Originally published March 2015
As the first point of contact for patients, the staff members of a medical practice set the welcoming tone. These individuals ensure the office runs efficiently and perform the essential tasks of answering patient telephone calls, obtaining and recording patient information, managing referrals and test results, and responding to requests for medical notes or third-party reports.
While delegating these administrative tasks to their employees gives physicians more time to focus on direct patient care, some physicians may not be aware of the medico-legal implications.
Hire experienced staff, provide training
Hiring professional, experienced office staff can go a long way to reducing medico-legal risks and regulatory authority (College) complaints. It is also prudent for physicians to spend time training employees on their responsibilities, particularly emphasizing the need to keep patient information confidential, to adhere to privacy obligations, and to communicate and document appropriately. Physicians should orient their staff to College guidelines on safe and effective office practice.
The CMPA experience
Medico-legal actions involving office practice often stem from a physician’s failure to establish an effective system to manage test results. Office staff may misfile or neglect to inform a physician about the availability of a test result, which can lead to a patient experiencing a delay in diagnosis or treatment. These types of medico-legal actions often result in unfavourable outcomes for the physician. Colleges and the courts expect physicians to have effective systems to track and follow up on patient investigations.
In addition to the effective management of test results, a review of medico-legal issues encountered in the administration of an office practice found other recurring themes: privacy, confidentiality, delegation, documentation, and office safety. The following cases illustrate some of these themes.
Case 1: Privacy
A 45-year-old woman has an appointment for a physical examination. While waiting, she notices that her physician’s office receptionist routinely spells back patient names, phone numbers, and reasons for their visit when booking appointments over the phone. When it was the patient’s turn to be seen, the receptionist announced the reason for her visit in front of other patients in the waiting room. The patient complains to the College, which results in a caution to the family physician on the importance of respecting the privacy of patients and of the physician’s obligation to educate office staff to not improperly disclose patients’ personal information.
Physicians have a legal duty to protect patients’ privacy, and an ethical and professional duty to maintain the confidentiality of patients’ personal information. Physicians may not be aware that these obligations for maintaining privacy also extend to their staff. Important office staff functions include checking patients’ contact and other demographic information, and providing appropriate information to patients. Care is needed to avoid inadvertently disclosing patients’ personal health information while carrying out these functions. Physicians and their staff must be mindful that patients waiting in an office may be able to overhear the staff’s telephone conversations. It may be necessary to physically arrange the office so privacy and confidentiality are protected, particularly if staff members repeat what a caller is saying as a way of confirming information.
When orienting new staff, physicians should take the opportunity to review office privacy policies and emphasize each employee’s role in maintaining patient confidentiality and safeguarding patient records. Physicians should be familiar with the privacy legislation in their jurisdiction. Staff should be reminded that they must obtain a patient’s consent before releasing personal health information to family members or to a third party. Similarly, doctors need to educate their staff not to discuss patient information, particularly outside of the office. Asking each staff member to sign a confidentiality agreement highlights the importance of these issues.
Case 2: Communication
A 44-year-old woman confirms her appointment for an influenza vaccination with the receptionist. When she arrives the following day for the appointment she is told that there is no vaccine available. The patient advises the receptionist that she had been told the vaccine was available. The receptionist agrees they had spoken, however states that the vaccine did not arrive. The patient complains to the College that her appointment should have been rescheduled as she took a half-day vacation to attend the appointment. The College reminds the physician that office staff must provide accurate information to patients.
Communication problems are frequently identified as a concern when patients submit complaints to Colleges. In addition to issues with a physician’s communication style, patients may also highlight that a physician’s staff was rude, insensitive, or inaccessible. The Colleges repeatedly remind physicians that they are responsible for making a good effort to ensure their office employees provide accurate, current, and timely advice to patients. Staff should also be sensitive to the unique circumstances of each patient, for example, age, gender, ethnicity, sexual orientation, religious beliefs, and socio-economic status, and take these into consideration when communicating. Dissatisfied patients may also file complaints with the Human Rights Commission. Having documentation of the advice that staff provided can greatly aid a physician’s response to these complaints.
It is important to educate staff about their role in patient care and about the amount and kind of information they are permitted to give patients and when it is necessary to transfer the information to the physician.
Risk management considerations for an office practice
- Create an office manual to provide guidance on office policies and procedures, and orient new staff to these rules.
- Have all staff sign confidentiality agreements.
- Ensure the office environment adequately allows staff to keep patient information private and confidential.
- Train staff to communicate with patients respectfully and professionally, and to be sensitive to the unique circumstances of each individual (e.g. culture, age, gender, sexual orientation, ethnicity, religious beliefs, socio-economic status).
- Inform staff members that it is the role of health professionals to determine the appropriate advice to be provided to patients.
- Inform staff about the types of communications with patients that should be documented in the medical record. Make explicit the office standards for handling and documenting telephone calls and voice mail messages to and from patients for prescription renewals and for no shows for appointments.
- Provide staff with clear parameters as to when they should notify physicians about patients’ telephone calls or calls from third parties.
- Establish a policy on how to follow-up with patients.
- Train staff members on their role in managing patient test results and patient referrals.
- Give staff instructions on what advice they can provide to patients when physicians are absent.
- Educate staff on the principles of consent and ask that they confirm the patient’s consent before sharing medical information with third parties.
- Consider what kind of messaging will be provided to patients who are seeking care when the office is closed.