Strategies for Prevention & Management of Adverse Outcomes
November 1, 1998
Strategies for Prevention & Management of Adverse Outcomes
Why Good Doctors Get Sued:
• they forget or fail to recognize how patients perceive quality
• they do not employ personal risk management strategies in daily practice
• they get caught in system failures
How Patients Perceive Quality:
• function as well or better after interaction
• low cost
• don’t want to be injured in process of Rx
• want to understand about their condition and treatment options
• humane, kind, respectful interaction with provider, nursing, and office staff
• short phone wait, prompt appointments, short office visits, and prompt follow-up
• short waits for test completion and prompt communication of results
• referral to specialist if not responding
• availability after hours for emergencies
• satisfaction with health plan and relationship of plan with provider
Traditional Risk Management Loss Prevention and Reduction:
• Establishing provider-patient relationship
• Once begun, prevention of injury to patient
• If yes, prevention of negligence claim
• If filed, prevention of malpractice suit
• If yes, winning the lawsuit
• Extends to issues of quality of care, prevention of injury, and helping injured deal with it most effectively
How Providers Perceive Quality:
• being able to make the diagnosis
• using a state-of-the-art approach to treatment
• having a low complication rate
• relying on top-quality consultants
• having the patient get well
Why Do Patients Seek Legal Advice?
• bad result or perception of bad result
• unhappy or dissatisfied patient
• social system that supports lawsuits
Communication Strategies:
• ability to listen effectively and allow patients to express their concerns
• ability to provide information in a way that ensures patient understanding
• conveyance of a feeling of respect for the patient
• feeling that the provider is willingly accessible and available
Functions of Effective Communication:
• data collection skills to understand the nature of the patient’s problem
• relationship skills to build and maintain maximum provider-patient rapport
• educational skills to ensure patient understanding, informed consent, and maximum adherence
Rapport-building skills: acknowledge and address emotions:
• reflection: acknowledge an observed response
• legitimation: validate patient’s emotions
• support: explicit statements of support
• partnership: statements confirming collegial approach to problem solving
• respect: acknowledge positive coping behaviors or coping mechanisms of patient
Data Gathering Skills:
• appropriate and effective questioning: "open-to-closed" cone of questioning
• facilitation: verbal ("tell me more . . ." "go on") and non-verbal (nodding) techniques
• surveying: e.g., what else? priorities?
• summarization: correct misunderstandings and provide additional information; confirms hearing and understanding to patient; builds rapport
Educational Skills:
• establish baseline of concerns and current knowledge
• correct any misinformation
• short and simple informative statements
• opportunity to ask questions
Goal: "accomplish complex education in situations of high emotional intensity!"
Informed Consent:
• what a reasonable provider would say about a procedure = what any reasonable patient would want to know about a procedure = what the individual patient would want to know to make a reasonable decision about the procedure
• state defines process in detail including documentation required in record
"Uncertainty":
• we as physicians are not certain of all outcomes
• in most instances, we are able to deal with these outcomes effectively, even if unexpected
• patients need to know this so they are not surprised and dismayed if an unexpected event occurs
• does not protect a provider from allegation of negligence
Provider Management:
• understand the dynamics and stress associated with behavior:
— disorganized thinking
— guilt and defensiveness
— fear of lawsuit and tendency to blame
— increase vulnerability to error
• maintain impeccable records; don’t change them; dictate promptly; document care personally
System Failures, Human Error, and Adverse Outcomes:
• adverse outcomes occur in context of excellent medical care
• adverse event: complication or negligence?
• system which establishes how care is given may contribute to adverse outcomes
• prevention of error through elimination of system failure
Taking Action: Premises:
• error rates in medicine are relatively high.
• blaming and search for culprits won’t work.
• achieving error reduction requires system changes.
• job for organization leaders; instill value.
• improvements will require measurement: to gain knowledge (not only carrots and sticks).
Pharmacy Techniques:
• familiarity and follow state and federal laws
• multiple drugs or drugs with narrow therapeutic index (e.g. dispense one at a time)
• contact the prescriber if any questions
• periodic written requests/file of phone orders
• don’t make substitutions without permission
• discuss therapy with patients; written instructions
• document actions taken and concerns
Medical Director Checklist:
• job description: informed oversight; uniform handling of decisions; legal/regulatory comply
• documentation: info and logic used for decision
• review: benefits, UR procedures, med records
• speak up: interview providers
• consult experts: standard of care applied
• time: be aware of required turnaround times; communicate delays, reason, and expected close
• appeal right: no inform = violate good faith
Follow-up Documentation: Defensible Office Systems:
• date test/referral ordered
• test/referral ordered
• reason for test/referral
• consequences explained for not undergoing test/referral
• date test/referral received
• date results read and initialed by MD
• additional tests, follow-up appointments, other recommendations
• date and manner patient notified of results and any further recommendation
• whether patient followed through on further testing/recommendation
Patient Abandonment: Minimizing accusations:
• check with health plan re: regulations
• notify patient in writing
• state reason for discharge from practice (e.g. non-medical compliance)
• indicate availability to provide care for period of time until new provider obtained
• send letters certified with return receipt
Attorney-Client Privilege:
• oldest protection of confidential communication
• encourages clients to be completely truthful
• promotes communication and eliminates fear of disclosure to third parties
• fosters voluntary compliance with the law by promoting freedom of consultation with attorney
• state and federal law generally the same
• establish: communication between privileged persons in confidence for legal assistance
Quality Assurance Privilege:
• available in some states, defined under law
• QA process: developed by health care entity and follows written standards and criteria
• includes activities and investigations related to: quality of care; practice review; training, experience, and conduct of licensed professionals; analysis of use of health services and facilities
• immunity for QA participants
• information and record of actions confidential/protected
Peer-Review Privilege:
• available in some states
• encourages self-critical analysis
• physicians organize to improve care
• review nature, quality, and necessity of care; prevention of complications and death
• need not identify provider or patient by name
• proceedings, records, and materials confidential and not subject to discovery
Source: Ross M. Miller, MD, MPH, Medical Director, Quality Management and Risk Management for major MCO, Los Angeles. (Information was included in a presentation on "Why Good Doctors Get Sued" at the National Managed Health Care Congress held in Atlanta in April.)
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