Lee A. Resnick, MD, FAAFP
My previous column presented the building blocks of a risk mitigation framework for your practice. This column specifies high-risk areas of urgent care practice that create exposure for both owner and clinicians and suggests ways to mitigate that risk.
Charting / Documentation: Your best defense when there is a bad outcome is documentation. The chart should clearly communicate your decision-making. The “standard of care” is not a guarantee against harm. It only requires that the clinician use reasonable clinical judgment relative to his/her training, experience and best practice in the discipline. When the “standard of care” is applied but a bad outcome occurs, the clinician is far less likely to be sued. That is, IF the documentation clearly communicates the rationale for the care provided. Spending extra time documenting so-called “at-risk encounters” with this principle in mind will reduce your risk. Remember, the way the tort system works, the plaintiff lawyers are on the hook for all of their expenses. So they are unlikely to take a case with excellent documentation and sound decision-making, regardless of the outcome. They want the low-hanging fruit. Don’t be that fruit!
EMR risks: Most EMRs use documentation shortcuts, which offer a provider efficiency gains. Tools that allow the provider to “auto populate” and “copy and paste” are often used. But when things go wrong, they are not your friend. They make a provider look careless and robotic (not appealing to a jury). These shortcuts should be avoided or supplemented for all high-risk encounters. A detailed explanation of medical decision-making is a more robust defense then a one-word diagnosis and auto-populated H&P.
Supervision of assistive medical personnel: The entire clinical team, front and back office, plays an important role in mitigating risk. Keys to success include:
- Effective communication:
- Eliminate verbal orders
- Ensure all meds and dosages are verified by the clinician prior to administration
- Ensure that only objective observations are used for the nurse note and nurse report to the clinician. Avoid subjective communications that reflect judgments, labels or assumptions.
- Policy and procedure:
- All nurse procedures and functions should have policy and procedure to guide their performance. This supports risk management, improves work flow, manages inventory more efficiently, and improves patient satisfaction. Pay particular attention to triage and med administration.
- Training and retraining:
- The value of a systematic training program with tracking and post-training assessment cannot be overstated. Most assistive clinical staff are non-licensed health care providers (most notably, medical assistants). Unlike nurses, they do not have any training standard that is monitored by the state medical boards and thus, their training is extremely variable. The urgent care nursing skill set is broad and many of these skills, including triage and emergency response, are nurse-level functions that are generally not taught in medical assistant programs.
- Many urgent care centers use shadowing as a training method, which is very helpful for providing real-life perspective but inadequate for ensuring comprehensive training and highly variable.
- Supervision:
- Adequate supervision is mandatory, and to be effective without losing efficiency, the level of supervision should be determined by a review of pre-hire training and experience, scope-of-practice laws specific to each state, and a proficiency assessment at hire and post-training.
Writing about risk mitigation in urgent care has been so much fun that I’ve decided to extend it to a three-part series! In my next column, the last in this series, I will cover specific clinical policies and procedures that can effectively reduce liability risk and enhance patient safety, quality, and satisfaction. The scenarios I will present represent the rare opportunity to manage all these critical interests at once. And who can argue with the value of that?
