Risk Management

Boost Practice Efficiency: Productivity, Liability and the Technician

By Anne M. Menke, RN, Ph.D, OMIC Risk Manager

 EyeNet, October 2007

Incorporating ophthalmic technicians into your practice can help maximize your practice’s productivity and minimize its malpractice risk. As Risk Manager at the Ophthalmic Mutual Insurance Company, I urge technicians to play an active role in promoting patient safety and watching out for liability pitfalls.

Reduce Malpractice Risk

Some patients may find it easier to share their concerns with ophthalmic person- nel than they do with physicians. This provides technicians with an opportunity to improve patient care and, conse- quently, reduce your practice’s malpractice risk.

Technicians are knowledgeable yet approachable. Patients who are too shy to ask questions when speaking with the ophthalmologist are usually comfortable talking to technicians. For example, patients commonly do not take their medications as prescribed. Many of those patients worry that they will alienate the physician if they admit to this, especially if financial problems, lack of understanding of their disease or an inability to read contribute to the nonadherence. Technicians have an important role to play in addressing this problem. When a new patient is given a medication, the technician can instruct the patient by stating, “Many patients have questions or concerns about new drugs, or may not feel they are really needed. Do you have any ques- tions I can answer now? If you don’t have questions now, you may think of some later. In that case, please call me.” At the next visit, the technician can follow up: “I remember that the doctor started you on a new medication on your last visit. Tell me how you are using it.”

The knowledge base of technicians is vital to the process of informed consent. They can begin the task of educating patients about their condition and its treatment options. They also can use their conversations with patients to help identify and resolve misunderstandings. Legally, however, only the surgeon may obtain the patient’s informed consent by discussing the risks, benefits and alternatives of the procedure. Once that oral exchange has taken place, any staff member can review the form and obtain the patient’s signature.

Liability Pitfalls to Avoid

Written protocols play a critical role in minimizing your practice’s malpractice risk. These protocols must be carefully tailored to your practice, patient popu-lation and personnel. You can further reduce your malpractice risk by holding regular staff meetings that address threats to patient safety. Such meetings are an invaluable way of making each staff member a risk manager.

The challenge of telephone screening. This is one of the top three “scope of service” issues in ophthalmology.

However talented, technicians are unlicensed and are thus generally limited to performing tasks that do not require the knowledge and skills of licensed personnel such as nurses, optometrists and ophthalmologists. Indeed, techni- cians and their employers may face mal- practice lawsuits and/or medical board investigations if they perform tasks that are part of a licensed practitioner’s scope of practice.

Telephone care can be very compli- cated: The patient may be a poor histo- rian, may not be able to explain his or her symptoms and may not understand what is important. The health care team member on the other side of the line does not have the benefit of evaluating the patient’s nonverbal language, performing an exam or reviewing records. Unlicensed personnel may screen calls to determine the type of appointment (routine, urgent or emergent), but they need to have written protocols to guide them when they do. They cannot diagnose, treat, prescribe or renew medica- tions, and must instead ask the physician to make these decisions. If ordered to do so, they may communicate treatment recommendations or fax in a prescrip- tion refill.

For information on the screening role that nonphysician staff may play in after-hours calls, please see “Who’s On Call?” by Paul Weber at www.omic.com.

The challenge of knowing one’s limits. Experienced technicians may have the knowledge to determine the cause of the patient’s visual complaints, know exactly what treatment the ophthalmologist will recommend or feel certain that the prescription refill request will be honored. For legal and patient safety reasons, however, they may not share this information with the patient or refill the prescription, unless instructed to do so by the physician.

Withholding known answers may make the technician uncomfortable, especially when the patient asking for information is frightened. The best approach is to validate the patient’s concern and either encourage the patient to discuss it directly with the physician or offer to do so on behalf of the patient: “Mrs. Robson, thank you for letting me know that steroid drops helped you the last time you had this problem. Let me ask the doctor about this and call you right back. May I have your pharmacy’s number just in case?” If asked for a diagnosis, the technician can again reassure the patient and defer to the physician: “You sound very wor- ried about this sudden loss of vision. The doctor will explain what she feels is causing it after she examines you.”

Learn from your practice’s mistakes

Let’s say, for example, that the ophthalmologist discovers that he has implanted the wrong IOL. Suppose that a technician’s errors during the A-scan contributed to that surgical mistake. Many people’s instinct is to reprimand the person responsible. Instead, it would be both more productive and reassuring to everybody in the practice if you schedule a staff meeting and explain: “Today, our topic will be IOLs. I’ve learned that wrong IOLs are the most frequent cause of medical malpractice lawsuits. We recently had such a problem here and we can all learn from it. Leslie, why don’t you start by explaining what happened so we can all see how easy it is for such a mistake to go unnoticed. I’m sure everyone has some suggestions on how to improve our process of care to make it safer.”

Know your state laws. State laws and regulations determine what tasks may be delegated to unlicensed personnel and when a license is required. Some states, such as California, have very explicit and accessible laws. Other states allow the physician to exercise professional judgment or are silent on this issue.