Promoting Patient Responsibility - Thurston County Chamber

Promoting Patient 

Responsibility 

Presented by: 

Dave McGrath, CPHRM 

Senior Healthcare Risk Management Consultant

Today’s program 

• Patient responsibility / accountability 

• Medical records 

• Informed Consent 

• Adverse events 

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Promoting Patient 

Responsibility 

Communication, documentation, 

accountability 


Effective healthcare 

requires a partnership 

between physician and 

patient 

…but patients often ignore their 

end of the bargain! 


This can lead to sub-optimal 

outcomes that often create patient 

dissatisfaction or even set the 

stage for malpractice litigation 

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The Physician’s Duties 

• Examine and evaluate patient 

• Arrive at diagnosis 

• Inform the patient of diagnosis 

• Discuss therapeutic options 

• Recommend and agree upon therapeutic course 

• Obtain informed consent-(PABRC) 

• Discuss and document importance of 

recommended follow-up 


Patient’s Responsibilities 

• Provide complete and accurate medical 

history 

• Submit to necessary diagnostic testing 

• Follow agreed upon prescribed course of 

treatment 

• Return for follow-up as directed 


So where are the problems? 

Patients often contribute to their health 

problems by “non-compliance” with 

medical advice regarding: 

• Fail to present for diagnostic testing 

• No show for important follow-up care 

• No show for annual exam 


Patients ignore medical advice… 

• Missed appointment with specialist 

• Fail to monitor blood pressure, glucose, 

anticoagulation, etc. 

• Fail to notify their physician as worsening 

symptoms or health changes occur 

• Ignoring recommendations for lifestyle 

changes (tobacco-alcohol-diet) 


But when problems occur ….. 

“Why didn't the doctor tell me the importance 

of seeing that specialist?” 

“I should have been told why that diagnostic 

test was so important. I would have had 

that test done if I had known…” 


Accountability Goals 

• Promote active patient participation in 

treatment 

• Improve patient compliance thereby 

improving patient outcomes 

• Reduce physician liability exposure 


Accountability 

• Patients need to be engaged in their care 

• Holding patients accountable for their 

inaction is often difficult because of poor 

communication and a lack of 

documentation 


Am I responsible for everything? 

• Washington State implements the doctrine 

of pure comparative fault. 

• This means that the “fact finder” (aka jury) 

can apportion responsibility to any party in 

the case. 

• If any responsibility is assigned to the 

patient the damage award is reduced by 

that percentage 


Making the argument… 

• The most common barrier to advancing 

the comparative negligence argument is a 

lack of supporting documentation in the 

patient’s chart 

• Remember that juries look to the chart as 

the unbiased witness in the courtroom 

• If it is documented it happened…if it 

wasn’t documented…? 


Importance of Documentation 

• Often the most important evidence 

allowing successful defense of a 

malpractice claim 

• Poor records are the most often sited 

reason for settlement 

• 35 to 40% of suits are compromised by 

the record 


Charting Issues in Malpractice 

• Patient instructions not documented 

• Delayed charting 

• Patient noncompliance not charted 

• No documentation of informed consent 

and patient education 

• Patient response to treatment not 

charted 

• Lack of a treatment plan 


Examples of Accountability Tools 

• Patient Care Agreement Form 

• Informed Consent Template 

• Refusal of Care Letter 

• Lost or Stolen Prescription Attestation 

Form 

• Agreement for Use of Medication in Pain 

Management 



Example – Informed Refusal of Care 


More Accountability Tools 

• Termination of care letter 

• Upset patient letter 


More Accountability Tools 

• Patient instruction sheet 

– Medication instructions 

– Post procedure instructions 

– Exercise instructions 

– Dietary instructions 




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Informed Consent

Informed consent and the law 

• Approximately 40% of medical malpractice 

lawsuits contain an allegation of “inadequate 

consent” 

• This is a very effective argument when consent 

documentation is absent or inadequate 

• Informed consent is necessary patient education 

and serves accountability goals 

• With good documentation, these claims can be 

successfully defended 


Patients and Physicians benefit 

• Good consent discussions improve overall 

care 

• Patient satisfaction is higher 

• Patient compliance is improved 

• Better clinical outcomes 

• Good consent practices reduce your 

liability exposure 


Informed Consent- What is it? 

• Informed consent is more than a form, it is a 

communication process 

• The process begins with a provider’s 

recommendation of a treatment plan or 

procedure 

• All “material facts” relating to the proposed care 

are shared with the patient by the provider 

• The discussion of material facts is a nondelegable 

duty 


What are the “material facts”? 

• The nature and character of proposed 

treatment 

• The anticipated results of proposed 

treatment 

• The recognized alternative forms of 

treatment 

• The recognized serious possible risks, 

complications, and anticipated benefits 



Informed Consent 

• Procedure-Alternatives-Benefits-Risks- 

Complications (PABRC) 

• Extent in direct correlation to potential 

risks and complications 

• Signed procedure specific consent 

document for significant procedures 

• Consent discussion is mandatory even 

when written consent obtained


Informed refusal 

• Based on a P-A-B-R-C discussion patient 

elects to forego recommended treatment 

• Decision may have significant negative 

impact on health and quality of life 

• Document P-A-B-R-C discussion and 

basis for patient’s decision 

• Draft a letter memorializing discussion and 

decision

Example – Informed Refusal of Care 


Informed Refusal letter excerpt: 

“On (date) you advised me that you do not wish to 

undergo this (test/treatment) because (use the reason 

patient provided) . During this discussion I expressed 

my concerns about your decision and explained to you 

the potential consequences of this decision, outlining 

what it may mean to your health. To summarize, your 

decision to forgo this (test/treatment) could result in, 

but is not limited to, the following possibilities: (name 

the significant consequences of forgoing care, e.g., 

failure to diagnose a life-threatening illness such as 

cancer) . Again, with full knowledge of the potential 

consequences of your decision, you have elected to 

forgo the (test/treatment) that I have recommended. “ 



Informed Refusal 

• Honest communication about the potential 

consequence of patient’s decision is important 

• Chart documentation is key to memorializing 

information provided to patient and patients 

decision 

• Informed refusal letter designed to reinforce 

verbal communication 

• Good documentation will insulate from 

allegations of inadequate consent process

Terminating Care 

Significant non-compliance 

can result in dismissal

Common reasons for 


terminating care 

• Significant patient non-compliance 

• Non-payment / collections 

• Violating “no-show” policy 

• Verbally abusive or hostile behavior 

• Abuse of pain meds/ prescription 

alteration 

• Threats against staff or physician


Terminating care 

• Remember…you can terminate relationship 

for any non-discriminatory reason 

• Exceptions are a hospital inpatient, an 

unstable patient, late term or high risk 

pregnancy, unless a transfer of care has 

occurred 

• Another exception is patient whose noncompliance 

results from a physical or 

psychological condition

Terminating the physician-patient 


relationship 

• Notify in writing – certified mail 

• A specific professional reason is optional 

• State clearly the effective date of termination 

• Provide resource for locating a new physician 

• Offer to transfer records upon receipt of signed 

authorization 

• Emergency care available for specified time 

following termination(unless abusive or 

threatening)

Terminating the physician-patient 


relationship 

• Letter in patient record 

• Chart all patient noncompliance, disruptive 

behavior, poor rapport, etc. to support your 

termination


For routine dismissals 

• Written notice to patient certified mail return 

receipt requested 

• Allow 30 days access to care for pending or 

urgent medical conditions 

• Outline the exact date the relationship ends 

• Advise that records will be sent to new 

physician upon request 

• Provide resource to locate new physician

Before you decide to terminate 


patient 

• Is there any discriminatory element to this 

decision? 

• Is patient stable? Late term/high risk 

pregnancy? 

• Is non-compliance the result of psychiatric 

disorder

When boundaries are crossed 

• Threats of physical violence or very 

disruptive behavior should be met with 

immediate termination 

• Abuse of pain medication policies can be a 

case by case decision (pain contract?) 

• Theft of prescription pads / alteration of 

script warrant immediate termination 


When boundaries are crossed 

• Immediate termination of care is 

permissible depending on circumstance 

• No statutes prevent immediate termination 

• Document all behaviors/threats/illegal 

activity resulting in termination 



Other considerations 

• Notify clinic managers at all ambulatory care 

sites within your organization of the dismissal 

• Keep a copy of the termination letter on file at 

the site 

• Set up a “pop up” screen in your computer 

system to alert front office if patient tries to 

reappoint

Educating Patients 

• Providing patients info on practice 

policies: 

– Patient Information brochure/postings 

• Services provided by the practice 

• Office hours / phone numbers 

• After-hours care 

• Prescription refill policy 

• Missed appointment policy 


Setting Limits With Patients 

• Educate your staff 

– Make sure they communicate practice 

policies 

– Train staff regarding inappropriate patient 

behavior (manipulation, abusive language, 

threats, sexual advances) 

– Reporting and documenting incidents 

– OK to say “No” to patients 


Adverse Events 


Adverse Events 

• Adverse events happen whether the 

result of error, known complications to 

treatment, or just bad luck 

• While significant efforts are taken to avoid 

adverse events, they are a part of 

medicine 

• It is what providers and staff do before 

and after an adverse event that largely 

determines how the patient will react to 

bad news 


Setting the Stage 

• Good patient rapport: some providers and staff 

members are naturals - others must work at it 

• Good rapport pays huge dividends especially 

when problems in care occur 

• Empathetic / honest communications set stage 

for good patient - provider relationships 

• Rapport building involves everyone from the 

front desk to the encounter room to the back 

office 


The Good News 

• Patients generally respond 

appropriately to an adverse outcome 

if dealt with directly and honestly 

• They can understand adverse 

events and bad outcomes 


Defensiveness is Trouble 

• Patients do not understand poor 

communication or defensiveness following 

an event 

• Poor communication or defensiveness can 

be perceived as 

– A lack of empathy by the provider 

– An attempt to cover up an error 

– The provider’s interests being placed above 

the patient’s needs 


Adverse outcome - what now? 

• Do not fear your patient 

• A sincere demonstration of your 

concern and empathy is appropriate 

• Be direct and advise patient as soon 

as practical 

• Outline the basic facts for the 

patient (and involved family 

members) 


Adverse outcome - what now? 

• Use language the patient will 

understand 

• Outline the intended course of action 

• Be certain patient understands and is 

not left with questions 

• Document the discussion, patient 

response, and plan of action 

• Stick to what is known 


Avoid… 

• Blaming others / shifting responsibility 

• Speculation about cause 

• Criticizing colleagues or staff 

• Withdrawing from the patient or patient’s 

family 

• Withholding important information 


Apology and the Law 

• Can you apologize? 

• RCW 5.64.010 

– Any statement, affirmation, gesture, or 

conduct expressing apology, fault, 

sympathy, commiseration, condolence, 

compassion, or a general sense of 

benevolence, is not admissible as 

evidence if: 


Apology and the Law 

• RCW 5.64.010 (continued) 

– Conveyed within 

• 30 days of the act or omission or 

• 30 days of the provider becoming 

aware of the act or omission; and 

– Relates to discomfort, pain, 

suffering, injury, or death of the 

injured person as a result of the 

alleged negligence 


Law Supports Apology 

• Intended to enhance the 

patient / provider relationship 

• Ethical duties prevail regardless of 

30-day time frame 

• What to do? 


Adverse Event Response 

• Document date you are aware of event 

• Investigate 

• Be timely 

• Coordinate with other staff and providers 

• Reach out 

• Disclose what you know 

– Disclosure with empathy 

– Disclosure with apology 


When Adverse Events Happen 

Patients and family need 

• Explanation of what happened 

• Empathy or apology as appropriate 

• Transparency 

• Steps taken to prevent recurrences 

• Impact on health 

• Treatment options 


MD to JD – What They Want You to Know 

“In my experience, a doctor who 

sympathetically tells a family, ‘I am sorry. 

Things didn’t go the way we expected. 

Here is what happened,…’ often won’t get 

sued.” 

Lee Goldsmith, MD, JD 

Medical Economics April 4, 2008 Doctors who 

become lawyers: What they want you to know. 


While everyone is on the 

full disclosure bandwagon, 

sometimes you can go too 

far! 


“This is gonna hurt like hell”

Thanks! 

For more information contact us: 

Phone: (206) 343-7300 or (800) 962-1399 

(509) 456-5868 or (800) 962-1398 

E-mail: risk@phyins.com 

Visit us at www.phyins.com

Promoting Patient Responsibility - Thurston County Chamber

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