Refreshing Practice and Limiting RiskThrough Purposeful Communications
Mary A. Seisser, MSN, RN, CPHRM, FASHRMCNA, Healthcare Segment, Risk ControlMay 19, 2017
2
Disclaimer
The purpose of this presentation is to provide information, rather than advice or opinion. It is accurate to the best of the speaker's knowledge as of the date of the presentation. Accordingly, this presentation should not be viewed as a substitute for the guidance and recommendations of a retained professional. In addition, CNA does not endorse any coverages, systems, processes or protocols addressed herein unless they are produced or created by CNA.
Any references to non-CNA Web sites are provided solely for convenience, and CNA disclaims any responsibility with respect to such Web sites.
To the extent this presentation contains any examples, please note that they are for illustrative purposes only and any similarity to actual individuals, entities, places or situations is unintentional and purely coincidental. In addition, any examples are not intended to establish any standards of care, to serve as legal advice appropriate for any particular factual situations, or to provide an acknowledgement that any given factual situation is covered under any CNA insurance policy. Please remember that only the relevant insurance policy can provide the actual terms, coverages, amounts, conditions and exclusions for an insured. All CNA products and services may not be available in all states and may be subject to change without notice.
Upon completion of this session, participants will be able to:
1.Describe the attributes of purposeful communication from a risk management perspective.
2.Discuss liability claim data involving communication issues, risks and errors that arise in the healthcare industry.
3.Formulate at least three evidence-based tactics that can be applied by all stakeholders (providers, leaders, patients/clients, systems and communities) to help improve communications and minimize liability risks.
4
Pop Quiz: True or False?
______________ Proof of medical negligence is the most frequently cited reason for patients to sue their providers.
_____ Disclosing to patients unanticipated medical outcomes negatively affects your company’s risk management program.
_____ Team communication skills in healthcare rarely improve through training.
_____ Your company’s communications on the Internet does not pose liability-related risk.
5/12/17
3
5
Defining Risk Management Communications
Purposeful (adj.) 1. resolutely aiming at a specific goal 2. directed to a specific end;; not meaningless.
Source: Webster’s New World Dictionary
Quality, Patient Safety and Risk Management “Communicate”
From a medical professional liability perspective:
1.A good quality program promotes good clinical outcomes and patient safety.2.Good clinical outcomes and patient safety initiatives promote the risk management program.3.A good risk management program supports business goals.
6
5/12/17
4
Communication Issues in Medical Malpractice Claims
• Unsatisfactory communications lead to patient dissatisfaction.
• Dissatisfied patients are more likely to file liability claims against their providers.
• The literature reports communication as a key factor in malpractice claims.
• Effective communications with patients and families, among healthcare providers, and communities remain a patient safety priority.
• Ineffective communication is a major factor in errors and near-misses, which may increase the likelihood of litigation.
7
8
Communication is a Cycle
Sender
1. Makes Message 2. Sends Message
3. Receives Message4. Interprets Message 5. Makes Response6. Sends Message
7. Message Interpreted(maybe yes)
Adapted from: American Society for HealthCare Risk Management. Risk Management Handbook, San Francisco: Jossey Bass, 2004.
Source: Maxfield et al. Silence Kills: The Seven Crucial Conversations in Healthcare (accessed at www.aacn.org)
11
Root Causes of Sentinel Events
12Source: Joint Commission
5/12/17
7
CNA Healthcare Professional Liability Closed Claim Experience
“… claim frequency has increased in non-hospital based specialties such as home health/hospice, reflecting the overall migration of healthcare toward outpatient settings. One consequence of this shift is that, more than ever, home health/hospice nurses must be in frequent communication with the patient’s practitioner, as illustrated by the following closed claims:•The home health nurse failed to notify the practitioner of the patient’s medical decline. The patient was on intravenous antibiotics for bacterial endocarditis, and on two visits to the patient’s house, the nurse failed to notify the referring cardiologist of the patient’s extremely abnormal vital signs.•Against practitioner orders, the nurse delayed administering pain medication to a hospice patient, resulting in unnecessary suffering.”
CNA Healthcare Professional Liability Closed Claim Experience (continued)
In the same report:“Closed claims involving the failure to invoke or utilize the chain of command account for 7.5 percent of the treatment and care closed claims, and reflect a high average severity. . . Approximately half of the chain of command closed claims occurred in labor and delivery units, with nearly all injured patients either dying or sustaining permanent total disability.” (page 22)
“Errors [medication] such as wrong rate of flow, wrong route, wrong dose, wrong medication and wrong patient are often caused by poor communication with the pharmacist and/or prescribing practitioner, failure to clarify the medication order, excessive workload or preoccupation/distraction.” (page 25)
CNA Healthcare Professional Liability Closed Claim Experience (continued)
• Communication as the primary allegation of loss was found in almost 2% of the CNA hospital claim report’s sample. “Specific allegations include failure to report or delay in reporting a test result, failure to inform or notify the provider of a change in condition or new condition, failure to timely report a postoperative complication or change in condition, handoff issues, and incorrect information provided or recorded regarding patient communications with staff” (page 41).
• Communication as a primary loss allegation in the analyzed closed hospital claim sample was associated with an average paid indemnity of $231,000. The associated average paid expense was $40,349 (page 13).
Source: CNA Hospital Professional Liability Claim Report 2015, accessed at www.cna.com
15
Evidence-Based Team Communications
• SBAR (Situation-Background-Assessment-Recommendation/Request)• Call-out• Check-back• Handoff (I PASS THE BATON)
Introduction Patient, Assessment, Situation, Safety ConcernsTHEBackground, Actions, Timing, Ownership, Next
• Briefs, huddles and debriefs• Cross-monitoring• Task assistance• Feedback
Source: TeamSTEPPS®, accessed at https://www.ahrq.gov/teamstepps
16
5/12/17
9
Evidence-Based Team Communications (continued)
• Two-Challenge Rule– Assertive, not aggressive – Chain of command policy and procedure
• CUS
– I am Concerned!– I am Uncomfortable!– This is a Safety Issue!
“Stop the line”
Source: TeamSTEPPS®, accessed at https://www.ahrq.gov/teamstepps
17
Evidence-Based Team Communications (continued)
• Resolving team conflicts through D-E-S-C:
• D – Describe the specific behavior or situation;; be concrete• E – Express how the situation makes you feel/your concerns• S – Suggest other alternatives and seek agreement• C – Consequences of not working toward team goals;; consensus needed
Source: TeamSTEPPS®, accessed at https://www.ahrq.gov/teamstepps
18
5/12/17
10
Preventing Claims
PURPOSES• Provide quality of care and quality services
• Comply with relevant standards of care, laws, regulatory requirements
• Minimize risk of poor outcomes and claims
• Empower patients• Empower staff and build organizational safety culture
• Promote critical thinking skills, situational awareness and a shared mental model among teams
ACTIONS• Culture of safety assessment • Hand-off communication policies and procedures– Framework for communicating organization-wide
– Empowerment• Disruptive communications policy and procedure
• Confidentiality• Patient education, Speak Up, Ask Me 3, AHRQ Health Literacy Universal Precautions Toolkit
• Interdisciplinary drills• Interdisciplinary education• Chain of command policy• “Near miss reporting” and failure mode effect analysis
19
Reducing the Severity of Claims
PURPOSES
• Patient safety• Continuous quality improvement
• Complying with regulatory and legal requirements
• Minimize likelihood of claim
• Protect the hospital’s reputation
• Ethical considerations• Trigger statute of limitations
ACTIONS• Incident reporting/investigation
– Team de-briefing– Address discoverability/admissibility concerns
– Investigation tactics– Root cause analysis– Communication with legal counsel and insurance team
• Disclosure of unanticipated outcomes policy and procedure– Preparation– Attending physician cooperation
• Public service• Consistent with mission statement• Support the quality improvement program• Transformational leadership• Avoiding promises and guarantees• Stopping poor publicity and public image• Promoting defensibility of claims
21
Communicating with Communities (continued)
• Risk prevention– Quality and legal review of organization’s Web site, advertisements, marketing materials
– Prepare news media protocol
– Appoint a spokesperson– Prepare a general template media response
– Staff orientation– Social media policy– Board education
• Risk reduction– Assemble task force to plan questions/responses
– Involve legal counsel to protect credibility
– Re-educate staff and board
– News conference, if necessary
– Provide closure– Use of disclaimers and legal consultation to address transparency
22
ACTIONS
5/12/17
12
23
Summary
• Purposeful healthcare communications support clinical quality, patient safety and the risk management program.
• Communication issues have been found to be a primary contributor to the development of medical malpractice claims.
• Communication techniques that incorporate quality, patient safety and risk management principles can be used by stakeholders to prevent and defend medical professional liability claims.
Pop Quiz Answers
False Proof of medical negligence is the most frequently cited reason for patients to sue their providers.
False Disclosing to patients unanticipated medical outcomes negatively affects your company’s risk management program.
False Team communication skills in healthcare rarely improve through training.
False Your company’s communications on the Internet does not pose liability-related risk.
24
5/12/17
13
Resources
Agency for Healthcare Research and Quality. www.ahrq.gov
American Society for Healthcare Risk Management. www.ashrm.org
CNA, Risk Control. www.cna.com
TeamSTEPPS®: Team Strategies & Tools to Enhance Performance in Patient Safety. www.ahrq.gov/teamstepps/index.html
