Dealing with Difficult Patients & Involuntary Discharge
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Transcript Dealing with Difficult Patients & Involuntary Discharge
Professionalism
&
Working with Difficult Patients
The ESRD Network of Texas, Inc.
Our Patients
“Patients with renal disease are challenged by many
stressors, including loss of biochemical and physiologic
kidney functions, development of digestive and
neurological disorders, bone disease and anemia,
inability to function in the family and to maintain one’s
occupation, decreased mobility, decreased physical and
cognitive competence, and loss of sexual function”
Kimmel, MD & Peterson, MD
Seminars in Dialysis, 2005
It’s not an easy life
Sometimes this causes denial, anger and behavior issues
What Do We Know?
That facilities are desperately seeking
ways to work with challenging patients.
That resources are few
That there are no concrete answers
That each individual patient represents a
new challenge
From CMS….
“we believe that every dialysis facility
has the resources and responsibility
to work with every patient, including
patients perceived to be disruptive or
challenging”
-Conditions of Coverage
ETHICS
MAIN GUIDING PRINCIPLE
FOR ALL PROFESSIONAL
ETHICS IS?
DO NO HARM!
What is needed?
More compassion
More understanding
More staff education
How to work with mentally challenged
individuals
In many cases PCT’s have limited training
on working with difficult patients
More support for staff and patients
Patients want from staff
Kindness
Recognition
Comfort
Emotional support
This requires Caring Communications
Compassion
(Advocacy)
Balance
Excellence
(Tension)
(Quality)
Jim Rohack, MD, Medical Director SWHP
Efficiency
(Stewardship)
Reasons for Conflict
Non-adherence
Mental Health & Substance Abuse Issues
Cultural & Racial Issues
Complex Environment
Communication Difficulties
10
Role of Network in grievances
Be objective
Hear all sides
Gather information
Facilitate resolution
Make a determination
Growing Number of
Involuntary Dismissals nationally
Tantamount to DEATH SENTENCE?
“We have no other choice”
“Our back is against the wall on this”
“We have tried everything else”
Some Will Die…
Number
Beneficiary/Representative Contacts
Category by Quarter for 2013
10
9
8
7
6
5
4
3
2
1
0
9
A total of 84
patient /family
contacts
7
5
5
3
00
2
1
1
Jan-March
00
April-June
July-Sept
Oct-Dec
Trending Involuntary Discharge
2008 to 2013
2013
19
2012
42
2011
42
2010
42
0
10
20
30
40
Maintaining a steady number is not good enough!
50
January-April, 2013
Number of all Involuntary Discharges by Type
Number =
19
Non-Payment
6
Severe Immediate Threat
10
Physician Termination
1
Ongoing Disruptive/Abusive
Behavior
2
0
5
10
15
How does Professionalism
&
Working with Difficult Patients
fit together?
Relationships:
Personal vs. Professional
Purpose
Balance of Power
Focus
Challenging situations
are often the delayed
result of professional
boundary violations.
Common Problems:
Boundaries Crossed
Becoming personally involved
Gifts
Showing favoritism
Dual relationships
Becoming Personally Involved
Sharing that shifts
FOCUS from pt to
professional
Lose ability to respond
objectively
React emotionally
Gifts
Unit policy against
giving/receiving of
gifts
Federal regulations
against giving to
patients
Protects pts from
feeling that they need
to pay extra for quality
Protects staff from
feeling they need to
give extra attention
Showing Favoritism
Show that you favor
one pt over another, or
facilitate a pt favoring
you over other staff
Creates expectation that
it will be done again
Expectation that other
staff will do the same
Distrust of other staff
Dual Relationships
Exchange of goods or services
SEXUAL MISCONDUCT
Demeaning to the patient
It is usually intentional
It is a breach of TRUST
Long-term effects can be devastating but may not be
readily apparent
THE BREACH OF TRUST IS USUALLY FAR MORE
SERIOUS THAN THE ACTUAL SEXUAL
CONTACT
TOOLS TO HELP
Decreasing Dialysis Patient- Provider Conflict Toolkit
Caring Communications Tips
DPC Toolbox
IG-”At the time of
publication of these rules,
each facility had received a
copy of an interactive
program developed by the
ESRD Networks on
Decreasing Dialysis Patient
Provider Conflict (DPC) that
addresses proactive
techniques to resolve such
issues before progression to
involuntary discharge.”
Toolbox Contents
1. Ethical, Legal,
7. Tip Sheets
Regulatory Statement 8. “Top Ten” Responses
2. Poster
9. Interactive Web-Based
3. Brochure
Training
4. Pocket Card
10. Training Modules
5. Bibliography
11. QI Tracking Tool
6. Taxonomy & Glossary
Toolbox Contents
cont.
Critical thinking algorithms and video
Clips of “real life” situations
Use of Taxonomy & Glossary
Use of conflict resolution techniques
Sent to each facility in US
Interactive educational software
DPC “CONFLICT”
Resolution Model
9 step program
“CONFLICT” Resolution Model
C-Create a Calm Environment L-Look for Solutions
O-Open Yourself to
I-Implement Change
Understanding
N-Need A Nonjudgmental
C-Continue to
Approach
Communicate
F-Focus on the Issue
T-Take Another Look
Create A Calm Environment
“In order to effectively
address a conflict, you need
to be aware of the physical
surroundings, as well as the
thoughts and feelings you are
experiencing because of the
conflict”
Open Yourself to Understanding Others
“When addressing a
conflict, it is important
to acknowledge the
perspective and
feelings of the other
individual(s)
involved”
Need A Nonjudgmental Approach
“As
a dialysis professional, it is
important for you to maintain an
objective and professional approach as
you address the conflict. Keep in
mind that words exchanged in the
heat of an argument are often not
intended as personal attacks.”
Focus On The Issue
“When
conflict occurs, there is a
tendency to lose sight of the issue that
started the disagreement. What starts out
as a concern about starting dialysis on
time can quickly become a disagreement
about the facility staff, the clinic
operations, or the physician care.”
Look For Solutions
“Not all conflicts can be
resolved nor are all
conflicts based on valid
complaints. But working
in collaboration with the
patient will improve the
likelihood of a positive
outcome.”
Implement Agreement
“If
you take the time to
work through the
conflict, it is likely that
you will reach a stage
of agreement when
changes will need to be
put into action.”
Continue To Communicate
“Effective resolution of a
conflict requires follow up
communication. This allows
you to monitor the progress
being made. And
demonstrates to the patient
your commitment to
resolving the conflict.”
Take Another Look
“Handling
a conflict, like successfully
performing dialysis related tasks,
requires practice, understanding,
education, and monitoring. Regardless
of whether a conflict is minor or major,
reviewing the steps used in addressing
the conflict will be beneficial.”
Tools to help you use the Conflict
Resolution Model
DPC Brochure: “Decreasing
Conflict & Building Bridges”
DPC CONFLICT Poster
DPC CONFLICT Pocket Guide
Heart-Head-Heart Communication:
Two Sides to a Satisfying Service
Experience
Heart
Head
Feelings, personal
attention, caring
Information, tasks
We’re so busy the heart
messages get lost.
Dialysis is so full of
tasks
Caring Communication Hints
1. Acknowledge patients likely feeling.
2. Share your good intentions: How are
your actions for the customer’s sake?
3. Ask open-ended, not yes-no questions.
4. Use the words “for you.”
5. Express appreciation to the person.
Messages Key to Patient Satisfaction
You are not a number.
YOU, uniquely YOU matter to me.
I respect your thoughts and feelings.
I want you to feel my support.
Yes, I’m here to care for you. And, I also care ABOUT you.
When the team is struggling with a
patient…
Educate their staff about caring
communications tips
Contact the Network as soon as possible
Suggestions, tips, ideas
Objective party
46
Additional ideas to
consider
Patient Care Conference (PCC)
Behavior Agreements
Patient Advocacy Meetings
Professionalism Trainings
How to handle a
situation…
If the patient is an actual and immediate danger to
others
Weapons
Striking others
CALL 911
Immediate Discharge
IG- An "immediate severe threat" is a threat of physical harm. For example, if
a patient has a gun or a knife or is making credible threats of physical harm,
this would be considered an "immediate severe threat."
The Renal Professional
You Make A Difference
ESRD Network of Texas,
Inc.
Thank you for your participation
For assistance contact the
Patient Services Department :
Treneva Butler
469-916-3808
Ron Davis
469-916-3810
Maria Bustamante 972-503-3215 ex 344