By Jock Hoffman, CRICO
As we encourage patients to be more engaged,
we may also see more who go beyond assertive to demanding care
unsupported by good clinical judgment. Understandably, physicians worry
that saying “no” to a patient increases their risk of being disliked,
dismissed, or even sued for medical malpractice. But the right mix of
clinical judgment, bedside manner, and documentation can help take the
“maybe” out of saying no to a request for unnecessary—or unsafe—testing
or treatment.
More transparency in health care means patients are more aware of
options for screening, testing, procedures, and medications—often via
direct campaigns. The advent of social media further expands the spread
of both legitimate and untrustworthy
health care information. Thus, an anxious or desperate patient may ask
for something about which they have heard or read, e.g., an MRI after a
negative mammogram, a better drug for acid reflux, a cesarean section
scheduled for convenience, an experimental procedure “like on House,
MD.” In the face of such requests, maintaining an effective patient
relationship, practicing appropriate care, and heeding the pressure to
control cost—can be a real challenge.
If your clinical judgment is to say no, then saying yes—because it is
easier, faster, less of a hassle—may pose hazards to both you and your
patient. Even relatively benign procedures can carry the risk of
unintended consequences. For example: changing a medication regimen can
destabilize a patient's health; a “convenience” delivery before 39-weeks
gestation may violate clinical guidelines
(or hospital policy); experimental procedures (even those from the real
world) are the purview of those physicians working to perfect a new
technique with patients selected via exacting criteria—not just foot
stomping.
Explaining to a patient the reasons behind “no” takes time and
patience. But thoughtfully discussing and documenting such requests will
improve your chances of maintaining good rapport and leave you less
vulnerable to an allegation of malpractice than if your refusal is curt,
dismissive, or poorly documented. Listening with respect to what the
patient's aunt or neighbor or favorite blogger has suggested gives you
an opportunity to respond with your own expertise and reasoning. Such conversations
also provide an opportunity to elicit suppressed concerns and a chance
to assure the patient that he or she is part of the process. Noting in
the record a) what the patient requested b) your rationale for denying
that request, and c) what you recommended instead, gives you, the
patient, and subsequent providers context for future requests and
decision making.
Of course, crossing your t’s and dotting your i’s after saying no
doesn’t mean a disgruntled patient won’t pursue a complaint—that’s
beyond your control. But if the complaint is in the form of a
malpractice allegation, then your medical professional liability insurer
will have such claims assessed by medical experts
in your specialty. Their opinion will be based on their own experience,
the prevailing standard of care, and your notes. To that end, a
properly documented decision based on solid clinical judgment and
matched by the practice of your peers is the best support for your
decision to say no.
Additional Material
Original Source, Strategies for Patient Safety
By Jock Hoffman, CRICO
It is a rare discussion among patient safety experts when someone in the room (physician, lawyer, CEO) doesn’t interject, “Let me tell you what happened the last time my mother saw her doctor.”
No matter what our role is in working to perfect patient safety, reduce adverse events, and prevent malpractice claims, we often also get to see systemic imperfections from the patient or family member’s perspective. Indeed, those anecdotes often help build the narratives we use to frame improvement efforts.
One such improvement effort is better coordinated care delivery systems. A recent New York Times article predicted that, by 2020, accountable care organizations (ACOs) and similar care consortiums will have replaced the U.S. health insurance industry. While that’s speculation, providers do need to ramp up their ability to explain new health care delivery models to the patient populations they will be managing. In doing so, those “my mother” patient-perspective narratives become even more poignant for participating physicians.
A key requirement for ACOs and similar entities is more fully engaging patients in their health-related decisions. Exactly how to achieve patient engagement is still a bit murky, but the essential component is enabling patients to conduct well-informed discussions with a coordinated team of providers about their health, care options, and medical decisions. The expected consequence is that patients who appreciate the more focused and synchronized approach to their care will make informed decisions that benefit both themselves and the overall population. An additional benefit is that a more engaged patient population serves as another layer of patient safety protection.
Of course, a patient’s motivation to be engaged in her care can be counterbalanced by skepticism if she doesn’t perceive a direct benefit. Friends, family and the popular media may influence an attitude that patient engagement is just a new tactic for advising everyone to diet and exercise more often. And, even without any external influence, change may engender frustration or distrust for some patients.
For example, decisions regarding what tests are ordered, what consults or referrals are proffered, and what treatment or medications are recommended, may be challenged. Increased access to medical records may introduce unfamiliar terms or information displays that trigger requests for clarification. How you answer your patients’ questions will be a key aspect of their attitudes toward engagement and a healthy physician-patient relationship.
CRICO, and other organizations are working to identify best practices for aligning patient engagement with patient safety. The better that physicians, and the organizations they’re affiliated with, are informed about risks and enabled by proven solutions, the better equipped you’ll be to help “my mother” become an engaged patient.
Additional Material
Original Source, Strategies for Patient Safety
By Jock Hoffman, CRICO
Health care constantly intersects with challenging decisions, perhaps none more unsettling than the choice between waiting, or acting on an ambiguous presentation. If the patient is not physically present (e.g., on the phone or emailing), then the provider has even fewer cues to guide that decision. When the remote communication of history, symptoms, and status involves third parties (parent, interpreter, answering service, etc.) the risks associated with making a “wait” or “don’t wait” decision increase significantly. Such situations are even further complicated if the patient (or spouse or parent) is hesitant to leave home for the doctor’s office or the nearest emergency room barring a sense of urgency. Physicians and nurses who routinely have remote care encounters are encouraged to review this case study from a recent CRICO malpractice claim.
Malpractice case studies present an important opportunity for providers to learn by exploring what went right, what went wrong, and what could have been done differently. Although these cases often represent negative and emotionally charged circumstances, positive learning can emerge from examining them. Staff from CRICO’s Patient Safety Department continually select and develop case studies (of closed claims or lawsuits) that offer teaching opportunities. More than 75 such case studies are available on the CRICO web site. Clinician facilitators who choose to incorporate abstracts from malpractice claims into their clinical presentations may want to read the suggestions offered in 10 Tips for Presenting Closed Claims Abstracts for Grand Rounds.
Additional Material
Original Source, Strategies for Patient Safety
By Jock Hoffman, CRICO
For virtually every physician-patient interaction, your patient’s past is prologue to today’s encounter and tomorrow’s care plan. But coordination of care—even over a brief office visit or hospital stay—is as much of a patient safety challenge as is making a proper diagnosis or carrying out a successful treatment. The path of care from the initial complaint to completion of treatment is far from seamless. Indeed, it is full of cracks—opportunities for losing, misdirecting, or misunderstanding critical information—that pose serious risks for the patient and his or her multiple health care providers.
Coordination of care risks can derive from patients you see often for chronic care and for those who you’ve never met (e.g., a patient new to your panel being seen in the ED). Most malpractice cases involving poorly coordinated care are those alleging a missed or delayed diagnosis, commonly due to a mismanaged test result, referral, or hand-off. For 522 cases filed against CRICO insureds from January 2005 to October 2010 with care coordination issues, the following three contributing factors were prominent:
- Mismanagement of test results
(234 cases*/average incurred loss=$1M)
- Mismanagement of referral
(230 cases/average incurred loss=$852K)
- Mismanagement of hand-off or sign-out
(255 cases/average incurred loss=$888K)
Those categories comprise myriad communication and documentation factors that prevent multiple caregivers from having a complete picture of the patient’s status and subsequent care needs. Relying solely on memory—yours or the patient’s—is ill-advised; systems that fail to keep everyone (including future providers) well-informed about past care and future responsibilities are equally inadequate.
At the broad level, CRICO is working with its insured organizations to enhance closed-loop communication of test results and referrals, and improve team communication at key transitions for providers (e.g., hand-offs) and patients (e.g., discharge). For individual physicians and nurses, CRICO and its clinical experts have developed answers to a series of Frequently Asked Questions that address many coordination of care issues.
A quick review might help you and your co-providers keep crucial patient information from slipping between the cracks.
*A single malpractice case may involve more than one factor
Additional Material
Original Source, Strategies for Patient Safety
