Risk Management

  1. Naturopathic state licensing board complaints are often a first resort for aggrieved patients.

 

  • General Trends:
    • Almost 60% of the actions filed against our naturopathic doctors were state licensing board complaints.
    • The most common misconduct alleged in licensing board complaints: incorrect treatment (30%), improper billing practices (20%), inadequate documentation (10%), lack of informed consent (10%), and boundary issues (10%).
    • Because anyone can file a board complaint, and there is no requirement that the patient suffered any harm (as is the case in litigation), naturopaths may be more likely to face a licensing board complaint than be sued.

 

  • Risk Management Tips:
    • The best way to prevent a board complaint? Deliver good clinical care.  Try the “Three C’s.”  Collect sufficient information about the patient and the patient’s condition; communicate effectively to the patient and other members of the treatment team; and carefully document informed consent, assessments, and decision-making.
    • Do not ignore the steps in the clinician-patient termination process. Many states require you to give a certain amount of notice before terminating the treatment relationship.
    • Contact your insurance program before responding to any licensing board complaint or other administrative action.

 

  1. Thoughtful and thorough documentation is your best defense.

 

  • General Trends:
    • Failing to document communications with other treatment team providers.
    • Failing to document new informed consent discussions after making significant medication changes.
    • Failing to document the discussion of unlikely but serious potential medication side effects.
    • Failing to document patients’ consent to various office billing practices.

 

  • Risk Management Tips:
    • Always document what medications have been ordered, the basis for prescribing the medications, and changes to medications.
    • Document your decision-making process including not only what actions were taken and why, but also what actions were considered, but rejected, and why.
    • Signed forms can play a role in the documentation of informed consent, but they cannot replace the naturopath-patient discussion.Informed consent discussions may need to be expanded for off-label uses of medications or treatment considered experimental or alternative.
    • Consider incorporating patient information handouts, such as medication information sheets.
    • Document communications with your patient and with other providers involved in the patient’s treatment.
    • Contemporaneous documentation is a must. Altering or adding to a patient record after an adverse event will appear self-serving.  If you think that certain additions or changes should be made to the record after an adverse event, contact your insurance program.
    • Discuss and document your patients’ understanding of office billing practices.
    • Remember, a thorough and thoughtful chart deters plaintiff attorneys. Good documentation prevents them from making up their own story about you did in treatment and why.

 

  1. Maintain a healthy respect for professional boundaries at all times.

 

  • General Trends:
  • Continuing to prescribe after the end of the treatment relationship.
  • Asking patients to provide testimonials or vouch for treatment.
  • Allowing patients to inappropriately influence the course of treatment.

 

  • Risk Management Tips:
    • Never engage in any form of treatment outside of the context of a current treatment relationship.
    • Due to the nature of the naturopath-patient relationship, naturopaths possess a great deal of influence over the patient.Therefore, one must be particularly careful in asking patients to provide testimonials or vouch for treatment. If patients are asked to endorse treatment, they must be assured the freedom to decline.  The patient must also sign an authorization if the physician wishes to release the testimonial.  Above all else, the naturopath’s primary obligation is to improving the health and well-being of the patient.
    • Don’t allow any patient to make you practice below the standard of care. While you must always take into account your patient’s treatment choices and preferences, never engage in a course of treatment you deem to be clinically inappropriate merely because the patient wishes you to do so.

 

  1. Fully understand your employer’s expectations.

 

  • General Trends
    • No contract governing the employer-employee relationship.
    • Lack of knowledge of billing practices occurring under the naturopath’s name.
    • Failure to supervise due to lack of clarity on exactly who was responsible for supervising.

 

  • Risk Management Tips:
    • Before accepting a job, seek a contract that fully defines your role and responsibilities.
    • Consider working with an employment attorney to ensure your employment contract is sound.
    • Clarify with your employer to whom the patients belong and who will own treatment records.
    • Determine how services will be billed, and what services will be billed under your name.
    • Be aware of any clinician or non-clinician that you may fall under your supervision.
    • Review any guidelines, rules, protocols, or notices provided by your employer.
    • When faced with organizational issues that affect your ability to meet the standard of care, relay those concerns in writing to the appropriate party.
    • Understand the employer’s hierarchy and know to whom to report after an adverse event has occurred.

 

  1. Tough case?Seek a consult with a colleague.

 

  • General Trends:
    • Failing to diagnose rapidly progressive injuries.
    • Misdiagnosing and improperly referring minor patients.
    • Failing to consult with other members in the treatment team regarding prescriptions or check the state prescription monitoring drug program.
    • Continuing on a course of treatment that has proven to be ineffective.
    • Allowing patients to dictate a course of treatment that doesn’t meet the standard of care.

 

  • Risk Management Tips:

 

  • Seeking consults with colleagues when appropriate shows thoughtfulness by the treating naturopath and benefits patient care.
  • When seeking an informal consult, first consider whether the advice or input that you seek would be more appropriate for a formal consult.
  • Factors that may be indicative of the need for a formal consult:
    • A situation presents complex issues or multiple variables to sort out.
    • The patient needs to be examined for advice to be given.
    • The question involves making a diagnosis.
    • Patient’s condition demands a specialist or expert in the area.
  • Clarify the nature of the consultation at the outset.All parties should understand clearly that the ultimate decision for which treatment to recommend lies with the treating naturopath.
  • Consider making treatment conditional upon the patient’s permission to consult with other treatment team providers.
  • Do not limit yourself to one consult if you think other opinions may be needed.

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