Debra Kane Hill, MBA, RN and Richard F. Cahill, JD

A review of The Doctors Company call data shows that patient relationship issues are the top reason that members request assistance. Our patient safety risk managers often assist with issues involving new patients whose behaviors may raise red flags during their very first encounter with the practice.

Unfortunately, difficult patient interactions have become more common—with both established and new patients. Frequent issues reported include rudeness, entitled attitudes, abusive language, drug-seeking behaviors, unrealistic expectations, threats to staff, and intimidating language about pursuing legal action if expected needs are not met. These interactions are challenging to manage because they are time consuming and drain staff resources, and they can lead to licensing board complaints and claims and contribute to practitioner and staff burnout. To mitigate adverse consequences and protect your practice, consider developing a plan to preemptively manage these challenging behaviors when they are first identified.

Consider the following examples: A new plastic surgery patient tells the checkout receptionist, “I will sue if I don’t have good results.” The practitioner must be made aware of this type of statement in order to address patient expectations and determine if an ongoing relationship is appropriate. Another example is a new patient who requests controlled substances, then intimidates the practitioner if the demands are not met. In this situation—particularly if the behavior is threatening—it may be wise to deny the individual acceptance into the practice from the start.

Once the practitioner-patient relationship is established (which typically occurs with the first encounter), the practice assumes care for the patient until steps are taken to dismiss the patient from the practice if it becomes necessary. (To better understand when practitioner-patient relationships are established and how they can be safely ended, see our continuing education on The Advanced Practice Clinician–Patient Relationship: When Does it Begin and When Does it End? and Patient Termination.)

As most practitioners will attest, not everyone who seeks care is a good match for a practice. To prevent establishing a practitioner-patient relationship with an individual who is not an appropriate fit, take steps to assess potential patients for acceptance into the practice during the very first meeting. While it may be unrealistic to evaluate every potential patient who presents to a busy family medicine or pediatric practice, it is prudent to do so in some specialties, such as plastic surgery, pain management, and psychiatry.

Create a Conditions of Treatment Agreement

Developing a Conditions of Treatment (sometimes referred to as “Terms of Service”) agreement for prospective patients can help practices determine whether an individual is a good fit for the practice. For transparency, notify individuals at the outset of the association about the practice’s expectations once they become established patients.

To avoid potential misunderstandings, use a clearly written Conditions of Treatment agreement that outlines the practice’s rules and office policies. It can include rules for payment, appointment scheduling and cancellation, no-show fees, decorum toward staff and visitors, weapons, personal hygiene, service animals, digital audio or video recording, and personal electronic devices (including smart phones). (Find a more detailed discussion regarding the use of recording devices in our article “Recording Office Visits and Procedures: Pros and Cons for Healthcare Professionals.”)

The agreement can also specify the expectations for the patient’s adherence with provider treatment plans, specialty referrals, recommended therapy modalities, and prescribed medication regimes. Without the patient’s agreement, optimum clinical outcomes are likely to be compromised and the trust necessary to support the practitioner-patient alliance will be significantly eroded.

Clearly indicate in the Conditions of Treatment agreement that failure to follow the practice’s policies may result in dismissal from the practice. (Find additional guidance about patient unwillingness to follow practitioner recommendations and termination in our articles “Nonadherent and Noncompliant Patients: Overcoming Barriers” and “Terminating Patient Relationships.”)

Evaluating Prospective Patients and Managing Established Patients

Consider taking the following steps to evaluate potential patients for acceptance into your practice and define expectations for an ongoing practitioner-patient relationship.

• Post a statement, such as the following, on your practice website, in your waiting room, and on new encounter office forms: “We evaluate potential patients to determine if they are a good match with our practice and the services we offer. Completing office forms, providing patient records, or attending an appointment for an initial evaluation does not establish a practitioner-patient relationship. After the initial evaluation, individuals will be notified if they are accepted into the practice as a patient.”
• Provide the Conditions of Treatment agreement for review at the first office encounter.
• Conduct an initial evaluation of the individual at the first encounter to assess clinical needs and expectations and determine any behavioral challenges. Document these findings in your records. Notify the individual at the end of the visit about acceptance into the practice.
• Document your acceptance of an individual into the practice in the new patient’s record. You may bill those who are accepted as patients.
• Have accepted new patients sign the Conditions of Treatment agreement that outlines expected behavior, office operations, and potential consequences if the patient violates office policies.
• Always send a letter (by first-class mail and certified mail, return receipt requested) to individuals who are denied acceptance into the practice, and place a copy in administrative files. Include wording that “a practitioner-patient relationship was not established” and the individual will not be charged for the encounter. Never prescribe medications or treatments for those who are denied acceptance into the practice, and do not bill for the evaluation. These actions suggest that a practitioner-patient relationship was established.
• Do not in any way refer to those individuals not accepted as “patients.”
• Ensure that individuals are not denied based on Equal Employment Opportunity Commission or Americans with Disabilities Act protected status. For example, denying individuals acceptance to your practice because they require an interpreter is illegal.
• Post office policy requirements on the practice’s website. For established patients who violate office policies, it may be helpful to sit down with the patient to go over the Conditions of Treatment and address specific issues.
• For repeat violations of office policies, send the patient a letter that identifies the problem, reminds the individual about the signed agreement to obey office rules and policies, and states that continued inappropriate behavior may result in discharge from the practice. Place a copy of the letter in the patient’s record.
• Display signage near the reception window regarding the payment of deductibles, assessed charges for missed appointments, possession of weapons, and other simple reminders to facilitate interactions with office staff and help expedite routine patient processing. (For more information, see our guide, Effective Patient Communication.)
• Provide concise, accurate, and complete documentation of patient interactions conducted onsite in the office, through remote telehealth encounters, or via the patient portal. To promote continuity of care, document conversations among the treatment team in the progress notes. (Find guidance regarding patient record entries in our article “Defensible Medical and Dental Records.”)
• Caution all persons entering the practice that there is a zero-tolerance policy for violence, brandishing weapons, and any form of sexual harassment. Employees of a clinic or other healthcare operation are legally entitled to protection against unsafe working conditions, violence, and confrontational behavior. The practice is responsible for being proactive in helping to ensure compliance. (For further information, see our article “Sexual Harassment Allegations in Healthcare: Rising Risks.”)
• Create internal policies and procedures that define the new patient acceptance or denial process. Educate staff in the application of these steps within the workplace.

Conclusion

It is imperative that practices are proactive in setting and managing expectations with prospective and existing patients so that potential issues are prevented or managed quickly before they escalate. Clear communication in the clinical setting constitutes a critical element in achieving optimum treatment outcomes, enhanced patient satisfaction, and reduced occurrences of adverse events often associated with risks of civil liability. Practitioners and staff who anticipate, plan for, and appropriately respond to challenging behaviors with the assistance of a Conditions of Treatment agreement can protect the practice from risk.

Debra Kane Hill, MBA, RN, is Senior Patient Safety Risk Manager, and Richard F. Cahill, JD is Vice President and Associate General Counsel for The Doctors Company

For further questions or assistance, please contact The Doctors Company Patient Safety and Risk Management Department at (800) 421-2368.

Additional Resources

Patient Relations: Anticipate and Address Challenging Situations

Patient Relations: Spotlight on Challenging Situations

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.