Meeting the Challenges of the Nonadherent Orthopedic Surgical Patient

Cynthia Morrison, RN, CPHRM, Senior Patient Safety Risk Manager, and Amy Wasdin, RN, CPHRM, Patient Safety Risk Manager II.

Orthopedic surgery as a specialty often requires time-sensitive treatment options. Patient compliance with the plan of care is essential.

As noted in our Orthopedics Closed Claims Study, nonadherent behaviors affect patient care outcomes. These behaviors include, but are not limited to, failing to comply with the recommended treatment plan (such as wound and cast care) and missing or canceling follow-up appointments. Consider the following tips for managing nonadherent behavior.

Overcome Communication Barriers

Effective communication provides the link to patient satisfaction—which leads to adherence and, ultimately, to a more favorable outcome. A patient’s failure to comprehend and adhere to the planned treatment process may be related to health literacy or competency level, cultural barriers, or financial restraints.

  • Determine the extent of the patient’s comprehension. Ask the patient or interpreter to repeat back what was said during the informed consent process, the treatment plan discussion, or any educational session with you or your staff.
  • Use language services for your limited English proficiency (LEP) patients. Educational tools, such as the Ask Me 3 approach, are also helpful. Ask Me 3 identifies three simple questions that all physicians should be ready to answer. For more information about the Ask Me 3 communication tool, go to
  • Establish written financial policies and procedures and consider using payment plans to assist patients in meeting their financial responsibilities.

Meet Patient Expectations

Provide the patient with the information he or she needs to make an informed decision. A patient who is comfortable and agrees to a recommended plan is more likely to comply. List the patient’s responsibilities as part of the written instruction plan, and provide a copy to the patient.

Document Nonadherent Behavior

Document the nonadherent behavior, such as canceled or no-show appointments and failure to follow instructions. A well-documented record that reflects the patient’s responses demonstrates the provider’s attempts to develop a plan of care. If, at some point, the physician-patient relationship is discontinued, documentation supports the physician’s efforts.

Involve the Patient

Emphasize patient involvement by using information tools, such as links to websites, bulletin boards, educational materials, written instructions, and reminder calls and notifications.

Manage Continued Nonadherent Behavior

Continued nonadherent behavior impedes the ability to establish a therapeutic physician-patient relationship and may require dismissing the patient from your practice. There are steps to be followed when dismissing a patient under your care. Your patient safety risk manager can assist you with this process.

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 considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

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