Policies and Procedures

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1 15 Policies and Procedures to Reduce Liability for Physician Practices By James W. Saxton, Esq. A book and CD-ROM set to provide standardization for your staff to help reduce liability, improve patient satisfaction, and ensure quality care. Additional HCPro titles for your physician practice library: The Top 15 Financial Management Policies and Procedures for Physician Practices Clinical Trials Roadmap for Physician Practices Paying Partners: Buy-In, Pay-Out, and Income Division Scheduling Strategies: Making Physicians More Productive Improve your Productivity The Satisfied Patient Solving Partner Level Challenges HCPro P.O. Box 1168 Marblehead, MA to Reduce Liability for Physician Practices TFPPR 15 Policies and Procedures Saxton Visit the Healthcare Marketplace at for more information on our products, or to sign up for any of our dozens of free online ezines. The Top About HCPro HCPro, Inc., is the premier publisher of information and training resources for the healthcare community. We produce newsletters, books, audioconferences, training handbooks, videos, online learning courses, and professional consulting seminars to meet the needs of specialists in health information management, compliance and accreditation, quality and patient safety, nursing, pharmaceuticals, medical staff, credentialing, long-term care, physician practice, infection control, and safety. The Top James W. Saxton, Esq.

2 Contents About the authors iv Introduction vii Chapter 1: Quality improvement, customer service, and patient satisfaction Addressing patient complaints policy Telephone communication procedure/policy Scheduling policy Chapter 2: Patient rights and responsibilities Cultural competency/issues policy Confidentiality and access to medical records policy Chapter 3: Documentation and medical records Informed consent and informed refusal policy Records retention policy Tracking referrals and test policy Chapter 4: Patient safety Disclosing medical errors policy Medical emergencies policy Handling high-risk patients policy Medication management policy Chapter 5: Legal issues Management of professional liability claims policy Terminating-a-patient policy Request for medical records release policy

3 Q u a l i t y i m p r o v e m e n t, c u s t o m e r s e r v i c e, a n d p a t i e n t s a t i s f a c t i o n C h a p t e r 1

4 C h a p t e r o n e Q u a l i t y i m p r o v e m e n t, c u s t o m e r s e r v i c e, a n d p a t i e n t s a t i s f a c t i o n Data has shown that malpractice does not cause malpractice claims; rather, many claims are linked to patient dissatisfaction, communication lapses, and customer service. Therefore, by improving customer service and satisfying patients, you can reduce liability risks and create a positive impact on your practice s bottom line. This chapter focuses on these issues, which are the top three areas of traditional risk in every physician s office and that also can affect patients satisfaction ratings. You can reduce liability by incorporating policies and procedures that address these three key areas of risk, by educating staff and physicians on those policies and procedures, and by complying with them. You ll also improve patient satisfaction and customer service. 1. Addressing patient complaints A physician s office benefits from appropriately handling patient complaints as they arise. They can do so by establishing an effective complaint process and involving the right person with the right complaint. Oftentimes, patients are frustrated and simply need a way to vent. In such cases, your role is to empathize, listen, and investigate. To the extent possible, you often can remedy the situation by explaining that your practice has created systems via policies and procedures to prevent reoccurrence of the same issue (when that is true). Patient complaints often result from misunderstandings or service lapses. You can address some complaints immediately, and others require a more comprehensive investigation. Inform patients about the investigation process, and give them a contact name and number at your practice should they have any questions. By handling patient complaints through this kind of process, you can improve patient satisfaction significantly.

5 Chapter one 2. Telephone communication A second area of high risk for office practices includes telephone triage, telephone advice, prescription refills, and after-hours calls. You can reduce much of the risk associated with these areas by using proper documentation, education, and training. Therefore, a policy that dictates a process and procedure for each of these areas is essential, and the medical staff and physicians must follow. Practices should look at the telephone as a useful tool in their daily practice and as one that staff must handle appropriately. For example, do not use the telephone as a way of treating or diagnosing patient conditions. Use it as a form of communication: Staff and patient time is valuable, so use the telephone to prioritize and manage patient needs and desires. Inquiries by telephone can range from emergent to routine needs, such as billing questions. Both staff and patients should know about your practice s after-hours calling process, so stick to it. Common reasons for after-hours calls include medication refills and concerns, pain, and acute illness. 3. Scheduling Patients often complain about the length of time it takes for a physician to see them and the process involved in making appointments. To minimize this dissatisfaction, examine your scheduling process and your practice s needs. Collect data on the number of patients you can see each day, your facility s office hours, and the physicians daily availability to see patients. Track and trend this data to create a realistic policy that is unique to your practice and that satisfies patient scheduling needs, while also considering any limitations of the practice. The policy should include protocols for handling high-risk symptoms and patients, scheduling new patients, and documenting properly. Areas of traditional risk include cancellations and no-shows, which can be used against a physician in a lawsuit if proper documentation and follow-up does not occur.

6 Quality improvement, customer service, and patient satisfaction 1. Sample addressing patient complaints policy Your practice name Subject: Addressing patient complaints Approved by: Policy number: Effective date: Review date: Revision date: Page 1 of 2 Purpose: To establish a patient-oriented process for the timely management of concerns or complaints expressed by patients/family members. Policy: Our practice will promptly address patient/family complaints or concerns in a proactive and positive manner. Procedure: Decide whether to notify the pertinent provider. Bring any concern expressed via telephone, in person, or in writing to the immediate attention of the person designated by the practice to handle complaints (often the practice manager), who shall ensure that the following occurs: Step 1: The designee determines who is best suited to communicate with the patient or family member. It may be the provider; whether it s the physician or not, it should be someone who can com- municate well. Step 2: When possible, address the issue when it is raised. More investigation is sometimes necessary. When that is the case, give the patient or family member an initial response, either by telephone or in person, in which you state that the matter is being investigated. Also, ask about the patient s needs and desires. Step 3: Ensure that review of the patient s complaint occurs through the practice s established quality improvement processes. Step 4: Follow up with the patient in the following ways: When appropriate, apologize (without admitting liability). For example, I m sorry that the injection caused you pain.

7 Chapter one 1. Sample addressing patient complaints policy (cont.) Give the patient an explanation. Ensure that systems are in place to prevent reoccurrence. Step 5: All communication with the patient or family member should employ the following service excellence communication skills: If in person, sit down with the individual and avoid any negative body language (i.e., looking at watch, etc.) that suggests you are in a hurry. Maintain as much eye contact as possible. When over the telephone, modulate your voice. Remember that the patient cannot see you, so only the tone of your voice and your choice of words will convey a positive or a negative message. Express your regret that the patient/family member is dissatisfied with the situation. Listen to the facts and feelings that the patient expresses. Reflect back, and validate the patient s feelings. Apologize without blaming anyone. Avoid medical jargon. Express gratitude for bringing attention to the problem. Summarize concerns that the patient relays. Reassure that patient you will follow up with him or her. Do not become angry or judgmental. Step 6: If they concern patient care, objectively document all conversations with the patient/family in the medical record. Record billing issues in the appropriate billing files. Be sure to limit documentation to the facts, and avoid memorializing your emotional response that if you use an incident report, provide only objective facts Step 7: Incorporate modifications to the appropriate policies and procedures based on information learned during the management of the patient s concern. Formal complaints (e.g., attorney letters): Call for expert legal/risk management advice. Related policies: Handling malpractice claims Terminating the physician-patient relationship HIPAA compliance policy

8 Quality improvement, customer service, and patient satisfaction 2. Sample telephone communication procedure/policy Your practice name Subject: Telephone communications: Triage, advice calls, prescription refills, and after-hours calls Approved by: Policy number: Effective date: Review date: Revision date: Page 1 of 3 Purpose: To manage telephone encounters with patients and others correctly, efficiently, and consistently to increase patient satisfaction and to reduce liability risk. Policy: Telephone calls will be fielded appropriately and in a timely fashion by personnel with the training and qualifications required by the kind of call. General procedures during office hours: A receptionist or designated office employee will answer all incoming calls in a friendly and efficient manner and either will transfer the call to the appropriate staff member or will take a detailed message. Patients should always be asked permission before being placed on hold and should not be left on hold for more than one minute. All clinical calls will be given to a clinical support person, who will then triage them. All calls from referring physicians or consultants will be referred to the provider or, if the provider is not available, to the clinical support person. All phone calls that are from or to patients and are of a clinical nature, including prescription refill requests, will be documented in the patient s medical record with the information required by this policy. Telephone triage: The screening and classification of patients are important aspects of medicine and will be conducted by an appropriately trained and qualified clinical support person. Telephone calls received will be classified and generally managed as follows: Emergency: The patient s signs and symptoms are potentially life threatening. The patient should be told immediately to call emergency care (911) or to go to the emergency room. No patient in an emergent situation should be placed on hold. Urgent: The patient s signs and symptoms are acute and need prompt attention that same day. The

9 Chapter one 2. Sample telephone communication procedure/policy (cont.) patient s call is transferred to scheduling, where staff should follow the policy and procedure for scheduling an urgent care patient. The patient should be instructed to go to the emergency room as clinically indicated. Nonurgent: The patient s signs and symptoms suggest the need for attention, not necessarily on the same day, but usually within hours. The patient s call is transferred to scheduling, where staff should follow the policy and procedure for scheduling a nonurgent care patient. Routine: Routine telephone calls include patients requesting appointments for exams, immunizations, and chronic illnesses. Such calls should be transferred to scheduling, where staff should follow the policy and procedure for scheduling a routine care patient. If questions arise as to the classification of a patient s call, refer it to a designated clinical support person or provider. Advice calls: Only the physician or an appropriately trained and qualified clinical support person, following written advice protocols that the physician approves, will give advice over the telephone. If possible, the physician or clinical support person should have the patient s medical record available at that time to review. Document all advice calls in the patient s medical record contemporaneously or upon completion of the call. Documentation should include the following: Patient s name (if the caller is not the patient, include the caller s name as well) Date and time of call Patient s question or concern Response or advice given If advice is given to the patient, the patient should be instructed to repeat the information provided by the practice employee and documentation of the same should be recorded in the patient s medical chart. If a patient does not concur with the advice or response given and asks to speak with another provider, follow the appropriate protocol. Prescription refills: Only the physician or an appropriately trained and qualified clinical support person who follows written prescription renewal protocols (approved by the physician) renews prescriptions over the telephone and only after

10 Quality improvement, customer service, and patient satisfaction 2. Sample telephone communication procedure/policy (cont.) reviewing the patient s medical record. Document all prescription renewals in the patient s medical record, including the date, time, medication, amount prescribed, and why. After-hours calls: After-hours calls will be received by an answering service that cannot answer clinical questions. The service should refer the calls to a provider on-call. The provider on-call schedule is posted at the office and is provided in a timely manner to the answering service. Providers who are on-call after office hours will return calls promptly. They must document significant phone conversations with patients on a phone message page (which can be inserted chronologically into the patient s medical record), via a dictated note in the office phone system, or on a hand-held device for transcription into the patient s medical record the following day. Do not place sticky notes into a patient s medical chart because they are easily lost. The information documented in a patient s chart should include the following: Patient s name (if the caller is not the patient, include the caller s name as well) Date and time of call Patient s question or concern Response or advice given Patient s understanding of the response or advice given Whether the patient was instructed to seek emergency attention When providing on-call coverage for colleagues patients, physicians should document significant telephone encounters in the same manner and fax them to the colleague s office the following day. Miscellaneous calls: Refer requests for records, scheduling inquiries, cancellations, personal calls, and other miscellaneous calls to the appropriate department or responsible individual. Related policy: Facsimile and communications

11 Chapter one 3. Sample scheduling policy Your practice name Subject: Appointment scheduling, no-shows, and cancellations Approved by: Policy number: Effective date: Review date: Revision date: Page 1 of 2 Purpose: To schedule patient appointments correctly, efficiently, and consistently to promote patient care. Policy: Office personnel will perform scheduling to ensure timeliness and appropriateness of treatment, efficient office operations, and patient satisfaction. Procedure: 1. Refer patients reporting high-risk symptoms to the clinical support person or physician to determine when they need to be seen. Send emergencies to the emergency room and call 911. (Note: The provider defines the specialty-specific high-risk symptoms.) 2. Record patient appointments in the schedule book/computer system. 3. Book urgent appointments based upon a provider s recommendation. Make every effort to schedule routine appointments as soon as possible but with no longer than a two-week wait time. 4. Book new patient appointments for (insert time e.g., 30 minutes). Tell patients about the anticipated length of appointment. 5. Book established patients appointments for (insert time e.g., 15 minutes) or as determined based on a provider s preference or recommendation. 6. Record the following information for each appointment: Full name Telephone number Address Brief description of problem Insurance plan or method of payment 10

12 Quality improvement, customer service, and patient satisfaction 3. Sample scheduling policy (cont.) 7. Post a daily schedule for all office personnel, and update it as necessary. 8. Keep appointment schedules for a period of 10 years (or as required by individual state law). Cancellations and no-shows 1. Note all cancellations and no-show appointments in the schedule and medical record. 2. Notify the provider about all missed or canceled appointments. 3. The appropriate staff will give the treating physician the medical chart of every patient who misses or cancels an appointment. (The provider will determine appropriate follow-up appointments.) 4. Based upon the patient s known medical conditions, call the patient, send a letter, or otherwise contact him or her to reschedule. If the patient is placing himself or herself at risk by failing to keep an appointment, consider an appropriately written at-risk letter via certified mail, with a return receipt requested. 5. Document any follow-up action such as a telephone contact to reschedule or a letter sent in the medical record. Include results, such as no answer or patient states that she feels better and did not need to be seen. 6. If a referring physician office schedules the appointment, notify that office of the no-show and document it in a telephone log or in the medical record. Related policies: Telephone communications: Triage Termination of patients Patient billing 11

13 Order your copy today! Please fill in the title, price, order code and quantity, and add applicable shipping and tax. For price and order code, please visit If you received a special offer or discount source code, please enter it below. Title Price Order Code Quantity Total Name Title Your order is fully covered by a 30-day, money-back guarantee. Enter your special Source Code here: Organization Street Address City State ZIP Telephone Fax Address $ Shipping* $ (see information below) Sales Tax** $ (see information below) Grand Total $ *Shipping Information Please include applicable shipping. For books under $100, add $10. For books over $100, add $18. For shipping to AK, HI, or PR, add $ **Tax Information Please include applicable sales tax. States that tax products and shipping and handling: CA, CO, CT, FL, GA, IL, IN, KY, LA, MA, MD, ME, MI, MN, MO, NC, NJ, NM, NY, OH, OK, PA, RI, SC, TN, TX, VA, VT, WA, WI, WV. State that taxes products only: AZ. Billing Options: Bill me Check enclosed (payable to HCPro, Inc.) Bill my facility with PO # Bill my (3 one): Visa MasterCard AmEx Discover Signature Account No. Exp. Date (Required for authorization) (Your credit card bill will reflect a charge from HCPro, Inc.) Order online at Or if you prefer: Mail The Completed order form to: HCPro, Inc. P.O. Box 1168, Marblehead, MA Call our customer service Department at: 800/ fax The Completed order form to: 800/ HCPro, Inc. HCPro, Inc. is not affiliated in any way with The Joint Commission, which owns the JCAHO and Joint Commission trademarks. Code: EBKPDF P.O. Box 1168 Marblehead, MA /

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