OCCUPATIONAL MEDICINE:

Risks & Risk Reduction Strategies

ROBERT MORTON, ARM, CPHRM, CPPSASSISTANT VICE PRESIDENT, PATIENT SAFETY AND RISK MANAGEMENT NW REGION, AUSTIN OFFICE

• Robert Morton earned his Bachelor’s Degree in English with a minor in Business Management from the University of Texas, El Paso. He is recognized as a Certified Professional in Healthcare Risk Management (CPHRM) and a Certified Professional in Patient Safety (CPPS). He is recognized as an Associate in Risk Management (ARM) by the Insurance Institute of America. He is a member of the American Society for Healthcare Risk Management and former board member of the South Texas Society for Healthcare Risk Management.

• Mr. Morton is a health care risk management and patient safety professional with more than 25 years of experience in hospital and physician medical liability insurance risk management. His expertise includes coaching, consulting, training, writing and speaking on risk and patient safety-related topics for health care professionals.

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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.

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Objectives

After completing this activity, learners will be able to:• Practice communication skills used to enhance the

physician patient relationship• Educate others about effective approaches to

manage a challenging patient using learned skills and building upon one’s own self-awareness and emotional intelligence

• Implement practice strategies to reduce risk of diagnosis-related malpractice claims involving X-Rays.

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Patient Communication & Patient Relations

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“…The single most powerful diagnostic tool is the doctor-patient conversation... However, what patients say and what doctors hear are often two vastly different things."

Danielle Ofri, MD

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Mismatched Communication

AHRQ Health Literacy Universal Precautions Toolkit, 2nd edition. Health Literacy: Hidden Barriers and Practical Strategies at Internet Citation: http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/index.html Accessed 11/19/18. Content last reviewed August 2018. Agency for Healthcare Research and Quality, Rockville, MD.

• Clinician Process: Giving information

• Patient Process: Understanding, remembering, and acting on information

Studies have shown that 40-80% of the medical information patients are told during office visits is forgotten immediately, and nearly half of the information retained is incorrect.

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Barriers To Effective Communication

• Patient anxiety

• Illness/Pain/Fatigue

• Multiple questions/instructions at once

- “TMI”

• Culture

• Language/Hearing barriers

• Low Health Literacy• Health literacy: patient

understanding of health-related issues

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Case Example

• 56-year-old Native American examined for pre-work physical

• Exam showed HTN, abnormal EKG, type I diabetes mellitus and 40-year history of tobacco use

• Given instructions to stop smoking, medication for HTN, and a return appointment

• Referred to cardiologist and dietician• Patient spoke little English but staff member translated

and patient nodded his head in response

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Case Example …continued

• Patient did not keep follow-up appointment or see cardiologist

• Physician unable to reach patient–no telephone; letter sent to patient explaining need for further care was in English

• Patient found dead at home three months later–large anterior MI

• Allegations-Substandard care including inadequate education-Discrimination–disregard for nationality

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Health Literacy: What is it?

It is the degree to which patients have the capacity to:

• Receive, process, and understand basic health information and services

• Act on information/informed decision-making

• Navigate the healthcare system including payment system

• Includes numeracy

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Source: U.S. Department of Health and Human Services. 2000. Healthy People 2010. Washington, DC: U.S. Government Printing Office.

Red Flags For Low Literacy

• Frequently missed appointments

• Incomplete registration forms

• Non-compliance with medication

• Unable to name medications, explain purpose or dosing

• Identifies pills by looking at them, not reading label

• Unable to give coherent, sequential history

• Ask fewer questions

• Lack of follow-through on tests or referrals

• Excuses: “I forgot my glasses” “I’m tired”

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Health Literacy Universal Precautions

• Structure the delivery of care as if everyone may have limited health literacy

– You cannot tell by looking

– Higher literacy skills ≠ understanding

– Anxiety can reduce ability to manage health information

– Everyone benefits from clear communications

• Confirm understanding with everyone.

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7 Tips For Clinicians

• Use plain language

• Limit information (3-5 key points)

• Be specific and concrete, not general

• Demonstrate, draw pictures, use models

• Repeat/summarize

• Teach-Back (confirm understanding)

• Be positive, hopeful, empowering

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Teach-Back Method - Examples

• Ensuring agreement and understanding about the care plan is essential to achieving adherence– “I want to make sure I explained it correctly. Can you

tell me in your words how you understand the plan?”

– “I teach this information a lot and sometimes forget to include everything. Please explain what we just discussed, so I can be sure I included everything and it was clear.”

– “What are the 2 things that I asked you to watch out for and to let me know if you get them?”

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Understanding

Clarify

Assess

Explain

Teach-Back

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Confirm Patient Understanding

• “Tell me what you’ve understood.”

• “What questions do you have?”

“I want to make sure I explained your medicine clearly. Can you tell me how you will take your medicine?”

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“Do you understand?”

“Do you have any questions?”

Patient Education: What We Know

• Written materials, when used alone, will not adequately inform.

• Patients prefer receiving key messages from their clinician with accompanying pamphlets.

• Focus needs to be “need-to-know” & “need-to do”

• Patients with low literacy tend to ask fewer questions.• Bring a family member and medication to

appointments.

18IOM: Report on Health Literacy 2004 Berkman et al. AHRQ Report 2004

Use Pictures and Models

Use more than just words when possible

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• Visual learners need pictures.

• Most health illustrations are too complicated.

• Physician drawings are often very good (not too complex).

• Patients say, “Show me,” and “I can do it.”

Words to Watch –Medical Word Examples

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Source: National Patient Safety Foundation, 2016.

Words to Watch –Value Judgment Word Examples

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Words to Watch –Concept Words

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Words to Watch –Category Word Examples

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The Patient’s Perspective on Listening Serving Three Main Functions

Listening: a defining feature of a “good” doctor

Benefits:1. Enables physicians to make accurate

diagnoses2. Instrumental in creating and maintaining a good

doctor-patient relationship3. Acts as a healing and therapeutic agent

24Patient Education and Counseling. Volume 85, Issue 3, December 2011, Pages 369-374

Listening Techniques & Skills

1) Let them speak2) Actively listen3) Paraphrase the story4) Validate the story 5) Create awareness of what is important to them

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Source: Clinician Experience Project by Practicing Excellence, accessed online 11/30/2018

What Is ASK ME 3™?

What is my main problem?Diagnosis

What do I need to do?Treatment

Why is this important for meto do this? Context

26http://www.askme3.org/

Patient Satisfaction and Filing of Lawsuits

Study after study has found a correlation between patient satisfaction and the filing of lawsuits.

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Source: * Stelfox, H.T., et al. 2005. The relation of patient satisfaction with complaints against physicians andmalpractice lawsuits. American Journal of Medicine. 118:126-33.

Patient Feedback

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• Promote patient feedback with:– Pen and paper

satisfaction surveys– Many resources– Online surveys– Implementing a patient

relations program• What do we do

right? • What should we

change?

Patient’s Definition of Quality

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The Patient

Don’t Harm Me

Be Nice to Me

Heal Me

Challenging Patients

Who Are The Challenging Patients?

• The patient who has unrealistic expectations• The needy patient • The pushy/manipulative patient• The patient who won’t follow the treatment plan• The confrontational patient

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Factors Contributing to Challenges

• Patient factors– Unrealistic expectation of

care– In pain or not feeling well– Anxiety over diagnosis– Previous dissatisfaction or

bad experience– Have unrecognized

psychiatric problems• Depression• Mood disorders

– Lack social/financial resources or support

– Life stressors

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• Provider Factors– Overworked– Poor communication skills– Discomfort and/or uncertainty– Personal beliefs/personality– Cognitive bias– Life stressors

• System– Productivity pressures– Prior authorizations– Payment/reimbursement

issues– Fragmentation of visits/care– Lack of availability of outside

information

Challenging Patients - Where To Start

• Understand that your reactions are normal– Anger – Resentment– “I don’t get paid enough for this”

• Take a deep breath and a moment to collect thoughts

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Challenging Patients - Where To Start

• Communication statistics– 60% of communication is by body language– 30% is in delivery and tone of voice– 10% is our choice of words

• When dealing with an upset patient, you have approximately seven seconds to set the tone for that encounter with facial expressions and body language

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Challenging Patients - Where To Start

• Listen to the patient– Try to remember where their actions might be

coming from – Apologize for “situation”

• “I’m sorry you are going through this, it must be very difficult for you.”

• Respond to questions, concerns, and complaints if you can– “What can I do to help?”– “Let’s see what we can do to make things better.”

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Why Do Patients Sue Their Doctors?

• Anger• Dissatisfaction with treatment• Want answers but no one will talk• Unhappy with staff or provider attitude• Feel like no one cares• Revenge or retaliation• Entitlement attitude

The physician-patient relationship and communication are factors in all of these reasons!

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Where Does The Anger Come From?

• Anxiety• Fear• Embarrassment• Uncertainty• Financial stress

All can manifest as anger and hostility

• Anger may be used to regain a feeling of control• Anger is not necessarily abusive or threatening

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Strategies for Managing Grievances

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Decrease your liability in dealing with challenging patient situations:• Acknowledge grievances promptly

- Do not hide from disgruntled patients• Allow the person to vent• Give patients the answers they request• Seek to understand, clarify, then empathize in your

words and gestures • Try to make things right• If valid complaint, consider dismissing bill

Handling Challenging Patients

• De-escalate; separate the hostile person from others• Listen to and acknowledge concerns, empathize• Maintain professional demeanor• If appropriate, include a witness/second party in the

room• If you do not know the answer, promise to follow up

and then make sure to do so.• Always alert the management/provider to the

situation• Always have an exit path• Explain why a particular demand cannot be met• Negotiate a plan to reach a compromise

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The Patient Making a Complaint

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Wants to:• Be taken seriously• Be treated with respect• Be listened to and heard• Have the problem

acknowledged• Have someone take

action• Be assured the problem

will not recur

Peace Offerings

• Gift cards, when patients are inconvenienced, can go far in diffusing anger for a long wait or a miscommunication– Examples: Starbucks, Chick-fil-A, grocery

store– Give patients a choice

• Refunds/Settlements– Contact the Claims Department

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Diagnostic Challenges

Diagnostic Error

• Error or delay in diagnosis• Failure to employ

indicated test• Use of outmoded test or

therapy• Failure to act on test

results

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Preventing Medical Injury. Qual Rev Bull. 19(5):144–149, 1993.

How We Think• System 1 (intuitive)

–Rapid thinking of common situations (pattern recognition)

–Best suited for simple task

–Minimal effort• System 2 (analytical)

–Not automatic, slower processing

–Requires cognitive awareness

–Requires more effort

44Source: http://www.improvediagnosis.org/?CognitiveError

Problems In Thinking

• Anchoring bias-After reaching primary diagnosis, thinking

stops• Confirmation bias

-Tendency to look for confirming vs. disconfirming evidence

• Diagnosis momentum (chart lore)-Once labels are attached to patients they

become sticky• Visceral bias (attribution)

-Negative feelings towards a patient leading to missed diagnosis

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Additional Considerations in Cognitive Focus

• Costs in multi-tasking, task switching-Efficiency/productivity-Accuracy-Performance

• Interruptions = forced multi-tasking• Digital distraction in healthcare

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APA, 2006. https://www.psychologytoday.com/us/blog/brain-wise/201209/the-true-cost-multi-tasking https://en.wikipedia.org/wiki/Task_switching_(psychology)

Case # 1: Alleged Failure To Diagnose Fractured Ankle• Pt seen 19 days after initial fall with multiple complaints of severe

pain in neck, left arm, lower back radiating into left leg and right ankle.

• X-ray of ankle showing no acute fx or dislocations. Dx with back, neck & ankle sprain. Pt given brace & crutches & referred to orthopedist.

• Seen a week later by ortho. Not better, gross swelling, more tender. MRI of right ankle & podiatry consult recommended.

• Two weeks later, MRI & arthrogram of right ankle showed separated fragment at the anterior aspect of the tibia at the tibiotalar junction, possible tear or sprain.

• Patient had surgery to foot and later fell, reinjuring foot.• Dismissed, no payment. • Issues coded: Clinical Judgment, misinterpretation of X-Rays.

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Case # 2: Alleged Failure to Diagnose and Delayed Treatment of Fractured Femur • 2/1 Pt fell and accidentally shot self in R thigh w nail gun, seen by

NP. • Hx uncontrolled DM. Wound irrigated & X-Rays initially read by NP =

no fx, but questioned if nail nicked bone. Rx Augmentin. Told f/u if s/s infect. D/c home.

• Films sent via Telerad to Rad -noted two linear lucencies. Possible non-displaced fx line.

• 2/4 NP signed report--Pt not sent copy, not notified of finding & no ortho referral made.

• 2/11 pt called & requested med for pain-Rx hydrocodone. No documentation of discussion of X-Ray result or ortho referral.

• 2/19 fell at work, unable to walk. To ER: Dx with spiral fx femur where previously struck by nail. Pt had multiple surgeries and infection complications.

• Case settled.48

Case # 2: Issues Coded

Issue Issue Type Category Subcategory Contributor Type

Rationale for Human Factor

AD1024 - Need for policy/protocol

HF - Human Factors

AD -Administrative AD5 - Policy/protocol Insured reporting dx study

results to pts

CJ1027 - Pt assess—misinterpretation of dx studies (x-rays, slides, fms)

RMI - Risk Management Issues

CJ - Clinical Judgment

CJ1 - Patient assessment issues Insured

CO4001 -Telemedicine/Teleradiology

RMI - Risk Management Issues

CO -Communication CO4 - Internet/telemedicine Non Insured

CJ4001 - Failure/delay in obtaining consult/referral

RMI - Risk Management Issues

CJ - Clinical Judgment

CJ4 - Failure/delay in obtaining consult/referral Insured

CS3011 - Patient did not receive results—no report or wrong report

RMI - Risk Management Issues

CS - Clinical Systems

CS3 - Failure/delay reporting findings/revised findings Insured

DO3008 - Insufficient/lack of documentation—phone advice to patient

RMI - Risk Management Issues

DO -Documentation

DO3 - Insufficient/lack of documentation Insured

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Case #3: Alleged Failure to Timely Diagnose Fracture• 3/1 Pt tripped & fell at work. Pt tried to stop fall by grabbing railing,

but hit wrist & hand on railing.• Dr. noted pt had full ROM of left wrist; no deformity & no tenderness

at left snuffbox. X-rays ordered; three views-initial read was wnl. Placed in wrist brace and given script for pain medications. X-rays over-read by radiologist who also found no fracture.

• 3/6 OV f/u-pt said some improvement but had restricted ROM to wrist. Order for PT. Pt went to PT & had ongoing pain throughout therapy.

• 3/23 PT ended & pt continued to c/o pain. Another X-ray ordered. Fxwith mildly impacted fx of distal half inch of left radius w 3-4 mm of ventral overriding. Later had 2 surgeries on wrist.

• Dismissed vs doctor.• Defense expert supportive of doctor. X-ray was misread by

radiologist but not below SOC for occupational med/FP med to miss this subtle fx.

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Strategy Wrap Up

• Assess and address patient understanding of the basics

• Ask Me 3, keep it simple

• Practice empathic listening

• Be aware of challenges to optimal cognitive functioning

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Tools To Try, Resources to Access

• Ask Me 3® (see Institute for Healthcare Improvement resources)

• Medical Office Survey on Patient Safety Culture (see AHRQ)

• TeamSTEPPS: Strategies and Tools to Enhance Performance and Patient Safety (see AHRQ)

• SBAR (see Institute for Healthcare Improvement resources)

• CME: How Healthcare Leaders Can Reduce Risks of Distracted Practice in Their Organization (see The Doctors Company CME)

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“I've learned that people will forget what you said, people will forget what you did,

but people will never forget how you made them feel.”

Maya Angelou1928-1914

Poet/Actress

Robert Morton, ARM, CPHRM, CPPSAssistant Vice President

Department of Patient Safety and Risk ManagementAustin Office

RMorton@thedoctors.com(800) 421-2368, extension 3836

Patient Safety and Risk Management, CMEeducationsupport@thedoctors.com

Additional resources and activities please visitwww.thedoctors.com

Contact Information

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