The Law: Can Your Staff Get You Sued?

Are your office's administrative procedures risk-free? If so, you stand a much greater chance of avoiding malpractice lawsuits and keeping your malpractice premiums in check.

That's because one of the most prevalent causes of nonsurgical malpractice suits is a failure to diagnose, and the biggest reason for a delayed or missed diagnosis is often the lack of good tracking systems in the office.

Every day, your office staff performs hundreds of steps to manage appointments, communicate test results, and follow up on billing issues. Surprisingly, nearly one-third of all medical offices lack adequate tracking systems for these routine, but important, tasks. Your office's risk is intensified depending on who has responsibility for most of the tracking. It's common for the job to be handled by the person at the front desk, who typically is the least experienced and most junior person in the office.

How dangerous can this be?

Imagine an energetic young staffer assigned to monitor the fax machine, trying to do a good job and taking initiative by filing lab reports directly into the charts from the fax machine. She wouldn't necessarily know that the doctor needs to see those reports.

Keep in mind that claims arising out of the medical office setting are expected to increase as healthcare shifts from the hospital to outpatient medical offices.

Effective communication between patients and medical professionals and attentive record-keeping decreases the likelihood that patients will take problems to the legal level.

You must make sure that your front- and back-office employees understand the potential ramifications of their interactions with patients. Do employees think they're "just staff?" Do they understand that they have a role to play in improving patient satisfaction and in risk management? It's your job to train and involve them so they know that they're a key part of the care continuum.

FIRST IMPRESSIONS COUNT

Risk management starts at the reception area, and first impressions really do count. The staff who greets patients should recognize that even these short interactions can have a huge impact on a patient's feelings about you. In fact, front-office risk management skills are important enough to be included in job descriptions, and those skills should be addressed during performance reviews and rewarded when done well.

Staff should take pains to greet patients by name and check them in as soon as possible. Staff should introduce themselves to patients and provide their titles - for example, "I'm Mary Brown, Dr. Smith's assistant." These are small touches, but they help make patients feel taken care of, from the first few minutes they set foot in your office.

Communication about delays is an important part of patient satisfaction. Your patient should never feel like he has been forgotten. To minimize anger resulting from delays, staff should keep track of patient arrival times and should explain the reasons for delays to anyone who's been waiting an unreasonable period of time.

Protecting a patient's privacy also begins at the reception desk. Do staff talk to incoming patients in a low tone of voice so that others in the waiting area can't hear the conversation? Are staff computer screens hidden from the view of people standing at the front desk? These seemingly minor considerations will help reassure patients about your office's attitudes toward patient privacy.

The front-office staff has the opportunity to conduct other key risk-management activities by asking patients to update their medical history forms on a regular basis. New information will help you make better decisions on changing the course of treatments and/or medications. Similarly, allergy alerts need to be updated and prominently displayed in a patient's file before the file is turned over to you.

When patients - particularly those in a high-risk category - miss appointments, your staff should carefully document the no-shows and attempt to reach them. If a patient does not respond to phone calls, you should be notified. A recommended practice at that point is to send such patients a registered letter, pointing out the risks of not complying with recommended care. If a high-risk patient still does not respond, the safest thing may be to discontinue that patient from your practice.

A bothersome billing experience can overshadow a patient's positive experience with medical care, too. Staff should have a system for informing you when a patient is disputing a bill. Just like the patient who sits in the waiting room while the minutes tick by, no patient wants to feel as though you are ignoring his billing complaint.

The front-office staff, in tandem with you, should carefully map out procedures for dealing consistently with patients with unpaid bills. For instance, you might decide to discontinue a patient from the practice because of unpaid bills, or for other reasons - but the patient must always be given adequate time to find a new provider so that there are no gaps in treatment. Also, make sure that staff seek your approval before turning an unhappy patient over to a collection agency.

HEART OF THE PRACTICE

When the patient moves into the heart of the office - the examination room - he should receive the same attentive, professional care that was evident in the waiting area. The examination room is where the greatest potential for liability claims occurs. That's why extensive documentation of the examination room interaction is critical for effective risk management.

The staff member who brings patients to the examination rooms must be a good listener. That is, she needs to treat the patient's health concerns with empathy and carefully record those concerns for you.

If circumstances delay your arrival to the examination room, someone should visit periodically and keep the patient informed about the timeline. Showing respect for the patient means protecting his privacy: Be careful to close examination-room doors and knock before entering.

MEDICATION CONTROLS

Medication errors commonly lead to liability claims. With careful education and training about medications for office staff, you can reduce the risk of claims while improving the level of care.

Be sure that your practice requires the use of medication forms and problem lists in the patient's medical record. Those techniques are sure to help you remember all of a patient's diagnoses or medications. Everyone who opens a file should be able to see at a glance what medication a patient is taking and staff should check it each time a refill is requested.

Documentation and careful note-taking are especially important when prescriptions are concerned. Prescribing errors are very common mistakes, and they can generate liability claims. Both you and your staff are vulnerable to making these mistakes, which can have fatal consequences. Medications whose names may sound similar to one another but have drastically different actions increase the risk of error.

For instance, a staff member might take a prescription order from a physician or from the medical record, and she might need to call that order into a pharmacy. Double-checking should be required in both scenarios because of the increased chance for mistakes, including tiny errors that can have a huge bearing on a patient's health. A simple oversight like forgetting to write a zero before the decimal point - for instance, writing ".2 mg" instead of "0.2 mg" -can lead to a pharmacist delivering a medication 10 times more powerful than that prescribed.

Errors can also happen when refills are ordered. To reduce mistakes, make sure staff understand and follow your refill guidelines such as refill limits by type of medication, symptoms that require evaluations prior to refilling, and medications that may not be renewed.

COMMUNICATION GAP

Be sure to maintain ongoing communication among office staff to help prevent liability claims that arise from the "communications gap" between the staff in the back and the front office. An office system can fall apart when the patient walks out the door because of poor exchanges about how follow-up visits, post-treatment procedures, or test results will be communicated. It is up to you to establish a very specific protocol to ensure that those who work in the front office know what you did, what tests were ordered, what medications were ordered, and when the patient is to return. One simple and effective tool is a checklist for communicating these matters between back-office and front-office staff.

If your office hasn't done so already, eliminate the "no news is good news" system of reporting test results to patients - that is, calling the patient only when there are abnormal results. If an abnormal test result is lost, a patient could, wrongly, assume that the result was normal, thus delaying a potentially serious diagnosis and perhaps triggering a liability claim down the road.

Do you have a system for logging every test result that comes in and ensuring that you have reviewed each result and ordered any necessary follow-up tests? You should. What's more, your practice should also be tracking tests that have been ordered, not just those that come in. Failing to perform this important step could cause delays in medical treatment if the test is never completed. In addition, it's important to have a mechanism in place that ensures you review all test results before they are filed.

SAFEGUARD MEDICAL RECORDS

No risk-management program is complete without careful attention to medical records. In the case of a claim, these records are your best defense - provided you've documented every in-office interaction with the patient along with post-visit follow-ups and test results.

In addition, your practice should have a clear policy for keeping and safeguarding medical records. The medical liability insurer that I work for, CAP-MPT, recommends that records be kept 10 years after an adult's last examination. Equally important is maintaining confidentiality. Is there a clear policy on how to release medical records to patients or third parties so that privacy is not compromised, while allowing patients their right to a copy of their records?

All of the above steps depend on a well-trained staff to carry them out and ensure that they are applied consistently. Education and training play important parts in reducing risk in the medical practice - and both new staff and long-timers benefit from ongoing education. When policies and protocols are consistently followed, patients and patient rights are protected. Education also increases staff confidence as they carry out their responsibilities.

Ultimately, you are responsible for ensuring policies for safety in the office. To reduce the risk of being named in a lawsuit, you, aided by your staff, should think about office policies and staff actions within the context of protecting the patient. In other words, you should be able to explain - to a jury if necessary - the steps your office took to reduce risks to patients and provide care in a safe manner in your practice. If any member of your staff thinks an action would sound careless or slipshod if he were testifying before a jury, then it's high time to revamp office procedures.

Waldene Drake, MBA, RN, is vice president of risk management and patient safety at CAP-MPT, a Los Angeles-based medical liability carrier. She can be reached at editor@physicianspractice.com or via wdrake@cap-mpt.com.

This article originally appeared in the March 2006 issue of Physicians Practice.