MANAGING CHALLENGING PATIENT RELATIONSHIPS€¦ · You can refuse to establish a physician-patient relationship based on the patient’s ability to pay, except Emergency Department

MANAGING CHALLENGING PATIENT RELATIONSHIPS

Ernest E. Allen, ARM, CSP, CPHRM, CHFM

Account Executive

Department Patient Safety and Risk Management 2017

Disclosure Statement

The Doctors Company would like to disclose that no one

in a position to control or influence the content of this

activity has reported relevant financial relationships with

commercial interests.

The information and guidelines contained in this activity

are generalized and may not apply to all practice

situations. The faculty recommends that legal advice be

obtained from a qualified attorney for specific application

to your practice. The information is intended for

educational purposes and should be used as a reference

guide only.

2 Managing Challenging Patients

Name of Presenter

Ernie Allen earned his Associate in Risk

Management from the Insurance Institute of

America and is a Certified Safety Professional.

Ernie is also a Certified Professional in

Healthcare Risk Management (CPHRM) and

Certified Healthcare Facility Manager (CHFM).

Mr. Allen has 30 years of healthcare

experience and speaks on the Joint

Commission’s Environment of Care and Life

Safety Standards at national seminars and

conducts surveys at hospitals around the

country.

Managing Challenging Patients

Title, Department, Company

3

OBJECTIVES

After completing this activity, learners will be able to:

▪ Provide recommendations on how to handle a problematic patient

▪ Minimize liability of the practice

▪ Know how to terminate a patient relationship

Managing Challenging Patients4

RECOGNIZE RED FLAG PATIENTS

Your office practice is at risk:

▪ Potentially violent patients or family members

▪ No Show new patients

▪ Patients unable to pay

▪ Patients who do not follow treatment plans

▪ Patients who refuse treatment options

▪ Patients angry after a bad outcome

▪ Patient relationships that require termination


Prevalence of Workplace Violence in Healthcare

▪ 80% of Emergency Department experience violence in their career

▪ 50% of healthcare workers experience acts of violence

▪ 40% of psychiatrists report physical assault

▪ 27% of healthcare worker violence results in a fatality

▪ Trust your gut instinct that a patient may present an elevated risk of

violence


▪ Recognize red-flagged patients

– Type of patients

– Verbal cues

– Non-verbal cues

Establish a safety plan

– Call 911 and have zero tolerance for workplace violence

– Office Code, for example as Dr. Strong

– De-escalation techniques

▪ Security procedures specific to your work space (locked/unlocked doors, use of

panic buttons or silent alarms, etc.).

▪7 Managing Challenging Patients

Develop a Practice Safety Plan

De-escalation Techniques

▪ Do

▪ Use the person’s name

▪ Speak slowly and use simple words

▪ Maintain eye contact

▪ Allow time for reflection

▪ Giver options

▪ Ask for the person’s idea or solution


De-escalation Techniques

▪ Don’t

▪ “Say calm down”

▪ Allow long waits

▪ Feign attention

▪ Agree with someone – take their side

▪ Get in a power struggle or argue

▪ Meet an angry person one on one

▪ Allow more than one staff member to talk to the person

▪ Look at or comment on the weapon (if present)


Identify Risks in the Office

▪ For detailed checklists that will help you assess your physical practice space,

staff level of training, and more, see OSHA’s Guidelines for Preventing

Workplace Violence for Healthcare and Social Service Workers at

www.osha.gov/Publications/osha3148.pdf.


http://www.osha.gov/Publications/osha3148.pdf

Decrease Risks in the Office

▪ Consider signage in waiting room on prosecution of violent patients

▪ Limit access to staff (secure door from waiting room)

▪ Install security cameras

▪ Install panic buttons and train staff on location

▪ Conduct drills

▪ Identify doors to lock for sheltering in place

▪ Identify escape routes


Sign posted in waiting room


No Show New Patients

▪ Place a disclaimer on paper forms:

▪ “Please be advised that completing preliminary health and insurance

questionnaires does not establish a physician-patient relationship with this

practice. Dr. _____ will review your health history and conduct an initial

evaluation to determine whether you a suitable candidate and whether the

practice will accept you as a patient.”

▪ Online forms:

▪ “Please be advised that by providing this form for you to contact our offices, we

are not confirming an appointment nor establishing a physician-patient

relationship. Our office will follow up with you in 24-48 hours after receiving the

form. This portal is not intended for acute, emergency or life-threatening health

conditions. If you are having a health emergency, contact 911 or go to the

nearest emergency department.”


Potential Patients Unable to Pay

▪ You can refuse to establish a physician-patient relationship based on the

patient’s ability to pay, except

▪ Emergency Department referrals must comply with the hospital’s bylaws and

rules/regulations. You will likely need to see the patient and comply with

EMTALA. Emergency treatment requires you to provide care regardless of the

patient’s ability to pay, but you can ask for payment or payment arrangements.

▪ Office staff should advise potential patients that making an appointment does

not automatically trigger a physician-patient relationship.

▪ If possible, confirm insurance coverage prior to the appointment.

▪ Photocopy the insurance card and ask for photo identification of the patient on

the appointment.


Established Patients Unable to Pay

▪ Give each patient the payment policy of the office on the initial visit.

▪ Place a sign by registration that payment is expected at the time of service.

▪ Consider adding additional languages if necessary to the sign.


Patients Who Do Not Follow Treatment Plans

▪ Explain the risk of not following the recommended treatment and document the

conversation in the medical record.

▪ Verify the patient has understood by asking him/her to repeat the risks

▪ Ask if they have any questions

▪ Obtain assistance of family members to encourage patient compliance.

▪ Encourage patients to be responsible by asking them to monitor blood sugar

levels, weight, blood pressure, and maintain a record to bring to you.

▪ Ask why the patient is not complying and see if alternatives can be

implemented, such as a cheaper or generic form of the medication.

▪ Be persistent and document your efforts in the record. Some patients need to

be told the same thing more than once in order to understand and comply


Patients Who Refuse Treatment Options

▪ Always document in the chart when a patient refuses a test or treatment option.

▪ Some offices use a refusal to treat form – a sample is available on our website;

www.thedoctor.com/consent

▪ Provide the reason for the recommended treatment/test/referral

▪ Review the possible risks, such as loss of a limb, or death.


http://www.thedoctor.com/consent

Patients Who Are Angry After a Bad Outcome

▪ Unfavorable outcomes or unanticipated results can results in patients reacting

by blaming the physician. Try the communication techniques below:

▪ Listen well and remain calm.

▪ Assess the patient’s level of understanding

▪ Apologize for the situation – “I’m sorry this happened”

▪ Michigan’s I’m Sorry law reviewed in next slide

▪ Be patient with questions

▪ Include the patient as a team member

▪ Under no circumstances lose your temper.

▪ Remain accessible


Michigan’s I’m Sorry Law

▪ Background

▪ The University of Michigan Health System estimated the average cost of

lawsuits were cut in half since it adopted an "I'm Sorry" policy. At the same time,

patient satisfaction increased. This was used as evidence in hearings on the

new legislation.

▪ Gov. Rick Snyder signed into law Public Act 21 of 2011

▪ Expressions of sympathy by a healthcare provider will not be held against them

in court.

▪ But, statements related to fault or negligence on the part of the health care

provider are not exempt under this bill.


The Importance of Informed Consent

▪ Also make an entry in the progress notes of discussion with the patient, that the

patient understood the risks and benefits, and he/she agreed to the procedure.

▪ Suggested statement:

▪ “While I wish I could guarantee there will be no problems during your treatment

or operation, that wouldn't be realistic. Sometimes there are problems that

cannot be foreseen, and you need to know about them. Please read about them

and let’s talk about it.”

▪ Avoid the following statement:

▪ “Don’t worry about a thing. I’ve taken care of hundreds of cases like yours. You’ll

do just fine”


Terminating Patient Relationships

▪ It is acceptable and reasonable to end relationships, such as the following

criteria:

▪ Treatment nonadherence

▪ Follow-up nonadherence

▪ Office policy nonadherence

▪ Verbal abuse and threats of violence

▪ Sexual harassment

▪ Nonpayment

▪ Lawsuit


Delay Termination if:

▪ The patient is in an acute phase of treatment, such as post-op or conducting a

workup for diagnosis.

▪ If you are the only source of care within a reasonable driving distance.

▪ You are the only source of specialized care, continue until the patient can be

transferred to another specialist

▪ Prepaid healthcare plan – communicate with the 3rd party payer and request a

transfer to another practitioner

▪ Pregnant patients can be terminated if:

– First trimester with uncomplicated pregnancy with time to find another OB

– Second trimester with uncomplicated pregnancy and transfer prior to actual

cessation of services

– Third trimester – only extreme circumstances (i.e. illness of practitioner)


Delay Termination if:

▪ The patient cannot be terminated solely because he/she has a disease in a

protected class established by federal antidiscrimination law, such as AIDS/HIV

▪ The presence of a patient’s disability cannot be the reason(s) for termination

unless the patient requires car or treatment for the particular disability that is

outside your expertise. Transfer care to a specialist who provides the particular

care.

▪ When in doubt, check with your malpractice insurance company.


Recommended Steps for Patient Termination

▪ A notice should include:

– Reason for termination (specific reason not required, but suggest phrase such as “inability to achieve or maintain rapport”

– Effective date of termination – usually 30 days, but can be immediate if threat of violence from patient or family member

– Interim care provisions

– Continued care provisions – refer to internet, medical society, hospital

– Offer to provide medical or dental record copies – include a release form

– Patient responsibility

– Medical refills – only to effective date of termination


Resources

▪ Hackenthal, V. Workplace violence rampant in healthcare. Medscape. April 27,

2016. www.medscape.com/viewarticle/862562. Accessed July 28, 2017.

▪ Modern Healthcare. Quelling a storm of violence in healthcare settings. March

11, 2017. www.modernhealthcare.com/article/20170311/MAGAZINE/303119990.

Accessed July 28, 2017.

▪ National Institute for Occupational Safety and Health (NIOSH). Occupational

violence. www.cdc.gov/niosh/topics/violence/default.html. Accessed July 28,

2017.

▪ Occupational Safety and Health Administration (OSHA). Guidelines for

preventing workplace violence for healthcare and social service workers.

www.osha.gov/Publications/osha3148.pdf. 2016. Accessed July 28, 2017.


http://www.medscape.com/viewarticle/862562

http://www.modernhealthcare.com/article/20170311/MAGAZINE/303119990

http://www.cdc.gov/niosh/topics/violence/default.html

http://www.osha.gov/Publications/osha3148.pdf

Resources

▪ Phillips, J. Workplace violence against health care workers in the United States.

New England Journal of Medicine 2016; 374:1661-9.

▪ Security: Solutions for Enabling and Assuring Business. 12 methods to de-

escalate violent situations. July 28, 2015.

www.securitymagazine.com/articles/86543-methods-to-de-escalate-violent-

situations. Accessed July 28, 2017.

▪


http://www.securitymagazine.com/articles/86543-methods-to-de-escalate-violent-situations

Questions?


The guidelines suggested here are not rules, do not constitute legal advice, and do not

ensure a successful outcome. The ultimate decision regarding the appropriateness of any

treatment must be made by each healthcare provider in light of all circumstances

prevailing in the individual situation and in accordance with the laws of the jurisdiction in

which the care is rendered.


Ernest E. Allen, ARM, CSP, CPHRM, CHFMAccount Executive

Department of Patient Safety and Risk Management

Northeast Region

Email

(800) 421-2368, ext. 5185

Patient Safety and Risk Management, [email protected]

Additional resources and activities please visitwww.thedoctors.com

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MANAGING CHALLENGING PATIENT RELATIONSHIPS€¦ · You can refuse to establish a physician-patient relationship based on the patient’s ability to pay, except Emergency Department