6 ways to reduce liability by improving doc-nurse teams

 

Positive relationships between physicians and nurses not only make for a smoother work environment, they also may reduce medical errors and lower the risk of lawsuits.

A recent study of closed claims by national medical malpractice insurer The Doctors Company found that poor physician oversight is a key contributor to lawsuits against nurses. Investigators analyzed 67 nurse practitioner (NP) claims from January 2011 to December 2016 and compared them with 1,358 claims against primary care physicians during the same time period.

Diagnostic and medication errors were the most common allegations against NPs, the study found, a trend that matched the most frequent allegations against primary care (internal medicine and family medicine) doctors. Top administrative factors that prompted lawsuits against nurses included inadequate physician supervision, failure to adhere to scope of practice, and absence of or deviation from written protocols.

The findings illustrate the importance of effective collaboration between physicians and NPs, said Darrell Ranum, vice president for patient safety and risk management for The Doctors Co. Below, legal experts share six ways to strengthen the physician-nurse relationship and at the same time, reduce liability:
 

1. Foster open dialogue. Cultivating a comfortable environment where nurses and physicians feel at ease sharing concerns and problems is a key step, says Louise B. Andrew, MD, JD, a physician and attorney who specializes in litigation stress management. A common scenario is a nurse who notices an abnormal vital sign but fails to mention it to the supervising physician because they feel they can handle it themselves or because they believe the doctor is too busy or too tired to be bothered, she said. The patient’s condition then worsens, resulting in a poor outcome that could have been avoided with better communication among providers. Delayed/wrong diagnosis accounted for 41% of claims against primary care physicians and 48% of claims against NPs in The Doctors Company study.

“Nurses must not be afraid to ask doctors why they are doing something, and to inquire further if they see something they don’t understand,” Dr. Andrew said in an interview. Doctors, on the other hand, have an obligation, no matter how stressed or hurried they may be, not to send signals – bodily or otherwise – that they are not to be approached. That is a recipe for disaster.”

Set the tone early by exemplifying positive and clear communication, practicing good listening, and remaining empathetic, yet firm when making your needs known, Dr. Andrew advised.

“In the medical setting, you are always communicating for the benefit of the patient, and it is good to both keep this in mind, and to say it out loud,” she said.
 

2. Stick to the scope. When hiring an NP, make sure their scope of practice is clearly understood by all parties and respect their limitations, said Melanie L. Balestra, a Newport Beach, Calif., attorney and nurse practitioner who represents health providers.

Start by knowing your state’s scope of practice law for nurse practitioners. In 23 states and the District of Columbia, NPs have full authority to practice independently and can evaluate, diagnose, and manage treatment. In 15 states, NPs have reduced practice authority that requires a regulated collaboration agreement with a physician. In 12 states, NPs have restricted practice authority that requires supervision, delegation, or team management by a doctor.

Nurses practitioners must refrain from overstepping their authority, but physicians also must be careful not to ask too much of their NPs, experts stress. Ms. Balestra notes there is frequent confusion among doctors and NPs over how and whether scope of practice can be expanded as needed.

“This happens all the time,” Ms. Balestra said. “I get at least two questions on this every week [from nurses] asking, ‘Can I do this? Can I do that?’ ”

The answer depends on the circumstances, the nurse’s training, and the type of practice being broadened, Ms. Balestra said. For example, an NP in cardiology care may be allowed to perform more procedures in that field after internal training, but an NP who is trained in the care of adults can see pediatric patients only by going back to school.

“Know who you’re hiring, where their expertise lies, and where they feel comfortable,” she emphasized.
 

3. Preplan reviews. Early in the doctor-NP relationship, discuss and decide what type of medical cases warrant physician review, Mr. Ranum said. This includes agreeing on the type of patient conditions that will require a physician review and determining the types and percentage of medical records the doctor will evaluate, he said.

 

“The numbers should be higher at the beginning of the relationship until the physician gains an understanding of the NP’s experience and competence,” Mr. Ranum said. “Setting expectations will open the door to more frequent and more effective communication.”

NPs, meanwhile, should feel confident in requesting the physician’s assistance when a patient’s presentation is complex or a patient has returned with the same complaints, he added.
 

4. Convene regularly. Schedule regular meetings to catch up and discuss patient cases – not just when something goes awry, said Ms. Balestra. During weekly or monthly meetings, physicians, NPs, and other team members can converse in a more relaxed atmosphere and share any concerns or ideas for improvements.

“Have a meeting, whether by phone or in person, just to see how things are going,” she said. “That way, the NP may be able to take some things off the plate for the physician and the physician can see how [he or she] can assist the NP.”

Short huddles at the start of each day also help clinicians and staff prepare for patients and discuss approaches to managing complex conditions or challenging patient personalities, Mr. Ranum said.

“It is often helpful to debrief on patients who were seen during that day and who represent complex conditions,” he said. “Physicians may see opportunities to improve care following the NP’s assessment and diagnosis.”
 

5. Consider noncompliant policy. Create a noncompliant patient policy and work together to address uncooperative patients. Noncompliant patients are a top lawsuit risk, Ms. Balestra said. A noncompliant patient for instance, may provide conflicting information to different health professionals or attempt to blame providers for adverse events, she said.

“Your noncompliant patient is your easiest patient for a lawsuit because they’re not following [instructions] and then something happens, and they say, ‘It’s your fault, you didn’t treat me right.’”

Physician and NPs should be on the same page about noncompliant patients, including taking time to discuss when and how to terminate them from the practice if necessary, she said. Consistent documentation about patients by both physician and NPs is also critical, experts emphasize. Insufficient or lack of documentation led to patient injuries in 17% of cases against primary care doctors and in 19% of cases against NPs in The Doctors Company study.
 

6. Keep patients out of it. When disagreements or grievances occur, discuss the problem in private and ensure all staff members do the same, Dr. Andrew said. Refrain from letting anger or annoyance with another team member carry into patient care or worse, trigger a negative comment about a staff member in front of a patient, she said.

“All it takes is for something to go wrong and a patient or family who has heard such sentiments is tuned into the fact there may be some culpability,” she said. “This is probably a key factor in many a claimant’s decision to seek redress for a bad outcome.”

Instead, address problems or differences as soon as possible and work toward a resolution. It may help to create a conflict resolution policy that outlines behavioral expectations from all team members and suggested solutions when concerns arise.

“We have to put our egos aside,” Ms. Balestra said. “The ultimate goal is the best care of the patient.”

 

Positive relationships between physicians and nurses not only make for a smoother work environment, they also may reduce medical errors and lower the risk of lawsuits.

A recent study of closed claims by national medical malpractice insurer The Doctors Company found that poor physician oversight is a key contributor to lawsuits against nurses. Investigators analyzed 67 nurse practitioner (NP) claims from January 2011 to December 2016 and compared them with 1,358 claims against primary care physicians during the same time period.

Diagnostic and medication errors were the most common allegations against NPs, the study found, a trend that matched the most frequent allegations against primary care (internal medicine and family medicine) doctors. Top administrative factors that prompted lawsuits against nurses included inadequate physician supervision, failure to adhere to scope of practice, and absence of or deviation from written protocols.

The findings illustrate the importance of effective collaboration between physicians and NPs, said Darrell Ranum, vice president for patient safety and risk management for The Doctors Co. Below, legal experts share six ways to strengthen the physician-nurse relationship and at the same time, reduce liability:
 

1. Foster open dialogue. Cultivating a comfortable environment where nurses and physicians feel at ease sharing concerns and problems is a key step, says Louise B. Andrew, MD, JD, a physician and attorney who specializes in litigation stress management. A common scenario is a nurse who notices an abnormal vital sign but fails to mention it to the supervising physician because they feel they can handle it themselves or because they believe the doctor is too busy or too tired to be bothered, she said. The patient’s condition then worsens, resulting in a poor outcome that could have been avoided with better communication among providers. Delayed/wrong diagnosis accounted for 41% of claims against primary care physicians and 48% of claims against NPs in The Doctors Company study.

“Nurses must not be afraid to ask doctors why they are doing something, and to inquire further if they see something they don’t understand,” Dr. Andrew said in an interview. Doctors, on the other hand, have an obligation, no matter how stressed or hurried they may be, not to send signals – bodily or otherwise – that they are not to be approached. That is a recipe for disaster.”

Set the tone early by exemplifying positive and clear communication, practicing good listening, and remaining empathetic, yet firm when making your needs known, Dr. Andrew advised.

“In the medical setting, you are always communicating for the benefit of the patient, and it is good to both keep this in mind, and to say it out loud,” she said.
 

2. Stick to the scope. When hiring an NP, make sure their scope of practice is clearly understood by all parties and respect their limitations, said Melanie L. Balestra, a Newport Beach, Calif., attorney and nurse practitioner who represents health providers.

Start by knowing your state’s scope of practice law for nurse practitioners. In 23 states and the District of Columbia, NPs have full authority to practice independently and can evaluate, diagnose, and manage treatment. In 15 states, NPs have reduced practice authority that requires a regulated collaboration agreement with a physician. In 12 states, NPs have restricted practice authority that requires supervision, delegation, or team management by a doctor.

Nurses practitioners must refrain from overstepping their authority, but physicians also must be careful not to ask too much of their NPs, experts stress. Ms. Balestra notes there is frequent confusion among doctors and NPs over how and whether scope of practice can be expanded as needed.

“This happens all the time,” Ms. Balestra said. “I get at least two questions on this every week [from nurses] asking, ‘Can I do this? Can I do that?’ ”

The answer depends on the circumstances, the nurse’s training, and the type of practice being broadened, Ms. Balestra said. For example, an NP in cardiology care may be allowed to perform more procedures in that field after internal training, but an NP who is trained in the care of adults can see pediatric patients only by going back to school.

“Know who you’re hiring, where their expertise lies, and where they feel comfortable,” she emphasized.
 

3. Preplan reviews. Early in the doctor-NP relationship, discuss and decide what type of medical cases warrant physician review, Mr. Ranum said. This includes agreeing on the type of patient conditions that will require a physician review and determining the types and percentage of medical records the doctor will evaluate, he said.

 

“The numbers should be higher at the beginning of the relationship until the physician gains an understanding of the NP’s experience and competence,” Mr. Ranum said. “Setting expectations will open the door to more frequent and more effective communication.”

NPs, meanwhile, should feel confident in requesting the physician’s assistance when a patient’s presentation is complex or a patient has returned with the same complaints, he added.
 

4. Convene regularly. Schedule regular meetings to catch up and discuss patient cases – not just when something goes awry, said Ms. Balestra. During weekly or monthly meetings, physicians, NPs, and other team members can converse in a more relaxed atmosphere and share any concerns or ideas for improvements.

“Have a meeting, whether by phone or in person, just to see how things are going,” she said. “That way, the NP may be able to take some things off the plate for the physician and the physician can see how [he or she] can assist the NP.”

Short huddles at the start of each day also help clinicians and staff prepare for patients and discuss approaches to managing complex conditions or challenging patient personalities, Mr. Ranum said.

“It is often helpful to debrief on patients who were seen during that day and who represent complex conditions,” he said. “Physicians may see opportunities to improve care following the NP’s assessment and diagnosis.”
 

5. Consider noncompliant policy. Create a noncompliant patient policy and work together to address uncooperative patients. Noncompliant patients are a top lawsuit risk, Ms. Balestra said. A noncompliant patient for instance, may provide conflicting information to different health professionals or attempt to blame providers for adverse events, she said.

“Your noncompliant patient is your easiest patient for a lawsuit because they’re not following [instructions] and then something happens, and they say, ‘It’s your fault, you didn’t treat me right.’”

Physician and NPs should be on the same page about noncompliant patients, including taking time to discuss when and how to terminate them from the practice if necessary, she said. Consistent documentation about patients by both physician and NPs is also critical, experts emphasize. Insufficient or lack of documentation led to patient injuries in 17% of cases against primary care doctors and in 19% of cases against NPs in The Doctors Company study.
 

6. Keep patients out of it. When disagreements or grievances occur, discuss the problem in private and ensure all staff members do the same, Dr. Andrew said. Refrain from letting anger or annoyance with another team member carry into patient care or worse, trigger a negative comment about a staff member in front of a patient, she said.

“All it takes is for something to go wrong and a patient or family who has heard such sentiments is tuned into the fact there may be some culpability,” she said. “This is probably a key factor in many a claimant’s decision to seek redress for a bad outcome.”

Instead, address problems or differences as soon as possible and work toward a resolution. It may help to create a conflict resolution policy that outlines behavioral expectations from all team members and suggested solutions when concerns arise.

“We have to put our egos aside,” Ms. Balestra said. “The ultimate goal is the best care of the patient.”

 

Positive relationships between physicians and nurses not only make for a smoother work environment, they also may reduce medical errors and lower the risk of lawsuits.

A recent study of closed claims by national medical malpractice insurer The Doctors Company found that poor physician oversight is a key contributor to lawsuits against nurses. Investigators analyzed 67 nurse practitioner (NP) claims from January 2011 to December 2016 and compared them with 1,358 claims against primary care physicians during the same time period.

Diagnostic and medication errors were the most common allegations against NPs, the study found, a trend that matched the most frequent allegations against primary care (internal medicine and family medicine) doctors. Top administrative factors that prompted lawsuits against nurses included inadequate physician supervision, failure to adhere to scope of practice, and absence of or deviation from written protocols.

The findings illustrate the importance of effective collaboration between physicians and NPs, said Darrell Ranum, vice president for patient safety and risk management for The Doctors Co. Below, legal experts share six ways to strengthen the physician-nurse relationship and at the same time, reduce liability:
 

1. Foster open dialogue. Cultivating a comfortable environment where nurses and physicians feel at ease sharing concerns and problems is a key step, says Louise B. Andrew, MD, JD, a physician and attorney who specializes in litigation stress management. A common scenario is a nurse who notices an abnormal vital sign but fails to mention it to the supervising physician because they feel they can handle it themselves or because they believe the doctor is too busy or too tired to be bothered, she said. The patient’s condition then worsens, resulting in a poor outcome that could have been avoided with better communication among providers. Delayed/wrong diagnosis accounted for 41% of claims against primary care physicians and 48% of claims against NPs in The Doctors Company study.

“Nurses must not be afraid to ask doctors why they are doing something, and to inquire further if they see something they don’t understand,” Dr. Andrew said in an interview. Doctors, on the other hand, have an obligation, no matter how stressed or hurried they may be, not to send signals – bodily or otherwise – that they are not to be approached. That is a recipe for disaster.”

Set the tone early by exemplifying positive and clear communication, practicing good listening, and remaining empathetic, yet firm when making your needs known, Dr. Andrew advised.

“In the medical setting, you are always communicating for the benefit of the patient, and it is good to both keep this in mind, and to say it out loud,” she said.
 

2. Stick to the scope. When hiring an NP, make sure their scope of practice is clearly understood by all parties and respect their limitations, said Melanie L. Balestra, a Newport Beach, Calif., attorney and nurse practitioner who represents health providers.

Start by knowing your state’s scope of practice law for nurse practitioners. In 23 states and the District of Columbia, NPs have full authority to practice independently and can evaluate, diagnose, and manage treatment. In 15 states, NPs have reduced practice authority that requires a regulated collaboration agreement with a physician. In 12 states, NPs have restricted practice authority that requires supervision, delegation, or team management by a doctor.

Nurses practitioners must refrain from overstepping their authority, but physicians also must be careful not to ask too much of their NPs, experts stress. Ms. Balestra notes there is frequent confusion among doctors and NPs over how and whether scope of practice can be expanded as needed.

“This happens all the time,” Ms. Balestra said. “I get at least two questions on this every week [from nurses] asking, ‘Can I do this? Can I do that?’ ”

The answer depends on the circumstances, the nurse’s training, and the type of practice being broadened, Ms. Balestra said. For example, an NP in cardiology care may be allowed to perform more procedures in that field after internal training, but an NP who is trained in the care of adults can see pediatric patients only by going back to school.

“Know who you’re hiring, where their expertise lies, and where they feel comfortable,” she emphasized.
 

3. Preplan reviews. Early in the doctor-NP relationship, discuss and decide what type of medical cases warrant physician review, Mr. Ranum said. This includes agreeing on the type of patient conditions that will require a physician review and determining the types and percentage of medical records the doctor will evaluate, he said.

 

“The numbers should be higher at the beginning of the relationship until the physician gains an understanding of the NP’s experience and competence,” Mr. Ranum said. “Setting expectations will open the door to more frequent and more effective communication.”

NPs, meanwhile, should feel confident in requesting the physician’s assistance when a patient’s presentation is complex or a patient has returned with the same complaints, he added.
 

4. Convene regularly. Schedule regular meetings to catch up and discuss patient cases – not just when something goes awry, said Ms. Balestra. During weekly or monthly meetings, physicians, NPs, and other team members can converse in a more relaxed atmosphere and share any concerns or ideas for improvements.

“Have a meeting, whether by phone or in person, just to see how things are going,” she said. “That way, the NP may be able to take some things off the plate for the physician and the physician can see how [he or she] can assist the NP.”

Short huddles at the start of each day also help clinicians and staff prepare for patients and discuss approaches to managing complex conditions or challenging patient personalities, Mr. Ranum said.

“It is often helpful to debrief on patients who were seen during that day and who represent complex conditions,” he said. “Physicians may see opportunities to improve care following the NP’s assessment and diagnosis.”
 

5. Consider noncompliant policy. Create a noncompliant patient policy and work together to address uncooperative patients. Noncompliant patients are a top lawsuit risk, Ms. Balestra said. A noncompliant patient for instance, may provide conflicting information to different health professionals or attempt to blame providers for adverse events, she said.

“Your noncompliant patient is your easiest patient for a lawsuit because they’re not following [instructions] and then something happens, and they say, ‘It’s your fault, you didn’t treat me right.’”

Physician and NPs should be on the same page about noncompliant patients, including taking time to discuss when and how to terminate them from the practice if necessary, she said. Consistent documentation about patients by both physician and NPs is also critical, experts emphasize. Insufficient or lack of documentation led to patient injuries in 17% of cases against primary care doctors and in 19% of cases against NPs in The Doctors Company study.
 

6. Keep patients out of it. When disagreements or grievances occur, discuss the problem in private and ensure all staff members do the same, Dr. Andrew said. Refrain from letting anger or annoyance with another team member carry into patient care or worse, trigger a negative comment about a staff member in front of a patient, she said.

“All it takes is for something to go wrong and a patient or family who has heard such sentiments is tuned into the fact there may be some culpability,” she said. “This is probably a key factor in many a claimant’s decision to seek redress for a bad outcome.”

Instead, address problems or differences as soon as possible and work toward a resolution. It may help to create a conflict resolution policy that outlines behavioral expectations from all team members and suggested solutions when concerns arise.

“We have to put our egos aside,” Ms. Balestra said. “The ultimate goal is the best care of the patient.”