Case History: Fetal Demise page 3. Telephone Triage Protocols page 4. Dealing with Challenging Patient Behavior page 5

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1 Issue 2 May 2015 Arizona Issue O Case History: Fetal Demise page 3 Telephone Triage Protocols page 4 Dealing with Challenging Patient Behavior page 5 PROVIDING MEDICAL PROFESSIONAL LIABILITY IN ARIZONA, COLORADO, NEVADA AND UTAH

2 About us Our mission is to protect and defend the practice of medicine in Arizona, Colorado, Nevada and Utah. Executive Staff: James F. Carland, III, M.D. President & Chief Executive Officer Ronald E. Malpiedi, Vice President & Chief Operating Officer Edward G. Marley, MBA, Vice President & Chief Financial Officer Darren J. Palmer, Vice President & Chief Information Officer Robin L. Charles, MBA, CIC Vice President, Marketing & Corporate Communication Walt Davis, Vice President, Claims Mary K. Hedin, MBA, RPLU, Vice President, Underwriting Leon W. Kochan, M.C.Ed, Vice President, Human Resources Julie A. Ritzman, MBA, Vice President, Risk Management Service Board of Trustees: James F. Carland, III, M.D., Chairman Marc L. Leib, M.D., Vice Chairman Joseph W. Hanss, Jr., M.D., Secretary Douglas P. Jensen, M.D., Treasurer Phyllis I. Biedess James G. Leiferman, M.D. Steven P. Matteucci, J.D. Jeffrey W. Morgan, D.O. Karen J. Nichols, D.O. David A. Pedersen, M.D. J. Greg Rula, M.D. Amy A. Silverthorn, M.D. Walter K. Sosey, M.D. Charles W. Swetnam, M.D. Michael A. Trainor, D.O. MICA was founded in 1976 after the largest medical professional liability (MPL) insurance carrier announced it was no longer underwriting MPL insurance coverage for the physicians of Arizona. MICA offers stability through the peaks and valleys of the insurance cycle. Our mission is to protect and defend the practice of medicine in Arizona, Colorado, Nevada and Utah. Our vision is to be the insurance company of choice for physicians and their groups, medical facilities and nurse practitioners. Our values include outstanding service to our members, affordable insurance coverage, prudent underwriting principles, relevant risk management programs to educate and protect our members, aggressive defense against claims, and paying dividends to our members when financial conditions warrant. In fact, over the past ten years, we have paid $337 million in dividends to our members*. * Dividends declared in a given policy year reflect the Company s financial performance during that year. Past performance does not guarantee future dividends. 2 MICA Risk Rundown May November

3 Case History: Fetal Demise A43-year-old woman at the end of her first trimester of pregnancy presented to a group OB/Gyn office for prenatal care. She had a history of two uncomplicated pregnancies and indicated she had been trying to get pregnant for over two years. Her husband asked many questions of the staff and appeared very anxious about the welfare of his wife and unborn child. During the pregnancy, the patient saw several different physicians as part of the routine care provided by the group. She was identified as high risk due to advanced maternal age and polyhydramnios. During the third trimester, twice-weekly Biophysical Profiles (BPP) were started. An ultrasound technician employed by the group was performing the BPPs. At eight months, the patient had a BPP score of 8 out of 8. An induction at 39 weeks was discussed with the patient. At 38 weeks, the patient s BPP score was reported as 6 out of 8. The patient reported normal fetal movement. She was instructed by the physician to do kick counts, and if they fell below a certain number, she should go to the hospital s labor and delivery unit right away; otherwise, she should keep her appointment with the group in one week. However, the patient went into labor before then and went to the hospital. On the patient s admission to the labor and delivery unit, there was no fetal heart rate detectable. Fetal demise was ultimately diagnosed. After induction, a stillborn infant was delivered with a tight nuchal cord. No fetal anomalies were identified. The parents filed a lawsuit alleging negligent prenatal care. This case was ultimately settled in the six figure range. Problems with this case: Subsequent testing such as a nonstress test was not done when the BPP was reported as 6 out of 8. Plaintiffs experts testified that additional testing could have confirmed fetal well-being or indicated a need for additional intervention. Questions were raised regarding the accuracy of the BPP scoring and the technician s understanding of how to score the test. Documentation of the technician s training, continued education, and oversight by the group, was lacking. The group did not maintain the recordings of ultrasound tests, so there was no record of the BPP test results other than notations in the chart and the written test report. Allegations of failure to maintain a complete patient record complicated this case. The husband expressed frustration that he had asked many questions about his wife s care during her pregnancy but felt the questions had not all been answered. The parents reported they had never received a visit from any of the physicians in the group to express their condolences after the fetal demise. Discussion: When test results change indicating a potential problem, additional testing should be considered. Not only might this extra step indicate a developing complication, but might also help establish well-being. This can be especially important when, as in this case, it was not determined when the tight nuchal cord began to affect the fetus. If the physician determines further testing is not justified, the reasoning process for the decision should be documented. Questions regarding the competency of staff, employed or contracted, may ultimately result in direct or vicarious liability, particularly if there is little or no documentation of supervision or oversight. Licensure, training, certification and experience should always be verified, and regular review of skills should be documented. In addition, in this time of expanding diagnostic technology, it is important to review the electronic data being generated to ensure appropriate records are being retained. Dealing with an adverse outcome is one of the most difficult aspects of medical practice. Unfortunately, reasonable errors of professional judgment can end up in litigation because of poor communication following an adverse event. When an adverse event occurs, compassion and expressing sincere sympathy to the patient and/or family is the best response. Sustaining the relationship with the patient by continued emotional support could help a patient better accept an unexpected complication. Avoiding patients may give the unwanted perception that you did something wrong or are abandoning them. Prompt communication in a nondefensive way can help dispel much of the patient s anger, distrust, and confusion. As with all patients and their families, maintaining open lines of communication is vital to good patient care and effective risk management in the event of an unexpected outcome. When the husband of the patient was presented as anxious and asked many questions, particularly with a patient history of difficulty getting pregnant, it may have been helpful to develop specific communication strategies for both parents. Lack of trust may develop when families feel their concerns are not addressed, which may ultimately contribute to litigation when complications occur. May 2015 MICA Risk Rundown 3

4 Telephone Triage Protocols Physician practices are looking for efficient and economic methods for managing the ever increasing volume of telephone calls. Despite the availability of Patient Portals, ing and texting, telephone calls remain an integral method for patients to communicate with their physicians and other healthcare clinicians. Billing issues, prescription refills, scheduling appointments, and concerns from sick patients are examples of telephone encounters office staff must address. Delayed or unreturned phone calls are a source of patient dissatisfaction and represent a significant liability risk for physicians. Important information can fall through the cracks, resulting in adverse patient outcomes when phone calls are not screened and appropriately triaged. Technology can play a pivotal role in educating patients about routine health issues, but practices must look for systems to manage phone calls involving serious health concerns so they are quickly identified and immediate steps are taken to address any urgent patient needs. Written protocols or guidelines for telephone triage are important to establish consistent care and minimize the practice s liability exposure. Written telephone triage protocols and commercial triage services are available for purchase, or the practice may want to develop their own protocols. Any of these options can be helpful, but all of them have risks and benefits that should be carefully considered. The physician(s) and other healthcare clinicians should carefully review the protocols to ensure they provide information consistent with the practice. Additionally, practices may want to check with their specialty organizations to see what resources related to telephone triage protocols are available. Risk Management strategies for developing a telephone triage system include: Patients associate any information obtained from a physician s office as originating from the physician. Therefore, only advice approved by physicians and other qualified practitioners should be provided. The protocols should list commonly asked questions, the appropriate responses, and/or additional questions that need to be asked. The protocols should clearly address those situations which are urgent and should be immediately referred to the physician or other healthcare practitioner. The threshold for obtaining a physician s or other qualified practitioner s response should be relatively low. Who will be triaging the calls: unlicensed staff, LPNs, RNs, PAs, or NPs? This will make a difference in the complexity of the protocols or guidelines you decide to use. The triage person must have the education and experience to recognize the limitations of telephone triage versus a face-to-face encounter and apply enhanced listening skills. All phone encounters involving any medical symptoms, medication use and/or medical history should be carefully documented in the medical record. This documentation should include the date, time, and reason for the call. Additionally, the medical record entry should include any advice, information or instructions provided, including at what point the patient should seek medical attention, and if a physician or other qualified practitioner was consulted. The patient s response to the exchange of information should be documented. Documentation should be sufficient to ensure continuity of the patient s care and reviewed routinely for quality monitoring purposes. 4 MICA Risk Rundown May 2015

5 problem situations in time to diffuse them. For example, awareness of the anxiety and irritation caused by a long wait provides impetus to keep patients informed and a reason to watch for signs of anger and aggression in the waiting room. Patient factors include: delirium, anxiety, pain, fear of the unknown, confusion, economic concerns, and healthcare literacy. Non-patient factors include: inexperienced staff, ineffective communication skills, long waits, understaffing, poor coordination of care, and lack of appropriate training for staff. Dealing with Challenging Patient Behavior The MICA Risk Management Hotline for insureds often receives calls asking for advice on dealing with challenging patient behavior. Factors such as economic issues, uncertainty regarding changes in healthcare payment systems, decreasing numbers of physicians to care for increasing numbers of patients, and what some perceive as an increasingly violent society can fuel challenging patient behaviors. It is important for physicians to be knowledgeable of the causes of patient frustration and anger, in order to assist patients to understand the healthcare system and their own healthcare, to de-escalate any anger and decrease the risks related to potential violence. Staff often experience difficulties related to no-shows and angry confrontations with patients or family members at the front desk. According to OSHA, the healthcare field has one of the highest rates for non-fatal incidents of violence. More detailed information on preventing workplace violence can be obtained at the OSHA website A variety of factors cause challenging patient and family behaviors. Knowledge of these factors may help staff identify potential A team approach is helpful in dealing with patients. A shared awareness of potential problems with patients known to be angry or upset, and family members who have exhibited challenging behaviors can assist staff to prepare for dealing with these issues. Staff training is essential to any prevention plan. It is helpful to provide key phrases that may be helpful in dealing with anger, such as I m so sorry you re this unhappy and Let me see if I can help or find someone else who can assist you. Guiding an unhappy patient or family member to a quieter place may also be helpful. However, care should be taken not to create a situation where a staff member is alone and isolated with an angry person. It is important for staff to be aware that some frustrated people simply require more information or clarification of misunderstandings to help them remain calm. Many challenging patients can become cooperative patients when given the appropriate assistance. It s important to document any incidents of challenging patient behavior. The actions should be objectively described as opposed to using labels such as uncooperative, disruptive, unpleasant or dangerous. In addition, staff should document all efforts to assist patients and/or family members including attempts to explain and to clarify answers to questions and offers to investigate concerns. If efforts ultimately fail to improve the behavior and it becomes necessary to terminate the patient-physician relationship, it s important to have complete documentation in the event of any allegations of unfair treatment. Stating clearly that violence will not be tolerated may be helpful when situations become threatening. Employees should be encouraged to report all incidents of violence and threats. Consider contacting the police whenever there is reason to believe staff and/or other patients may be in danger or are being physically threatened. Establish a plan to handle such a situation including ready access to appropriate phone numbers. You may also wish to investigate community resources for psychiatric and neuropsychiatric referrals. There are opportunities to diffuse an escalation to violence and to assist a troubled patient with knowledge of the causes of challenging behavior. In this way, you can protect patients and staff. May 2015 MICA Risk Rundown 5

6 2602 E Thomas Rd Phoenix, AZ PRSRT STD U.S. POSTAGE PAID SALT LAKE CITY, UT PERMIT NO Mutual Insurance Company of Arizona The information contained in this publication is intended to provide general information for review and consideration. The contents do not constitute legal advice and should not be relied on as such. If you need legal advice or assistance, it is strongly recommended that you contact an attorney as to your specific circumstances. SINCE MICA S FOUNDING, OUR MEMBERS HAVE RECEIVED OVER $ MILLION IN DIVIDENDS As a mutual company, MICA distributes dividends to its members when financial conditions warrant. With the announcement of a $27 million dividend for the 2014 policy year, MICA s total dividends distributed to members totals more than half a billion dollars. MEDICAL PROFESSIONAL LIABILITY INSURANCE (602) , (800) Dividends declared for a given policy year reflect the Company s financial performance during that year. Past performance does not guarantee future dividends.