Lee A. Resnick, MD, FAAFP
Editor’s Note: This is the first of a two-part column that examines ways to reduce liability in the urgent care setting.
Our discipline is evolving rapidly and best practices are beginning to be defined. Staying abreast of practice standards for urgent care and implementing a disciplined risk mitigation plan will help your practice avoid the disruptive burdens of a medical malpractice lawsuit. The urgent care approach to risk management should be unique because our practice carries unique risks. I hope to provide some easy-to-integrate and “urgent care-centric” risk management tools for any urgent care practice, regardless of size.
Before creating a strategy for managing your liability risk, whether for your own personal protection or for the purpose of protecting the practice, it might be good to review the current state of medical liability in this country and its relevance to urgent care. Let’s start with the incidence of lawsuits nationally. According to recent statistics (NEJM, Aug 8, 2011), the incidence of lawsuits for family practice physicians hovers around 5% annually. Of these defendants, only about 1% end up making payments to the plaintiffs. The incidence of lawsuits for emergency medicine physicians is approximately 7.5% annually, with only 1.5% resulting in payments. Although urgent care claims are not tracked nationally on a large scale, the consensus is that urgent care risk probably lies somewhere between emergency medicine and family medicine, although some argue that it may even be higher due to the lack of advanced diagnostics and variable training of urgent care clinicians. These numbers tell a very sad story that has led most physicians to practice in fear, despite the low incidence of actual payments to plaintiffs. The data demonstrate a huge disparity between number of lawsuits and number of payments, reflecting that too many lawsuits are filed. The need for reform is apparent.
At this point however, the best offense is defense, and we will therefore focus our discussion on strategies to lower your personal and practice risk.
The single most important caveat in risk management is to focus on what you CAN control. There are many variables that contribute to risk in health care. Only some of them are under our control, but identifying those that are, and creating risk mitigation strategies around them will make a significant impact. Kicking and screaming about what you cannot control will not! And it should not be lost on anyone that each of these strategies also supports patient safety and care quality, the importance of which we can all appreciate.
Staying up to date: Before all else, each of us has a responsibility to make a commitment to keeping up with best practice and established guidelines as they pertain to urgent care. Several educational resources are available that define best practices in urgent care. The scope of competencies in urgent care is broad. Staying up to date requires a commitment to lifelong learning in your identified area of practice.
Identifying “at-risk encounters”: Establishing a short list of high-risk conditions and presentations is an exercise that every urgent care practice should go through. While beyond the scope of this column, a typical list would include things like chest pain, shortness of breath, confusion, altered level of consciousness, abnormal vitals, etc. For each, protocols for triage, physician evaluation, documentation, disposition and follow-up should be created. This sets the stage for ensuring risk mitigation at each stage of the encounter. A sample list can be found at www.jucm.com. Additional attention should be paid to the disruptive or conflict-oriented patient. An angry patient is more likely to sue when things go wrong; therefore, additional attention is required to the key areas of the encounter listed above.
Once you have defined “at-risk encounters,” you have a platform for your risk mitigation strategy. In next month’s column, I will target areas of urgent care practice where risk flourishes, often unnoticed. These include charting/documentation, electronic medical record risks, supervision of the clinical team, policy and procedure gaps, and an all-too-common urgent care practice I call “pretriage,” in which patients are told to go elsewhere for their care (most notably the emergency department) without having a physician evaluation.