The FTCA and You (aka How to avoid getting sued before it ever happens)

The FTCA and YouThe FTCA and You

(aka How to avoid getting (aka How to avoid getting sued before it ever happens) sued before it ever happens)

FTCA – FTCA – The Federal Tort Claims The Federal Tort Claims

ActAct

FTCA 101FTCA 101

• Provides medical malpractice Provides medical malpractice coverage to providers and staff at coverage to providers and staff at community health centers, as well as community health centers, as well as the VA, IHS, military hospitals and the VA, IHS, military hospitals and other federal facilitiesother federal facilities

FTCA 101FTCA 101

• Since 1992Since 1992

• Saves malpractice costs for FQHCsSaves malpractice costs for FQHCs

• Provides a degree of legal Provides a degree of legal “immunity” to providers at FQHCs“immunity” to providers at FQHCs

FTCA 101FTCA 101How the game is played… How the game is played…

• Jane Doe decides that her chronic Jane Doe decides that her chronic back pain is your faultback pain is your fault

• Jane Doe calls a lawyer that she saw Jane Doe calls a lawyer that she saw on daytime TV adon daytime TV ad

• Lawyer files suit in county or state Lawyer files suit in county or state court alleging malpracticecourt alleging malpractice


• Provider receives subpoenaProvider receives subpoena

• Provider panics, cusses, etc…Provider panics, cusses, etc…

• Medical Director notified ASAPMedical Director notified ASAP

• Medical Director contacts FTCA Medical Director contacts FTCA guardian angels at US Department of guardian angels at US Department of JusticeJustice


FTCA coordinators contact local lawyer to FTCA coordinators contact local lawyer to clarify certain key issues…clarify certain key issues…

1.1. Because the provider is covered by the Because the provider is covered by the FTCA, all suits must be filed in federal FTCA, all suits must be filed in federal courtcourt

2.2. The provider is represented by the US The provider is represented by the US Department of Justice… and they don’t Department of Justice… and they don’t look kindly upon frivolous lawsuitslook kindly upon frivolous lawsuits


FTCA coordinators contact local lawyer to FTCA coordinators contact local lawyer to clarify certain key issues…clarify certain key issues…

3.3. They can’t sue the provider or their They can’t sue the provider or their family… The US government becomes the family… The US government becomes the sole defendant.sole defendant.

4.4. An independent medical review board will An independent medical review board will consider the merit of the claim prior to any consider the merit of the claim prior to any proceedingsproceedings

5.5. If a case is filed and pursued, there will be If a case is filed and pursued, there will be no jury trial. A federal judge would hear the no jury trial. A federal judge would hear the case. No jury = No sympathy card… and case. No jury = No sympathy card… and minimal damages for pain and suffering. minimal damages for pain and suffering.

FTCA 101FTCA 101

Most frivolous lawsuits are dropped Most frivolous lawsuits are dropped

within the first weekwithin the first week

FTCA 101FTCA 101

Even if it proceeds…Even if it proceeds…

And Uncle Sam loses or agrees to And Uncle Sam loses or agrees to settle…settle…

Your personal assets are protectedYour personal assets are protected

However… you’d still get a “ding” in However… you’d still get a “ding” in the National Practitioner Data Basethe National Practitioner Data Base

Practical Advice on How to Practical Advice on How to Avoid Getting Sued in the First Avoid Getting Sued in the First

PlacePlace

Cardiovascular DiseaseCardiovascular Disease

• Chest pain should always be Chest pain should always be investigated.investigated.

• Assume that it is heart disease until Assume that it is heart disease until proven otherwise.proven otherwise.

• Document management of risk factors Document management of risk factors and adherence (or lack of) to treatment.and adherence (or lack of) to treatment.

• Maintain a Maintain a high index of suspicionhigh index of suspicion in in patients with patients with diabetes, the elderly and diabetes, the elderly and women.women.

Cardiovascular DiseaseCardiovascular Disease

• Hypertension: enhanced emphasis in Hypertension: enhanced emphasis in reaching reaching goalsgoals for selected for selected populations, i.e., diabetes, pre-populations, i.e., diabetes, pre-existing heart disease.existing heart disease.

• Extremities: document pulses, look Extremities: document pulses, look for infection in patients with diabetes for infection in patients with diabetes and those who use tobacco and those who use tobacco (peripheral vascular disease).(peripheral vascular disease).

MedicationsMedications

• Ask about Ask about allergiesallergies and the nature of and the nature of the problem.the problem.

• Ask again and again (every visit).Ask again and again (every visit).

• Be alert to Be alert to drug interactionsdrug interactions and and document your conversation with document your conversation with patients.patients.

• Consider the use of an Consider the use of an electronic electronic sourcesource of pharmacologic information. of pharmacologic information.


• AnticoagulantsAnticoagulants: risk of hemorrhage; drug : risk of hemorrhage; drug interactions with antibiotics and othersinteractions with antibiotics and others

• NarcoticsNarcotics: sedation, risk of falls: sedation, risk of falls

• AntibioticsAntibiotics: allergies: allergies

• DigoxinDigoxin: check dose in the elderly, nausea: check dose in the elderly, nausea

• StatinsStatins: obtain CPK and follow it, tell them : obtain CPK and follow it, tell them about myositis and the symptomsabout myositis and the symptoms


• LithiumLithium: increased levels with : increased levels with dehydration, certain meds and renal dehydration, certain meds and renal failurefailure

• Do not refill until you are sure of the Do not refill until you are sure of the dose.dose.

• Monitor for adverse effects (consider Monitor for adverse effects (consider standing order for blood tests).standing order for blood tests).

• Bring medications to Bring medications to everyevery visit. visit.

Abdominal PainAbdominal Pain

• High index of suspicionHigh index of suspicion, particularly , particularly in elderly.in elderly.

• If not sure or severe, admit and If not sure or severe, admit and obtain consultations.obtain consultations.

• Think abscess, pancreatitis, Think abscess, pancreatitis, gallstones, bowel ischemia, gallstones, bowel ischemia, appendicitisappendicitis

InfectionsInfections

• Urinary Tract Infections: think Urinary Tract Infections: think pyelonephritis/bacteremia-fever, flank pain, pyelonephritis/bacteremia-fever, flank pain, nausea, tachypnea, relative hypotension.nausea, tachypnea, relative hypotension.

• Look for skin lesions, respiratory rate and Look for skin lesions, respiratory rate and subtle evidence of severe diseasesubtle evidence of severe disease (sepsis). (sepsis).

• Skin infections: suspect deep involvement Skin infections: suspect deep involvement when when pain is out of proportion to what you pain is out of proportion to what you seesee..

• Look for clues that may dictate admission.Look for clues that may dictate admission.

Back PainBack Pain

• Look for alarm signalsLook for alarm signals• Recent trauma, history of cancerRecent trauma, history of cancer• Bowel and/or urinary incontinence or Bowel and/or urinary incontinence or

retention (cauda equina)retention (cauda equina)• Fever (epidural abscess)Fever (epidural abscess)• Cancer (epidural met and spinal Cancer (epidural met and spinal

compression)compression)• Weight loss (malignancy)Weight loss (malignancy)

CancerCancer

• Colon: bleeding, pain, change in Colon: bleeding, pain, change in bowel habitsbowel habits

• Bladder: hematuriaBladder: hematuria• Lung: lung nodule, never assume that Lung: lung nodule, never assume that

it is benign unless you are sure; referit is benign unless you are sure; refer• Ovarian: abdominal enlargement, Ovarian: abdominal enlargement,

constipationconstipation• Cervical: HSV, HPVCervical: HSV, HPV

Breast CancerBreast Cancer

• Investigate all breast symptoms.Investigate all breast symptoms.• Perform mammography.Perform mammography.• Palpable lesions must be investigated Palpable lesions must be investigated

even with a normal mammogram.even with a normal mammogram.• Nonpalpable lesions with an abnormal Nonpalpable lesions with an abnormal

mammogram should be investigated.mammogram should be investigated.• Follow up and tracking if decide not to Follow up and tracking if decide not to

intervene.intervene.• Obtain consultations when in doubt.Obtain consultations when in doubt.

PulmonaryPulmonary

• Evaluate shortness of breath; think of Evaluate shortness of breath; think of pulmonary embolismpulmonary embolism

• Treat acute asthma according to Treat acute asthma according to guidelines; early use of steroids, guidelines; early use of steroids, monitor, admit, if necessarymonitor, admit, if necessary

• Follow up on abnormal chest x-rays, Follow up on abnormal chest x-rays, particularly in smokers or former particularly in smokers or former smokerssmokers

CNSCNS

• SAH: severe headache (never had it), SAH: severe headache (never had it), neck pain; do CT neck pain; do CT and LPand LP, if needed, , if needed, neuro consultationneuro consultation

• Headaches: alarm signals: new onset Headaches: alarm signals: new onset in elderly, progressive, cancer in elderly, progressive, cancer history, neuro signs, papilledemahistory, neuro signs, papilledema

MetabolicMetabolic

• B12 deficiency (elevated methylmalonic B12 deficiency (elevated methylmalonic acid with low-normal level): neuropathy, acid with low-normal level): neuropathy, cognitive dysfunction, anemiacognitive dysfunction, anemia

• Anemia: look for iron deficiency and, if Anemia: look for iron deficiency and, if present, check for present, check for occult GI blood lossoccult GI blood loss

• Electrolytes: diuretics (low sodium)-Electrolytes: diuretics (low sodium)-elderly femaleselderly females

ExtremitiesExtremities

• Document your exam (neuro, Document your exam (neuro, vascular) during lacerations.vascular) during lacerations.

• If trauma and a If trauma and a lot of painlot of pain, think , think compartment syndromecompartment syndrome..

• If there is infection and a If there is infection and a lot of painlot of pain, , think think necrotizing fasciitis.necrotizing fasciitis.

ExtremitiesExtremities

• Trauma: Obtain Trauma: Obtain x-raysx-rays to look for a to look for a foreign bodyforeign body

ReferralsReferrals

• Tracking to prevent lost reports or Tracking to prevent lost reports or nonadherence to consultations.nonadherence to consultations.

• Try to implement for x-rays, Try to implement for x-rays, mammograms and labs.mammograms and labs.

Patient CommunicationPatient Communication

• One of the most important factors.One of the most important factors.• Call for follow up when ill and just seen.Call for follow up when ill and just seen.• Call when new medications are started and Call when new medications are started and

you have a concern.you have a concern.• Express empathy and compassion.Express empathy and compassion.• Do not make inappropriate or judgmental Do not make inappropriate or judgmental

comments.comments.• Become a good listener.Become a good listener.• Do not blame for nonadherence to Do not blame for nonadherence to

treatment.treatment.

LegibilityLegibility

• All prescriptions and medical records All prescriptions and medical records must be legible.must be legible.

• Consider use of transcription or other Consider use of transcription or other electronic means.electronic means.

• The medical record is to document The medical record is to document facts, not criticize other providers facts, not criticize other providers (bad idea).(bad idea).

Office EnvironmentOffice Environment

• Courtesy, respect of staff towards Courtesy, respect of staff towards patientspatients

• Training and monitoringTraining and monitoring

• Define unacceptable behaviors at the Define unacceptable behaviors at the CHC (includes providers)-CHC (includes providers)-Performance ManagementPerformance Management

• Define disruptive behaviorDefine disruptive behavior

Preventive StrategiesPreventive Strategies

• Communicate with patient.Communicate with patient.

• Show respect and courtesy.Show respect and courtesy.

• Alert them if they are going to wait Alert them if they are going to wait more than 15-20 minutes.more than 15-20 minutes.

• Develop referral tracking system.Develop referral tracking system.

• Do not make derogatory comments Do not make derogatory comments toward patients.toward patients.

TrackingTracking

• MammogramsMammograms

• Pap smearsPap smears

• PSA’sPSA’s

• Chest x-raysChest x-rays

• CT scansCT scans

• MRI’sMRI’s

• Blood testsBlood tests

ERER

• Develop good relationships with the Develop good relationships with the ER to facilitate follow up.ER to facilitate follow up.

• Develop protocols to obtain ER Develop protocols to obtain ER records of your patients.records of your patients.

• Do not make negative comments Do not make negative comments about the ER staff or the about the ER staff or the management.management.

RecommendationsRecommendations

• Read daily and develop high clinical knowledge.Read daily and develop high clinical knowledge.• Maintain a high index of suspicion when dealing Maintain a high index of suspicion when dealing

with certain situations.with certain situations.• Call your patients when they are being treated.Call your patients when they are being treated.• Develop referral tracking systems.Develop referral tracking systems.• Write legibly.Write legibly.• Do not make negative comments about others Do not make negative comments about others

in the medical record.in the medical record.• Keep in mind common high risk situations.Keep in mind common high risk situations.

ThanksThanks

Documents

The FTCA and You (aka How to avoid getting sued before it ever happens)