Liability

PART 2 Mitigating Disgruntled Patıents

Prevent the opening for a medical malpractice suits by planning for patient threats.

Hans K. Bruhn, MHS, San Francisco, CA

When patients are displeased with some aspect of their experience, they may become aggravated with the doctors, the staff or both. They may direct their dissatisfaction at the front desk by making a scene, threatening legal action, or even resorting to violence. Learning to navigate this dark side of patient care may prove vital one day. First, be sure you’re covered legally. Then, prepare for this unpleasant situation.

This article reviews the risk posed by disgruntled patients and the legal and systemic means to handling these confrontations.

The informed consent process

Documentation evidencing that a patient was advised about the care proposed by the physician, in particular a surgical procedure, requires a specific consent from the patient.

What is “informed consent”? It is an oral agreement reached after the surgeon advises the patient of his or her diagnosis and proposed treatment. Risks, benefits, and alternatives are explained including consequences of refusing treatment. Nurses and technicians are often responsible for providing information to the patient about the procedure, preparing the patient for the required discussion with the physician to answer any remaining questions about the procedure prior to obtaining consent. Procedure-specific consent forms are often available from your professional liability insurer. These documents are typically the responsibility of the clinical practice to obtain.

In contrast, staff at a surgical facility is responsible for obtaining consent from patients to proceed with the general risks associated with surgery. Anesthesia providers, if needed, are also involved in this general consent discussion.

Disgruntled patients

Once a surgical procedure is completed or medical treatment has been administered, the post-op period and routine follow up of patients can pose an additional risk to the practice. Sometimes patients become frustrated with the outcome of care or the recovery process. A difficult patient may threaten to file a claim or even act in a violent manner. These situations range from patients who are merely complaining about their treatment and perhaps demanding a refund, to physical assaults on the ophthalmologist or staff.

As far back as 2000, data from the Bureau of Labor Statistics showed 48% of all non-fatal injuries from occupational assaults and violent acts occurred in health care and social services. OSHA, which publishes guidelines to prevent workplace violence, believes that the actual numbers are much higher. Practice staff may not be aware of their rights when it comes to dealing with difficult patients. Practices should develop policies and procedures identifying staff responsibilities for dealing with this contingency.

Non-violent criticism

Typically, ophthalmologists and their staff are confronted with non-violent expressions of anger and aggression in the form of malicious oral and written criticisms of care, ultimatums for fee refunds, and threats of litigation. Some disgruntled patients are taking to posting negative comments about a physician and practice online. Generally, these situations don’t occur suddenly without warning, but rather rise to a boiling point over a period of time. So, staff need to notify their ophthalmologist immediately when there is a problem.

Standards of Behavior

Often patients act very differently with technicians and nurses than they do with the physician. The ophthalmologist should determine what is acceptable behavior in the practice and the staff needs to help enforce that standard of behavior. Recognition of worrisome behaviors and prompt discussion between the ophthalmologist and staff about how to proceed are undoubtedly the best first steps in managing the problem. Because all situations are not alike, it is recommended that you involve the risk management department of your professional liability insurer to help craft a response to handling these patients. Often, by the time a practice calls their insurer, they have already tried more than one approach to reason with and accommodate the patient, and have concluded that the patient’s behavior has become so inappropriate that the ophthalmologist can no longer effectively provide the needed eye care. Even when the decision has been made to terminate the physician-patient relationship, there are several issues that staff needs to ask themselves about the patient:

1. What is the reason for the patient’s anger? Oftentimes, a patient’s anger is understandable (e.g., a complicated surgery results in a poor outcome.)
2. Are family members involved? When a spouse or other family member who accompanies the patient is acting inappropriately (threatening litigation, calling or writing the ophthalmologist, or otherwise making it difficult for the ophthalmologist to provide care), it may seem unfair to terminate the relationship with the patient. However, the patient is usually implicitly or explicitly allowing the other person to interfere and there may be no alternative but termination.
3. What is the patient’s current clinical status? It may not be possible to terminate a patient who is in an acute stage of an illness; however, if another provider is willing to take over care, even an acutely ill patient may be transferred out of the practice. Most patients can be safely discharged from care with 30 days notice.

Develop an office policy for handling disruptive or dangerous patients. This policy should outline specific procedures for notifying employees, outside authorities, and others in an emergency situation, including how to assess the severity of the situation and its impact on the office, when to call police or other appropriate authorities. Each employee and supervisor should know their specific responsibilities in an emergency and at what point those responsibilities shift to others. The most important thing is to take some action with disruptive patients. Not doing anything typically results in an escalation of the behavior and a delay in treatment (due to the disruptive behavior).

Knowing which patients to treat first, honoring their right to make informed decisions about their care, all while maintaining a safe environment for all patients and staff requires a team working off a set of policies and procedures that ensures a consistent commitment to patient safety and mitigation of liability risk for the practice. OP

Mr.. Bruhn, is the senior risk management specialist at Ophthalmic Mutual Insurance Company is San Francisco, Calif. The first part of his article appeared in the January/February issue of Ophthalmic Professional.