podiatrist requesting him to
investigate.
Investigative report received by Board.
Discussed in Board meeting. Investigator to be
asked to submit his final recommendations before
next meeting, and both parties to be invited to next
meeting for an informal review of complaint.
Discussed in Board meeting. Parties had not been
invited to meeting because of recommendation by
Attorney General representative that two Board
members meet with the parties and make
recommendations to entire Board. The Board votes to
suspend further interviews and hold a formal hearing.
All complaint- related documents were turned over to
the Attorney General representative to prepare for
the hearing.
Board notified parties that a formal hearing would
be held.
Board sent letter to Attorney General representative
reminding him to follow up on this complaint and
other matters.
Discussed in Board meeting. No response received
from Attorney General representative.
- Date
October 5, 1979 Discussed i n Board meeting. Attorney General
r e p r e s e n t a t i v e reported t h a t he is reviewing
documents but needs t o contact p o d i a t r i s t who did
o r i g i n a l i n v e s t i g a t i o n . Board expressed concern
over length of time f o r resolving t h i s complaint.
Attorney General r e p r e s e n t a t i v e responded t h a t he
would give t h i s case p r i o r i t y .
November 14, 1979 Discussed i n Board meeting. Formal hearing to be
held December 19, 1979.
December 1979 I- Iearing postponed. No i n d i c a t i o n i n Board records
a s t o reason f o r postponement.
January 30, 1980 Formal hearing held. Complaint dismissed; Board
determined t h e r e was no v i o l a t i o n of s t a t u t e s .
Comment: A t its May 4, 1979, meeting the Board voted t o hold a formal
hearing. A l l complaint- related documents were turned over t o the Attorney
General r e p r e s e n t a t i v e on May 16, 1979, i n order t o prepare f o r the
hearing. On May 21, 1979, the Board n o t i f i e d both p a r t i e s t h a t a formal
hearing would be held. However, s i x months passed before a hearing date
was s e t . Total time t o resolve complaint was 17 months.
According t o the Board's c u r r e n t Attorney General r e p r e s e n t a t i v e , the
observed delays i n Attorney General response t o Board requests f o r
a s s i s t a n c e were due t o an overwhelming workload and competing p r i o r i t i e s
f o r Attorney General r e p r e s e n t a t i v e s , who oftentimes represent more than
one board.
Use of P o d i a t r i s t s A s
Volunteer I n v e s t i g a t o r s
The Board has most often r e l i e d on p o d i a t r i s t s f o r i n v e s t i g a t i v e
s e r v i c e s . These p o d i a t r i s t s a r e reimbursed f o r d i r e c t out- of- pocket
expenses but a r e not compensated f o r t h e i r time. We found t h a t , i n
general, t h i s is not an e f f e c t i v e means of obtaining i n v e s t i g a t i v e
s e r v i c e s because
1. Some complaints r e q u i r e a s u b s t a n t i a l number of hours t o
i n v e s t i g a t e f o r which the p o d i a t r i s t receives no compensation;
2. Some investigations are not completed i n a timely or adequate
manner; and
3. Volunteer p o d i a t r i s t s a r e not trained a s t o how to investigate
complaints.
In the l a s t t h r e e y e a r s the Board has called upon a t l e a s t seven
p o d i a t r i s t s , exclusive of Board members, t o conduct investigations.
Interviews with f i v e of these p o d i a t r i s t s revealed t h a t two took an
average of 15- 20 hours t o conduct each i n v e s t i g a t i o n , whereas the other
three devoted only one or two hours to each investigation. A p o d i a t r i s t
who spent about 45 hours i n v e s t i g a t i n g three complaints said t h a t he
thought he would be paid f o r h i s time but learned l a t e r t h a t he would
not. This p o d i a t r i s t , as well as two others we interviewed, expressed a
reluctance t o do additional investigations f o r the Board without
compensation.
Because volunteer i n v e s t i g a t o r s can conduct i n v e s t i g a t i c n s only as time
and t h e i r schedules allow, i n v e s t i g a t i o n s a r e not always done i n a timely
or adequate manner. For example, the Board requested a p o d i a t r i s t t o
conduct an i n v e s t i g a t i o n to determine i f a person was practicing podiatry
without a license. According to the investigating p o d i a t r i s t , he spent
only one hour on the case, however, Board records show that the Board
waited three months t o receive h i s one- page report. Furthermore, when the
Board received the report it was incomplete and i n s u f f i c i e n t f o r Board
purposes. Although t h e r e p o r t included a recommendation "... that the
Board pursue its i n v e s t i g a t i o n of t h i s individual ...," the Board requested
t h a t the i n v e s t i g a t o r provide more information but none was provided.
Finally, the Board dropped the matter, f r u s t r a t e d over the lack of
i n v e s t i g a t i v e resources t o pursue it to a conclusion.
A s shown above, the time devoted to investigations by p o d i a t r i s t s and the
r e s u l t a n t q u a l i t y of those investigations varied g r e a t l y from p o d i a t r i s t
to p o d i a t r i s t . This appears to be p a r t l y a function of the f a c t t h a t
these volunteer i n v e s t i g a t o r s a r e not l i k e l y t o be trained i n
i n v e s t i g a t i v e procedures.
Board Has Failed to Initiate
Investigations or Follow up
In a Timely Manner
Our review of complaint- related documents and Board meeting minutes also
revealed that in some cases the Board has not initiated the investigative
process in a timely manner or promptly followed up on information
obtained. These delays in the complaint process can be attributed to one
or more of the following factors:
- extended periods between Board meetings, sometimes as long as five
months ;
- no full- time staff to investigate or be responsible for
information- gathering activities between meetings;
- lack of funds for immediate investigations, extra Board meetings,
or additional hearings; and
- Board officers allowing meetings to pass without placing complaints
on the agenda.
The following two cases illustrate several of these factors.
CASE IV
Nature of complaint: Unnecessary surgery recommended by two podiatrists
suspected of collusion.
- Date Action/ Comment
October 24, 1978
November 29, 1978
January 31, 1979
February 21, 1979
April 10, 1979
May 4, 1979
June 20, 1979
October 5, 1979
Complaint received in Board office.
Board meeting held; complaint not discussed because
Board officers failed to add it to meeting agenda.
Discussed in Board meeting. Podiatrist to be
appointed to investigate.
Letter sent to podiatrist requesting an
investigation.
Investigative report received in Board Office.
Investigative report reviewed in Board meeting. All
parties to be invited to next meeting to resolve
informally.
Discussed in Board meeting; parties appeared.
Complaint tabled to later meeting due to
"... uncertainty of budgetary availability to pursue
[ complaint] at this time."
Board meeting held; no mention of complaint in
minutes.
Date ~ c t i o n / ~ o m m e n t
November 14, 1979 Discussed i n Board meeting. Conplaint dismissed
"... on the b a s i s t h a t t h e r e was not s u f f i c i e n t
evidence t o support b e l i e f of probable v i o l a t i o n of
the podiatry s t a t u t e s . "
Comment: Three months passed from the date the complaint was received
u n t i l it was discussed i n a Board meeting and t h e i n v e s t i g a t i v e process
was i n i t i a t e d . A f t e r t h e i n v e s t i g a t i v e report was reviewed and the
p a r t i e s appeared a t a Board meeting ( ~ u n e2 0, 1979), the Board tabled the
matter due t o budgetary c o n s t r a i n t s . According t o the Board P r e s i d e n t ,
Board funds were c r i t i c a l l y low and did not permit a d d i t i o n a l meetings,
hearings, or i n v e s t i g a t i o n s . A s a r e s u l t , t h i s complaint a s well a s
several o t h e r s were tabled t o a l a t e r time. Note, however, t h a t no
a d d i t i o n a l information w a s gathered a f t e r the June 20, 1979, meeting
regarding t h i s complaint and yet f i v e months l a t e r the Board disposed of
it.
CASE V
Nature of complaint: P o d i a t r i s t not w i l l i n g t o r e l e a s e X- rays f o r a
second opinion; insurance/ fee dispute.
Date Action/ Cornment
March 18, 1981
May 13, 1981
June 5, 1981
August 10, 1981
January 19, 1981 Complaint received i n Board o f f i c e .
February 17, 1981 L e t t e r s e n t t o complainant by Board President
explaining t h a t Board does not have j u r i s d i c t i o n
over t h i s complaint, but he w i l l r e f e r it t o the
p r o f e s s i o n a l a s s o c i a t i o n and the Board w i l l formally
consider j u r i s d i c t i o n a t the next regular Board
meeting.
Board meeting held; complaint n o t d i s c u s s e d because
Board o f f i c e r s f a i l e d t o add it t o meeting agenda.
Discussed a t Board meeting. Both p a r t i e s t o be
i n v i t e d t o a t t e n d next Board meeting f o r an informal
review of complaint.
Neither party could attend Board meeting, so matter
deferred u n t i l next regular Board meeting.
Board received l e t t e r from p o d i a t r i s t explaining h i s
point of view.
Comment: This complaint i n i t i a l l y appeared to be outside the Board's
jurisdiction. However, when the Board f i n a l l y reviewed the complaint some
four months l a t e r , it decided t h a t the complaint merited investigation.
Without s t a f f to contact the p a r t i e s and gather information, the Board
requested t h e i r appearance a t a l a t e r meeting; however, neither party
could attend. Therefore, a s of October 1, 1981 - eight months a f t e r
receipt of the complaint - the Board had received only minimal information
on which to base a decision to pursue or dismiss the complaint.
Case I1 on page 12 also i l l u s t r a t e s Board delays i n following up on
information received. In t h a t case the Board agreed on November 19, 1980,
t o appoint a p o d i a t r i s t t o g a t h e r a d d i t i o n a l information. However, as of
October 14, 1981, 11 months l a t e r , the Board had not appointed a
p o d i a t r i s t . A s a r e s u l t , as of October 1, 1981 - 22 months a f t e r receipt
of the complaint - the matter was still pending. The Board President told
us t h a t a d d i t i o n a l i n v e s t i g a t i v e resources were not devoted t o t h i s
complaint because it was not a high- priority item.
BOMEX Better Equipped
To Resolve Complaints
The Board of Medical Examiners ( BOMEX) disposes of complaints i n an
average time of l e s s than four months per complaint - l e s s than half the
average time taken by the Podiatry Board. BOMEX receives approximately
300 complaints p e r y e a r , p l u s an additional 200- 300 malpractice action
reports from insurance companies; the l a t t e r a r e a l s o investigated i n a
manner similar to complaints. BOMEX is able to resolve so many complaints
i n a timely manner because it has a support s t a f f of 23.5 FTEs ( 1981- 82
f i s c a l year), including f o u r f u l l - t i m e i n v e s t i g a t o r s and three half- time
s t a f f physicians for i n v e s t i g a t i v e a c t i v i t i e s .
When a complaint is received in the BOIEX office, the staff a. ? ciate
director immediately reviews it and determines what investigstlve steps,
if any, should be taken before the Board reviews the complaint. Bornally,
within a week of its receipt a complaint is assigned to a full- time
investigator and/ or physician consultant. Staff investigators interview
witnesses, conduct pharmacy surveys and personally serve subpoenas and
other legal papers required throughout the investigative and heoring
stages. Part- time physician consultants are readily available for
evaluating the appropriateness and quality of medical procedures when such
are issues in complaints. An Attorney General representative located in
the BOMEX office expedites the preparation of subpoenas and other legal
papers. Upon completion of staff investigative activities, a
comprehensive report - complete with recommendations - is prepared and
given to a designated member of the Board. This Board member reviews the
case, conducts an " investigational interview" with the doctor, if needed,
and presents the case along with his recommendation to the full Board.
Nearly all complaints are reviewed by the Board as a whole only once, at
the point of final disposition.
Medical and Podiatrv Boards
Combined In 13 Other States
During our audit we identified at least 13 states which have only one
board to license and regulate both medical doctors and podiatrists.
Oregon was the most recent of these states to adopt such a structure,
making the change in July 1981. We surveyed each of these 13 states to
determine the nature and duties of the board. The results are shown in
Table 3. We also contacted a representative of the podiatry association
in most of these states to learn of the associations' opinions regarding a
combined board. Their comments are also included in Table 3.
Tliiiii< 5
Hh'CULATOI! Y STi! UCTUHE I N SrI'ATh'S WIICH COKbINg TI! E MELICAL AlID PODIATRY BOl? l! DS
Membership of D u t i e s o f
1, icen: sc~ i By
:;,,, to !? o? rrl*
! ! . v., k:< PI , ijf'?,, CO
: e l i f o r n i a Tuolve r e l a t e d
t i e l l ti. p r o f e s s i o n s
( inr: l! ldlng
i n t r i s t s )
: olorrido MU, li'M, DO
Board P o d i a t r y Advisory Board P o d i a t r y Advisory
o r Committc> c Bonrd o r Committee
No advisory board
Number of S t a t e P o d i a t r y P r o s o r Cons Kentioned by Board o r A s s o c i a t i o n Contect: -
1' odlntl'iot: l A : i : ~ r ~ c i u t i uCro~ m ment - P r o s - Conn
12 Asnociation i n a c t i v e
Mcmbcr: shin
5 M U s , 2 p u b l i c
12 MDs, 7 p u b l i c P o d i a t r i s t s and p u b l i c Examinntions and
c o m p l a i n t s ; n c t i o n n
reviewed by r e g u l a r
board
5 DPMs Prepnre exam; a d v i s e
r e e u l n r board upon
r e q u e s t
1,250 Generally s a t i s f i e d More p r e s t i g d f o r
but p r e f e r t o be p o d i a t r i s t s * "
independent
100 Generally s a t i s f i e d ;
s e e s no o t h e r
f e a s i b l e
a l t e r n a t i v e
10 Generally s a t i s f i e d
p r a c t i c i n g but p r e f e r t o be
i n s t a t e independent
11 MDs, 2 p u b l i c Economies of scale**/*** R i v a l r y among professionsC*
7 MDs, 2 p u b l i c P o d i a t r i s t s P r e p a r e exam E f f i c i e n c i e s i n a d m i n i s t e r i n g
examsr**
MDs uncomfort. nble r e g u l a t i n g
podiatrists***
Disagreement over scope of
p r a c t i c e f * *
Board d i s i n t e r e s t e d i n
p o d i a t r i s t s ' needsx*
rn4i.! r1:> Ml), rP: fi, PU, DC, P': 5 MDs, 1 DO,
1 DC
3 m s , 4 DPMS P e e r review of
complaints; a d v i s e
r e g u l a r board
400 S a t i s f i e d Economies of scalex**
More e f f e c t i v e c o n t r o l over
scope of p r a c t i c e
v i o l a t i o n s H *
More e f f e c t i v e c o n t r o l over
scope of p r a c t i c e
violations***
Loui:: i- in? MD. Pi'?.:, !) O 7 MDs 3 DPNs Prepare and a d m i n i s t e r
exam
65 Generally s a t i s f i e d
but p r e f e r t o be
independent
Board n o t s y m p a t h e t i c t o
p o d i a t r i s t s * *
: leu Zeraey RD, DPM, PO, DC, LD 9 MDs, 1 DO, No advisory board
1 LPN, 1 DC,
1 LO,
1 g o v ' t rep
2 p u b l i c
7 MEs, 1 DO, No a d v i s o r y board
1 DPM, 1 p u b l i c
Economics**
601 S a t i s f i e d Economies of scale***
More p r e s t i g e f o r
p o d i a t r i s t s * "
Disagreement over scope of
practicei**
? hio MD, P??, DO, massage
t k e r s y i s t ,
e l ~ c t r o i y s i s
Oregor~ : CC, CO, CP!?, PT,
Energency Kedical
'? ec?. nicinn, nurse
P r q c t i t i o n e r ,
A c c ~ p u n c t u r i s t s
Vermot~ t MD, D'PX, P':
692 S a t i s f i e d More p r e s t i g e f o r
p o d i a t r i s t s * *
Law not enforced a s vigorously a::
p o s s i b l e f *
Lose p r o f e s s i o n a l i d e n t i t y i *
Disagreements with orthopedists*'
6 K D s , 2 C O s , l M D , 3 D P M s ,
1 p u b l i c 1 p u b l i c
P r e p a r e and a d m i n i s t e r 100 No comment ( changes More resources f o r
exam; a d v i s e i n r e g u l a t i o n too complaintsX*
i n v e s t i g a t o r s r e c e n t ) Econonies of scale*"
5 MDs, 1 PA, No a d v i s o r y board
1 DPM, 2 p u b l i c
1 D 1 D No a d v i s o r y board
1 DC, 1 PhD,
1 DO
20 A s s o c i a t i o n i n a c t i v e
60 S a t i s f i e d Hard t o be heard with so many
p r o f e s s i o n s representedX*
Xes:
V i r g i n i a MD, DPZ 11 MDs, 2 DP! Is, No a d v i s o r y board
2 p u b l i c
60 Unable t o c o n t a c t More r e s o u r c e s f o r D i f f e r e n t l i c e n s i n g q u a l i f i c a t i o r :
a s s o c i a t i o n d i s c i p l i n i n g p o d i a t r i s t s , complicate a d m i n i s t r a t i v e
i f neededx** and/ or c l e r i c a l tasksf**
Economies of scale***
263 S a t i s f i e d A s s o c i a t i o n w i t h powerful MD P o d i a t r i s t s want a DPM on r e g u l s r
profession** boardx**
S e l f - s u p p o r t i n g t h r u feesi*
v?. ,. l scc:!.-:;: I K3, CI'P!, P?, PA 7 MDs, 1 DO, 3 DPXs, 1 p u b l i c Advise r e g u l a r board
1 p u b l i c on proposed changes
t o s t a t u t e s and
r u l e s ;
Prepare and
a d m i n i s t e r exam
2 - c d o c t o r s ; I]?:'.- podiatrists; DO- osteopaths; DC- chiropractors;
r:-;, b,: , : : ! , . , j 1 4 . : : :. i,-! nSor-.'. nr: i 4 i r e c t o r s ; PA- phynicinn's a s s i s t a n t s ;
~ h . I ~ - ? l : l : : - ~ , pl ;, :: r ! . > c ! : : i .
.*"* h a s o c i , : + i , ~ n !'".,*,!
A s shown by Table 3 , a v a r i e t y of regulatory s t r u c t u r e s e x i s t s amon& the
13 s t a t e s with combined boards. Most of the combined boards l i c e n s e other
p r a c t i t i o n e r s i n a d d i t i o n t o medical doctors and p o d i a t r i s t s . The two
most common means of giving r e p r e s e n t a t i o n to t h e p o d i a t r i s t s a r e
1) placing one or more p o d i a t r i s t s on the f u l l board, or 2) c r e a t i n g an
advisory board of p o d i a t r i s t s . The most frequently mentioned duty of an
advisory board is t o prepare and administer t h e l i c e n s i n g examination.
The podiatry a s s o c i a t i o n s contacted a r e generally s a t i s f i e d with the
combined regulatory s t r u c t u r e s . The most frequently mentioned advantages
of t h i s arrangement a r e 1) g r e a t e r e f f i c i e n c y or economy of s c a l e , and
2) increased p r e s t i g e f o r the podiatry profession
BOMEX Could Absorb the Board of
Podiatry Examiners With Only
S l i ~ h t l vG r e a t e r O v e r a l l Costs
It is our opinion t h a t the two boards could be combined with only s l i g h t l y
higher o v e r a l l c o s t s . The main b e n e f i t of such a c o n s o l i d a t i o n would be a
dramatic improvement i n the t i m e l i n e s s and thoroughness of complaint
r e s o l u t i o n .
BOMEX executive d i r e c t o r estimated t h a t h i s s t a f f could absorb the
Podiatry Board workload with the a d d i t i o n of one s e c r e t a r i a l p o s i t i o n plus
funds t o pay f o r occasional consulting s e r v i c e s from a p o d i a t r i s t at the
r a t e of approximately $ 150 per r e p o r t . This estimate is based on the
following assumptions:
- Podiatry l i c e n s e s would be renewed on the same cycle a s M. D.
l i c e n s e s .
- The same f e e s t r u c t u r e would be used f o r Podiatry and M. D.
licenses.*
- A n a t i o n a l l y administered examination would be used a s the
w r i t t e n l i c e n s i n g examination f o r p o d i a t r i s t s .
" Current BOPEX f e e s : $ 200 f o r examination and l i c e n s u r e ; $ 70 f o r
l i c e n s e renewal. Current Board of Podiatry Examiner's fees: $ 225 f o r
examination and l i c e n s u r e ; $ 10 f o r l i c e n s e renewal.
Table 4 presents a comparison of estimated c o s t s f o r r e g u l a t i n g
p o d i a t r i s t s under two possible arrangements: 1) e x i s t i n & s t r u c t u r e , and
2) combining BOKEX with an advisory board of p o d i a t r i s t s t o administer
~ r a l / ~ r a c t i c aexl a minations.
TABLE 4
COKPARISON OF CURRENT OPERATING COSTS
WITH COSTS UNDER COKBINED EOARDS
Cost Category
Personal s e r v i c e s
Existing S t r u c t u r e Additional BOMEX
Estimated Expenditures Operating Costs I f
For F i s c a l Year 1981- 82 Boards Are Combined*
Employee- related expenditures 0 2,700
P r o f e s s i o n a l and outside
s e r v i c e s
Travel ( i n s t a t e ) 1,700 5 00
Other operating expenditures 1,100 1,300
Total $ 14.900 $ 17,700 *"*
A s shown above, the c o s t s of operating a s e p a r a t e p o d i a t r y board and a
combined board a r e comparable.
Medical Malpractice
Information Not R e ~ o r t e d or U t i l i z e d
Insurance companies have not c o n s i s t e n t l y reported malpractice information
t o the Board, as required by s t a t e law. In a d d i t i o n , t h a t information
which has been reported has not been f u l l y u t i l i z e d by the Board i n its
r e g u l a t i o n of the profession.
* Explanation of cost e s t i m a t e s : Personal s e r v i c e s - $ 11,600 f o r a
Secretary 11 p o s i t i o n , grade 9, s t e p 3 ; $ 500 per diem f o r advisory
board members to administer exams. P r o f e s s i o n a l and outside s e r v i c e s
- $ 1,500 f o r t e n limited i n v e s t i g a t i v e r e p o r t s from consulting
p o d i a t r i s t s , a t $ 150 p e r r e p o r t . Travel ( i n S t a t e ) - $ 500 f o r t r a v e l
by advisory board members.
** $ 10,600 includes $ 9,000 f o r ASBAO s e r v i c e s .
**" An a d d i t i o n a l $ 1,300 may be needed during the f i r s t year to acquire
equipment f o r t h e S e c r e t a r y I1 p o s i t i o n .
Legislation passed i n 1977 ( e f f e c t i v e August 27, 1977 ) requires insurance
companies which provide malpractice coverage to report t o the Board within
30 days a l l claims and settlements a g a i n s t p o d i a t r i s t s . A. R. S.
$ 32- 852.02, subsections A and C , s t a t e :
" A. Any i n s u r e r providing professional l i a b i l i t y
insurance t o a p o d i a t r i s t licensed by the board
pursuant t o t h i s chapter s h a l l report to the board,
within t h i r t y days of its r e c e i p t , any written o r o r a l
claim or action f o r damages f o r personal i n j u r i e s
claimed to have been caused by an e r r o r , omission or
negligence i n the performance of such insured's
p r o f e s s i o n a l s e r v i c e s or based on a claimed performance
of professional services without consent or based upon
breach of contract f o r professional services by a
p o d i a t r i s t .
" C. Every insurer required t o report to the board
pursuant t o t h i s section s h a l l also be required t o
advise the board of any settlements or judgments
against a p o d i a t r i s t within t h i r t y days a f t e r such
settlement or judgment of any t r i a l court."
The Board is required to review a l l malpractice reports f i l e d by
insurers. It may. take d i s c i p l i n a r y a c t i o n against the p o d i a t r i s t s
involved i n accordance with A. R. S. $ 32- 852.02, subsection E:
" E. The board s h a l l i n s t i t u t e procedures f o r an
annual review of a l l records kept i n accordance with
t h i s chapter i n order t o determine whether it s h a l l be
necessary f o r the board t o take r e h a b i l i t a t i v e or
d i s c i p l i n a r y measures p r i o r t o the renewal of a
p o d i a t r i s t ' s license t o practice."
I n October 1977, soon a f t e r the law went i n t o e f f e c t , the Board n o t i f i e d
14 insurance companies of the new law. From 1978 to 1980 the Board
received n o t i c e of e i g h t claims, a t l e a s t three of which were not reported
within the 30- day time l i m i t s p e c i f i e d i n A. E. S. 532- 852.02,
subsection A.* Only one of t h e s e e i g h t claims was connected with a
complaint received by the Board from another source. There is no
i n d i c a t i o n i n Board f i l e s o r meeting minutes t h a t the other seven
malpractice r e p o r t s were reviewed by the Board or t h a t i n v e s t i g a t i v e s t e p s
were taken t o determine i f d i s c i p l i n a r y measures were warranted.
Between July and September 1981 the Board again contacted t h r e e insurance
companies and asked them t o r e p o r t any claims or a c t i o n s during the period
July 1, 1980, through June 30, 1981. One company responded with a list of
eleven claims, two of which had been reported i n d i v i d u a l l y a t e a r l i e r
dates. Of the remaining nine, seven had been f i l e d with t h e i n s u r e r more
than 30 days p r i o r and f i v e had been f i l e d with the i n s u r e r i n 1980 or
e a r l i e r . Thus, the i n s u r e r had not reported within the time l i m i t s of the
law. The Board P r e s i d e n t i n t e n d s t o review t h i s l a t e s t l i s t of claims a t
the next Board meeting.
According to the L e g i s l a t i v e Council, i n s u r e r s who f a i l t o r e p o r t claims
or s e t t l e m e n t s , o r r e p o r t l a t e , a r e not i n compliance with the law.
However, the law lacks enforcement provisions. L e g i s l a t i v e Council issued
an opinion regarding the medical malpractice reporting provisions of the
BOTIIEX s t a t u t e s which a r e nearly i d e n t i c a l t o the malpractice reporting
provisions of the Podiatry s t a t u t e s . That opinion, i n p a r t , s t a t e s :
" With respect t o a l l claims made or s e t t l e m e n t s o r
judgments entered a g a i n s t a medical doctor from and
a f t e r the e f f e c t i v e d a t e of A. R. S. s e c t i o n 32- 1451.02,
the burden on t h e p r o f e s s i o n a l l i a b i l i t y i n s u r e r is
c l e a r . The i n s u r e r must report the s t a t u t o r i l j -
required information i n a timely fashion ...."
* I n the other f i v e cases we were unable to determine when the claim was
reported t o t h e i n s u r e r .
" The basic problem i n enforcing the reporting
provisions of A. R. S. s e c t i o n 72- 1451.02 i s t h a t the
s t a t u t e s do not prescribe any consequences f o r the
f a i l u r e t o r e p o r t . F a i l u r e t o report i n a timely
fashion is not even declared t o be unlawful and an
offense ...."
A s a r e s u l t of noncompliance by i n s u r e r s with reporting requirements, the
Board of Podiatry Examiners is not i n possession of timely important
inf onnation p e r t a i n i n g t o the p o d i a t r i s t s it r e g u l a t e s . According t o the
L e g i s l a t i v e Council, i n the opinion rendered on the BOMEX s t a t u t e s :
" Failure of p r o f e s s i o n a l l i a b i l i t y i n s u r e r s t o report
claims f i l e d o r s e t t l e m e n t s or judgments entered
pursuant t o A. R. S. s e c t i o n 32- 1451.02 w i l l hinder the
a b i l i t y of BOMEX t o regulate the medical profession a s
intended by the L e g i s l a t u r e ...."
The same can be said about the f a i l u r e of i n s u r e r s to report malpractice
information involving p o d i a t r i s t s . For example, f i v e of the 17 t o t a l
malpractice a c t i o n s reported t o the Board since 1977 involved the same
p o d i a t r i s t and were f i l e d a s claims with t h e i n s u r e r over a three- year
period. Such information may have been h e l p f u l t o the Board had it been
reported i n a timely manner.
A possible s o l u t i o n t o the f a i l u r e of insurance companies t o report
malpractice data would be t o make such p r a c t i c e s a v i o l a t i o n of the
insurance code-- possibly with a f i n e or other penalty f o r noncompliance.
The Department of Insurance could then monitor and enforce the reporting
provisions through its market conduct examinations and other regulatory
programs. Further, under t h i s system i f nonreporting was found, a c t i o n
could be taken by the Department of Insurance, which is involved i n the
d a i l y r e g u l a t i o n of insurance companies and not i n l i c e n s i n g boards.
CONCLUSICN
The Board has not i n v e s t i g a t e d and resolved complaints i n a timely
manner. Limited funding and lack of full- time s t a f f has forced the Board
t o r e l y on its own members, the Attorney General s t a f f o r volunteer
p o d i a t r i s t s f o r any i n v e s t i g a t i v e a c t i o n s needed to resolve complaints.
I n many cases the Board has not received adequate or timely responses from
these sources.
I n a d d i t i o n , insurance companies a r e not reporting malpractice a c t i o n s
involving Arizona p o d i a t r i s t s w i t h i n t h e time period required by law and
the Board is not f u l l y u t i l i z i n g such information when it is received. A s
a r e s u l t , the Board's e f f e c t i v e n e s s i n r e g u l a t i n g the profession is
hampered.
RECOMMENDATIONS
Consideration should be given t o the following recommendations:
1. The L e g i s l a t u r e adopt one of the following a l t e r n a t i v e s :
a. Transfer t h e r e s p o n s i b i l i t y f o r r e g u l a t i n g p o d i a t r i s t s t o the
Board of Medical Examiners and provide f o r r e p r e s e n t a t i o n of the
podiatry profession by e i t h e r 1) p l a c i n g a p o d i a t r i s t on the
Board of Medical Examiners, or 2) c r e a t i n g a small advisory
committee/ board of p o d i a t r i s t s .
b. Increase funding of the Board of Podiatry Examiners i n order t o
support more i n v e s t i g a t i v e a c t i v i t i e s .
2. The L e g i s l a t u r e amend insurance s t a t u t e s t o require i n s u r e r s t o
report malpractice claims or s e t t l e m e n t s t o the appropriate Arizona
regulatory boards and provide a p e n a l t y f o r noncompliance.
3. The Department of Insurance monitor compliance with the malpractice
r e p o r t i n g p r o v i s i o n s through its market conduct examinations or
other regulatory programs.
4. The Board review malpractice information a s i t is reported and take
appropriate i n v e s t i g a t i v e s t e p s t o determine i f d i s c i p l i n a r y
measures a r e warranted.
FINDING I1
PROCEDURES REGARDING THE PREPARATION AND GRADIXTG OF THE EOASD'S hTI? TEK
EXAPIINATION NEED TO BE IKPROVED.
Arizona Revised Statutes ( A. R. S.) $ 572- 824 and 32- 825 require that
applicants for a license to practice podiatry pass a written and a
practical examination. An applicant meeting certain requirements may take
an oral examination in lieu of the written examination. Our review of the
written examination prepared and administered by the Board revealed that
improvements need to be made in preparation and grading procedures because
the Board
- Does not sufficiently revise examination questions,
- Grades examinations in a questionable manner,
- Does not document grading procedures in its minutes,
- Calculated incorrectly scores for one Board examination, and
- Did not grade the last 30 questions of a 75- question examination
although candidates answered all questions.
One solution to remedy these deficiencies would be for the Board to use a
nationally prepared written examination in lieu of the written examination
prepared by the Board. Currently 35 states either use the national
examination instead of a state- prepared written examination or accept the
national examination in lieu of their state- prepared written
examinations. In addition, some states license solely on the basis of the
national examination.
Examination Questions Have
Not Been Revised Sufficiently
The Board administers its written and practical examination twice a year.
The written examination since October 1978 has consisted of 75 questions,
most of which were multiple choice.
The six written examinations prepared and adninistered by the Board from
October 1978 to May 1981 have consisted of many of the same questions and
twice the exact same examination was administered for consecutive
examination sittings. Table 5 shows the Board's repeated use of
examination questions on the written examination.
TABLE 5
REPEATED USE OF EXAMINATION QUESTIONS IN EXAKS GIVEN BY
THE BOARD FROM OCTOBER 1978 TO YAY 1981
- -
Date Of Number Of
Examination Examination Questions
October 1978 75
May 1979 7 5
October 1979 7 5
May 1980 7 5
October 1980 7 5
May 1981 75
Number Of Questions Repeated
From Preceding Examination Percent
0 0%
7 5 100
5 3 71
7 5 100
40 5 7
6 8 9 1
It is generally accepted that the same examination should not be repeated,
particularly if applicants retake the examination as is the case with the
Board's written examination. For example, the National Board of Podiatry
Examiners, who administers the National Podiatry Examination, prepares new
questions for each national examination except for a series of repeated
questions which are used to gauge the difficulty of the examination.
Examinations Graded In
A Questionable Manner
Our review revealed that the Board grades written examinations in a
questionable manner in that 1) the Board's method of identifying unfair
questions appears to be inconsistent, 2) questions the Board determined
to be unfair were used in later examinations, and 3) scores are
artificially inflated by adjusting all applicants' scores for unfair
questions regardless of whether or not they missed the questions
deternined to be unfair. We also found one instance in which the Board
did not correct all the questions on the examinations, and another
instance in which seven of nine examination scores were calculated
incorrectly.
When grading the October 1979, May 1980 and October 1980 w r i t t e n
examinations, the Board added 9.8, 10.8 and 9.1 p o i n t s r e s p e c t i v e l y t o
each c a n d i d a t e ' s raw score t o cornpensate f o r t h o s e q u e s t i o n s the Board
determined t o be u n f a i r . According t o the Board, the c r i t e r i o n f o r
i d e n t i f y i n g u n f a i r questions was t h o s e q u e s t i o n s missed by most
candidates. However, our review revealed t h a t the frequency of missed
questions did not always correspond t o the questions determined by the
Board t o be u n f a i r f o r the October 1979 and May 1980 examinations.
Table 6 shows how t h e Board t r e a t e d questions missed by four o r more of
the nine a p p l i c a n t s t h a t took the October 1979 w r i t t e n examination.
TABLE 6
BOARD TREATMENT OF QUESTIONS MISSED BY
FOUR OR MORE OF THE NINE APPLICANTS THAT TOOK THE
OCTOBER 1979 WRITTEN EXAMINATION
Question Number
11
17
21
23
3 7
60
16
27
28
5 2
67
68
12
14
22
3 1
35
42
4 3
47
65
7 5
Number Of
I n c o r r e c t Responses
7
6
6
6
6
6
5
5
5
5
5
5
4
4
4
4
4
4
4
4
4
4
Question Determined
To Be Unfair
Yes
Yes
Yes
N 0
Yes
No
Yes
N 0
No
Yes
N 0
No
No
No
N 0
N 0
N 0
m 0
No
N 0
Yes
N 0
As shown above, six applicants missed questions number 23 and 62, yet the
Board did not determine these questions to be unfair; however, it did
consider question number 65 to be unfair which was missed by only four
applicants.
The Board often determines a question to be unfair and gives each
candidate point credit for those questions. This procedure was followed
by the Board for the October 1979, May 1980 and October 1980
examinations. However, questions the Board determined to be unfair were
often used on successive examinations. For example, the Board determined
that seven questions were unfair on the October 1979 Board examination.
However, when the exact same examination was given in May 1980 these seven
questions were - not determined by the Board to be unfair, but eight other
questions were determined to be unfair. Further, when the Board included
in its October 1980 examination five of the 15 questions previously
determined to be unfair, none of the five were determined to be unfair but
seven other questions were.
As was noted earlier, the Board adds points to each applicant's raw score
to compensate for questions determined to be unfair. In applying this
practice the Board adds the same point value to each applicant's score
regardless of whether the applicant missed the unfair question or not.
This practice not only artificially inflates the grades of all applicants
but may have resulted in several candidates passing the examination who
did not achieve the required passing score. Board rules and regulations
state: " All applicants ... shall complete and pass a written
examination... with a general average grade of not less than 75% ...." Were
it not for the Board awarding additional points, six applicants that
passed the October 1979, May 1980 and October 1980 examinations would have
failed.
Further, our review of the Board's May 1979 written examination revealed
that the last 70 questions of the 75- question examination were not graded,
although applicants were required to answer all 75 questions. Board
members could not explain why the last 30 questions were not graded. One
Board member commented that the Board may have licensed applicants who
might have failed had all examination questions been graded.
F i n a l l y , our review of the Board's October 1979 w r i t t e n examination
revealed t h a t the Board i n c o r r e c t l y c a l c u l a t e d the grades f o r seven of the
n i n e a p p l i c a n t s who took the t e s t . A s a r e s u l t , one candidate who passed
the examination should not have. Board members could not explain why the
examination grades had been c a l c u l a t e d i n c o r r e c t l y .
Inadequate Documentation Of
Examination Grading Procedures
A. R. S. $ 38- 431.01 r e q u i r e s t h a t Board l e g a l a c t i o n s be conducted a t public
meetings and documented i n its minutes. A " l e g a l action" is defined as a
c o l l e c t i v e decision made by the Board. According t o L e g i s l a t i v e Council,
such l e g a l a c t i o n s i n c l u d e d e c i s i o n s by boards regarding methods used t o
score examinations. A. R. S. 530- 431.05 f u r t h e r provides t h a t l e g a l a c t i o n
taken i n v i o l a t i o n of these provisions s h a l l be declared n u l l and void.
Our review of Board minutes from January 1979 t o August 1981 revealed t h a t
its minutes do not include information a s to how the Board determined
grades, i n s p i t e of Board decisions t o give e x t r a p o i n t s t o a l l candidates
based upon questions determined t o be u n f a i r . Also, information was not
provided a s t o which questions were determined t o be u n f a i r and why.
A l t e r n a t i v e To the Written
Examination Prepared By t h e Board
A report by the Educational Testing Service ( ETS) a t Princeton, New Jersey
t o the U. S. Department of Labor i n d i c a t e s t h a t n a t i o n a l l y prepared
examinations a r e p r e f e r a b l e t o l o c a l l y prepared examinations. It was
s t a t e d i n t h i s r e p o r t t h a t n a t i o n a l examinations a r e of higher q u a l i t y
than l o c a l l y prepared examinations because l o c a l l y prepared examinetions
a r e prepared by Board members who a r e s k i l l e d i n t h e i r professions but
seldom have e x p e r t i s e i n the f i e l d of measurement.
On the other hand, questions on n a t i o n a l t e s t s a r e w r i t t e n by e x p e r t s ,
reviewed by o t h e r experts and subjected t o item a n a l y s i s .
The National Board of Podiatry Examiners administers the National Boar?
Exam ( NRE) to a l l podiatry students. P a r t I of the N5E is taken by
s t u d e n t s a f t e r two years o f p o d i a t r y school and P a r t I1 is taken i n the
l a s t year of school. Each p a r t of the NBE c o n s i s t s of over 500 questions
and a p p l i c a n t s a r e given 1 1/ 2 days t o complete each p a r t . T h i r t y - f i v e
s t a t e s e i t h e r use the NBE i n s t e a d of a separate s t a t e w r i t t e n examination
o r accept the NBE i n l i e u of t h e i r state- prepared w r i t t e n examinations.
A t l e a s t four of these 75 s t a t e s p r e s e n t l y l i c e n s e a p p l i c a n t s s o l e l y on
the b a s i s of the MBE ( t h a t is, no p r a c t i c a l / o r a l examination is given),
and two other s t a t e s a r e i n the process of adopting t h a t policy.
F i n a l l y , we found t h a t seven boards which regulate h e a l t h p r o f e s s i o n a l s i n
Arizona use n a t i o n a l l y prepared w r i t t e n examinations r a t h e r than preparing
t h e i r own. Use of the NBE t o replace the s t a t e w r i t t e n examination i n
Arizona would eliminate the problems of questionable grading procedures
and revising examination questions. It should a l s o be noted t h a t the
Eoard President is personally i n favor of eliminating the S t a t e w r i t t e n
examination by requiring the NBE i n s t e a d . He s t a t e s t h a t t h i s p r a c t i c e
would simplify the l i c e n s i n g process.
S t a t u t o r y changes would be necessary t o use the NBE. A. R. S. $ 72- 825,
subsection C , allows the NBE t o be s u b s t i t u t e d f o r the S t a t e w r i t t e n
examination i n conjunction w i t h a n o r a l and p r a c t i c a l examination.
However, A. R. S. $ 72- 827 requires t h a t an a p p l i c a n t , t o q u a l i f y f o r
l i c e n s u r e without w r i t t e n examination, must have p r a c t i c e d p o d i a t r y f o r
f i v e years i n another s t a t e or country. These two sections would need t o
be amended t o allow the NBE to replace the S t a t e w r i t t e n examination
without requiring a p p l i c a n t s t o have practiced f o r f i v e years i n another
s t a t e or country.
C ONCLTJSI ON
Procedures for the preparation and grading of the written examination
administered by the Board of Podiatry Examiners need to be improved.
Specifically, questions are not changed or revised frequently enough and
questions determined by the Board to b* ~ i~ faira ppear to have been
selected in an arbitrary manner. Further, Board grading procedures result
in artificially inflated grades. Also, the Board inco~ rectly calculated
examination scores for its October 1979 examination resultinp in one
candidate passing who should have failed. In addition, the Board did not
grade the last 30 questions of its May 1979 examination. Finally, Board
decisions on grading procedures are not documented adequately in Board
minutes. The NBE administered by the National Board of Podiatry Examiners
is a viable alternative to the State written examination.
RECOMI'ENDATIONS
Consideration should be given to the following alternatives:
Alternative 1
The Legislature amend A. R. S. $ 532- 825, subsection C, and 32- 827 to
require the NBE and eliminate the State written examination.
Alternative 2
- The Board revise more frequently examination questions for each
examination date.
- The Board define procedures for determining when exam questions
are unfair and consistently follow these procedures for each exam.
- Questions determined to be unfair should not be used on
subsequent exams.
- The Board base a candidate's grade on the number of examination
questions, exclusive of any questions determined to be unfair.
- The Board establish procedures to assure that all examination
questions are graded and that grades are calculated correctly.
- The Board adequately document in its minutes decisions regarding
examination grading methods and questions found to be unfair.
FINDIKG I11
BOARD RECORDS ARE INCOKPLETE. DISORGANIZED AND NOT I COIPLIAh'CE WITI!
STATUTES.
S t a t e law e s t a b l i s h e s requirements regarding the documentation of l e g a l
a c t i o n s and management of public records. The records of the Board of
Podiatry Examiners a r e not adequately maintained i n t h a t 1) minutes do
not record a l l l e g a l a c t i o n s , and 2) complaint and examination f i l e s a r e
disorganized and incomplete. Inadequate records r e s t r i c t e d our a b i l i t y to
evaluate Board a c t i v i t i e s a s p a r t of the Sunset Review process.
Arizona S t a t u t e s Reauire
Board To Maintain Records
Arizona Revised S t a t u t e s r e l a t i n g t o public records and open meetings
require the Board t o keep accurate records. A. R. S. 541- 1346 defines
agency r e s p o n s i b i l i t y f o r records management:
" A. The head of each s t a t e and l o c a l agency s h a l l :
" 1. E s t a b l i s h and maintain a n a c t i v e , continuing
program f o r t h e economical and e f f i c i e n t
management of the public r e c o r d s o f the agency.
" 2. Wake and maintain r e c o r d s c o n t a i n i n g adequate and
DroDer documentation of the organization. A 1 -
f u n c t i o n s , p c l i c i e s , d e c i s i o n s , procedures and
e s s e n t i a l t r a n s a c t i o n s of the agency designed t o
f u r n i s h information t o p r o t e c t t h e r i g h t s of the
s t a t e and of Dersons d i r e c t l v a f f e c t e d bv the
agency's a c t i v i t i e s . " ( Emphasis added)
Further, Arizona law requires each governing body i n the S t a t e to hold
open meetings and t o document l e g a l a c t i o n s taken i n those meetings.
A. R. S. 838- 431.01 s t a t e s :
" A. A l l meetings of any public body s h a l l be public
meetings and a l l persons so d e s i r i n g s h a l l be
permitted t o a t t e n d and l i s t e n t o the
d e l i b e r a t i o n s and proceedings.
" B. A l l pubic bodies.. . s h a l l provide f o r the taking of
w r i t t e n minutes o r a recording of a l l t h e i r
meetings. Such minutes o r recording s h a l l
include, but not be limited to.. .[ - a] n accurate
d e s c r i p t i o n of a l l l e g a l a c t i o n s proposed,
discussed or taken.. . ." ( ~ m ~ h a saidsd ed)
The term " l e g a l action" includes discussions and d e l i b e r a t i o n s by members
of the public body i n a d d i t i o n t o the r e s u l t s of formal votes by the
Board. An August 1975 opinion by the Arizona Attorney General defined
l e g a l a c t i o n s a s follows:
". . . it is our opinion t h a t a l l d i s c u s s i o n s ,
--
d e l i b e r a t i o n s , considerations or c o n s u l t a t i o n s among a
m a j o r i t y o f the members of a governing body regarding
matters which may foreseeably require f i n a l a c t i o n o r a
f i n a l decision of the governing body c o n s t i t u t e ' l e g a l
a c t i o n ' and must be conducted i n an open meetin2 .-..."
- is added)
I n a June 18, 1979, memorandum, L e g i s l a t i v e Council a l s o recommended t h a t
" l e g a l action" be defined broadly:
" . . . l e g a l a c t i o n should be construed broadly and i s not
only the mere formal a c t of voting but includes
discussions and d e l i b e r a t i o n s by members of the public
body p r i o r t o the f i n a l d e c i s l ~ n . "
A review of the Board's records reveals t h a t adequate records have not
been maintained.
Documentation O f Zeeal Actions I?:
Board Minutes Has Been Inadegua- 5
A s required by A. R. S. $ 38- 431.01, a l l l e g a l a c t i o n s of the Board must be
conducted at public meetings and documented i n the minutes. However, the
Board's minutes do not adequately record a l l of the l e g a l a c t i o n s taken by
the Board regarding t h e i n v e s t i g a t i o n and d i s p o s i t i o n of complaints.
Table 7 reveals the extent of documentation i n the Board minutes f o r
complaints received and disposed of since January 1, 1978.
TABLE 7
DOCUMENTATION I N BOARD MIMUTES FOR CONPLAINTS RECEIVED AND
DISPOSED OF SINCE JANUARY 1, 1978"
Total
- Yes - N 0 Complaints
Nature of complaint i d e n t i f i e d 9 10 19
A summary of discussion o r d e l i b e r a t i o n 10 9 19
D i s p o s i t i o n i n d i c a t e d 19 0 19
Grounds o r b a s i s f o r d i s p o s i t i o n explained 13 6 19
A s shown i n Table 7, the Board h a s n o t adequately or c o n s i s t e n t l y
documented its a c t i o n s r e l a t i n g t o t h e r e s o l u t i o n o f conplaints i n its
minutes.
Board F i l e s Are
Disorganized and Incomplete
Since l a t e 1977, the Board has contracted with the Arizona S t a t e Boards
Administrative Office ( ASBAO) f o r c l e r i c a l support s e r v i c e s , including
r e c e i p t of complaints, maintenance of Board f i l e s and processing of
l i c e n s e renewals. Neeting minutes a r e recorded by a Board member and
typed by the ASBAO s t a f f .
ASBAO h a s n o t adequately maintained the Board's examination and complaint
f i l e s . For example, ASBAO does not maintain a c e n t r a l log o r list
i d e n t i f y i n g complaints received by the Board and the c u r r e n t s t a t u s of
each. I n a d d i t i o n , examination and complaint f i l e s lack organization and
t h e r e a r e inadequate c o n t r o l s over the removal of these f i l e s from ASBAO
premises.
* Does n o t i n c l u d e seven complaints involving f e e d i s p u t e s which were
r e f e r r e d t o the Arizona Podiatry Association.
Audit Impaired By
Poor Record keeping
Incomplete minutes and disorganized files impaired our ability to evaluate
Board activities. For example, excessive time was consumed by audit staff
in locating complaint and examination documents which were not in
designated files. Several files were eventually found in the possession
of Board members or at other locations within ASBAO. Excessive time was
also spent in reconstructing the history of Board actions with regard to
particular complaints. In some cases, the absence of information such as
the grounds or basis for disposition prevented us from evaluating the
appropriateness of final Board decisions. The dispersion and
disorganization of examination- related documents also made it difficult
for us to determine if examination procedures were fair and consistent.
Guidelines For
Record keeping Are Needed
Failure to record complete minutes appears to be due to a lack of
understanding of statutory requirements. The Board president was not
aware that meeting minutes did not conf o m to statutory requirements.
ASBAO and the Attorney General's Office could provide guidelines to the
Board. Since 1976, three different members of the Board have kept
minutes, underscoring the need for such guidelines.
Board records have not been maintained in an adequate manner in that
1) minutes of Board meetings do not record all legal actions, and
2) complaint and examination files are disorganized and incomplete. As a
result, our ability to evaluai. Board activities as part of the Sunset
Review process was impaired.
RECOFMENDATI ONS
Consideration should be given to the following recommendations:
1. ASBAO and the Attorney General's Cffice provide guidelines to the
Board regarding the keeping of adequate meeting minutes.
2. ASBAO adopt and implement formal p o l i c i e s and procedures
governing the management of a l l Board records.
State of Arizona
Board of Podiatry Examiners
1645 W. Jefferson Room 4 18
Phoenix, AZ 85007
December 16, 1981
Douglas R. Norton, CPA
Office of the Auditor General
State of Arizona
Legislative Services Wing
Suite 200, State Capitol
Phoenix, AZ 85007
Re: Performance Audit of the Board of Podiatry Examiners
Dear Mr. Norton:
This letter is written as an official response to the above referenced
audit. Your report is accepted in the spirit for which it was intended-that
this Board recognizes that it is a constructive tool to be used for
enhancing Board activity and thus better serving the needs of the State
of Arizona. This response will focus on those areas of the report that
the Board feels need further comnlent or clarification.
The Auditor General recommends that the Legislature consider adoption
of the following alternatives for regulating podiatrists:
A. Transfer the responsibility to the Board of Medical Examiners.
B. Increase funding of the Podiatry Board in order to support
more investigative activities.
If the order in which these occur also reflects the order of recommen-dation
priority, this Board views alternative B as the preferred manner
of resolving any and all podiatric regulation issues raised in the audit.
The vesting of podiatry professional interests within the statutes
regulating the practice o f allopathic ( M. D.) medicine ( ie: BOMEX) would,
in our opinion, be i l l conceived. The mixing of these two medical
disciplines at a regulatory Board level would cause an immediate loss
of autonomy and podiatric representation at a time when our profession
already is concerned about the general lack of action taken by allopathic
hospitals, controlled by allopathic physicians, to affect podiatry
representation on its staffs and privileges coninlensurate with the statute
defined scope of podiatry practice.
Douglas R. Norton Page 2 December 16, 1981
Under Finding I the Board regrets that Case I1 was referred to as a
complaint matter in its minutes whereas it was actually perceived as an
inquiry made by a podiatrist. The minutes fail to reflect that this
case was never given a high priority in view of the other complaint
niatters before it and that the investigation has now been completed and
the inquiry answered to the satisfactory conclusion of the Board.
Finding I also states the " Board Has Failed to Initiate Investigations
or Follow Up In a Tiniely klanner." One factor cited relates to extended
~ eriods between Board meetinqs: the Board has implemented a reqularly
scheduled monthly meeting during 1982 and also plans to conduct some
Board business by telephone conference. Both of these avenues are
measures that will assist in overcoming this deficiency.
As president I assume sole responsibility for the failure of placing
certain coniplaints on specific meeting agendas during my tenure. This
failure was usually due to establishing of priority items to come before
a meeting in a given time period and on at least one occasion was a
regretful oversight. Increased Board meeting time should also eliminate
this problem.
Finally, under Finding I, the audit reports that the Board has not fully
utilized information pertaining to eight malpractice claim reports filed
with the Board from 1978 to 1980. - One of these claims was being treated
under a complaint process. Of the remaining seven, the Board members
had never seen three of them until identified by your staff at our
Executive S e s s i m Decerriber 9, 1981; this was clearly an oversight
of ASBAO to distribute the information received. One of the remaining
four was not acted upon, by advise of Board counsel, because of a concern
fiossible conflict in a complaint process already before the Board
involving the saille practitioner. One of the remaining three involved a
practitioner who was satisfactorily serving a one year probation, at the
time the report was filed, for similar complaint matters. The other - two
were discussed by the Board with no action felt necessary.
The minutes fail to reflect the activity of the Board concerning these
individual actions and thus the impression left to the Office of the
Auditor General that the Board had not fully utilized information it
did receive. This is not to mean that the Board denies this finding
en toto and acknowledges that definitive policy procedures must and will
be instituted to ensure Board activity on this clatter as stipulated by
statute.
Finding I1 deals with procedures regarding the preparation and grading
of the Board's written examination. Information reported under this
finding is of itself factual. However I would submit that all written
exams were conducted, graded and analyzed with the objective that the
Board would 1 icense those candidates who rnet the minimum requirenients of
a general grade of not less than 75%. The methodology of arriving at a
final percentage grade has a number of variables and not withstanding
math error should be applicable as deemed appropriate by the Board
members grading same. The Board recognizes that it needs to sirilplify
grading procedures.
Douglas R. Norton Page 3 Dece~ ber 16, 19S1
Individual questions and ultimately exam validity can also be tested by
various means. The frequency with which a question is missed or correct
may not by itself establish validity within a single sample. Questions
were often repeated in subsequent exanis to test thern among a different
group of candidates.
None of the professional Board members feel they are experts in the
area of testing generally but apply the skills they do have to the best
of their ability and with the frailty to human error we all possess.
The Board applied reporting of the Iiovember 1901 exaln information to the
minutes of December 9, 1981 in keeping with your alternative recommen-dations
that the Board adequately document decisions regarding exaln
grading methods etc. Failure to comply in this regard in the past was
strictly due to lack of knowledge that it should be done as opposed to
hiding sonrething.
Finding 111 that includes the statement that " Documentation Of Legal
Actions In Board Minutes Has Been Inadequate" is really answered under
d r eit reads that " failure
to record conwlete minutes a. p . p ears to be due to a lack of understanding
of statutory requirements." This is absolutely true and I recorninend that
orientation of Board members take place upon appointnient to deal with
legal aspects of Board activity as well as administrative developnient and
distribution of a Board procedural and policy manual.
Finally, there are some problem areas of activity concerning this Board
at the ASBAO level. One is identified in this letter and several are
reported in your audit. The Board recom~ nends that the niatters dealing
with ASBAO be handled internally by them or by a higher adininistrative
authority.
In summary I would like to state that the Board feels that this audit
process has been a positive one. Deficiencies cited were often curnmulative
oversights which the Board will now have the opportunity to focus its
attention on and improve its functional activity. Lastly, we feel that
maintaining the present Board structure will best serve the needs of both
the safety and welfare of the public and the podiatry profession in Arizona.
Sincerely,
William Friedman, D. P. M.
President
cc: Board Members
Julia Smock, Assistant Attorney General