The Doctor’s Advocate | Third Quarter 2018
An Ounce of Prevention
Medical Office Assessments Uncover Hidden Liability Risks
We have always been fiercely committed to protecting the practice of good medicine. Our commitment extends to providing members with the tools and services they need to increase quality and enhance safety.
The Practice Risk INSIGHT program can help you pinpoint risks in your practice and identify ways to minimize liability. Recent participants range from small offices to practices that are part of large integrated delivery systems.
We use a standardized tool to ensure evaluation of eight key areas of risk. Figure 1 summarizes the findings from the 424 most recent office assessments completed by our patient safety risk managers.
At least one telephone communication issue was identified as a risk in 21 percent of the practices. Areas of exposure included the following:
- No established system for tracking incoming telephone calls (during and after hours) from patients and families. This included staff procedures for documenting the medical record, relaying information to the provider, and documenting the provider’s response.
- No provider-developed written protocols for front office staff or unlicensed personnel outlining how to respond to patient questions and concerns.
Provider-to-patient communication is a critical component of patient care. Without an established telephone communication system in place, vital information may not reach the provider and necessary care, or follow-up may be overlooked.
Potential weaknesses were identified in the informed consent process in 18 percent of the surveyed practices. Examples included having no written informed consent documents, no documented informed consent discussion, and no documented informed refusal. This finding is consistent with our closed claims studies—which have frequently observed that insufficient informed consent or failure to document discussions can lead to patient allegations that complications are due to negligence. Informed consent protects and informs both the patient and the physician.
Consultation and Test Tracking
Issues related to consultation tracking were identified in 16 percent of the surveyed practices. Risks in test tracking were found in 14 percent. Some practices depended on passively waiting for consultation reports or a return appointment by the patient. In some cases, there was no evidence of provider review before reports were placed in the chart or electronic health record (EHR). In our closed claims analyses that included alleged missed or delayed diagnoses, failure or delay in ordering diagnostic tests was one of the most common contributing factors.
Appointment management, which includes scheduling and follow-up, was identified as a risk issue in 10 percent of the surveyed practices. Examples included failure to obtain physician review of missed appointments and lack of reminders for age-, gender-, and disease-specific testing. An effective appointment management system may decrease adverse outcomes by limiting the severity of complications or the incidence of delayed diagnoses.
Medical record documentation was an issue in 10 percent of the reviews. Examples included illegible paper records, inaccurate corrections, and incorrect use of templates, drop-down boxes, alerts, and audits in EHRs. We also identified failure to verify autopopulated fields, lack of source verification, and failure to use clinical decision support tools as contributing problems. Complete and timely documentation of the medical record not only enhances patient care, but it also serves to strengthen credibility in the event of a claim.
Medication management was an issue in 8 percent of the surveyed practices. Examples included lack of a complete medication list in the record, not updating the list of medications during each visit, or not documenting allergy information in a prominent location. Having a complete list of the patient’s current medications and allergy information decreases the chances of prescribing contraindicated medications—a leading risk factor for inadequate medication management.
We found that failing to gather pertinent data created risk in 3 percent of the practices surveyed. Examples included inadequate patient histories and current problem lists. Diagnosis and treatment depend on skilled patient assessments.
Risk Mitigation Strategies
The following strategies can assist in preventing some of the issues identified in the assessments:
1. Telephone Communication
- Use a standardized format for managing and documenting all calls during office hours and after hours.
- Ensure that all staff members use the same process to reduce the likelihood of incomplete follow‐up and missed patient care.
- Documentation should include the nature of the call and the physician’s instructions to the patient.
2. Informed Consent
- Conduct a meaningful informed consent discussion with the patient (and/or legal representative or family member) about proposed test or treatment recommendations. The informed consent process may require multiple discussions and, in most instances, cannot be delegated. Discuss the proposed test’s or treatment’s risks and benefits, alternatives, and risks of refusal.
- Communicate information in terms the patient can understand. An interpreter may be necessary for limited English proficiency (LEP) patients and for hearing or visually impaired individuals.
- Document the patient’s refusal of a proposed test or treatment. The written informed refusal should include the key risks of not proceeding with the recommended test or treatment. Find sample consent and refusal forms at thedoctors.com/informedconsent.
3. Consultation and Test Tracking
- Use the EHR functions to provide automation for some steps in the tracking process.
- Assign specific staff to proactively manage outstanding test and consultation reports.
- Establish a mechanism to determine which provider will be responsible for the patient’s overall care, testing, treatment, and follow‐up based on each specialty consultation.
- Ensure that the physician reviews and initials/dates reports before they are filed in the chart.
- Verify that the specialist will communicate results to the patient. To ensure timely communication with the patient, never assume that the specialist will handle it.
- Identify a mechanism—such as a secure patient portal, letter, or telephone call—for communicating normal results.
- Have a plan for contacting patients who cannot be reached by telephone when you need to communicate abnormal but nonemergent results that require timely follow‐up. Consider using certified mail.
Figure 2 details the top three risk categories by selected specialties.
The Doctor’s Advocate is published by The Doctors Company to advise and inform its members about loss prevention and insurance issues.
The guidelines suggested in this newsletter are not rules, do not constitute legal advice, and do not ensure a successful outcome. They attempt to define principles of practice for providing appropriate care. The principles are not inclusive of all proper methods of care nor exclusive of other methods reasonably directed at obtaining the same results.
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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