1. The FTCA and You (aka How to avoid getting sued before it ever happens)

2. FTCA – The Federal Tort Claims Act

3. FTCA 101 Provides medical malpractice coverage to providers and staff at community health centers, as well as the VA, IHS, military hospitals and other federal facilities Provides medical malpractice coverage to providers and staff at community health centers, as well as the VA, IHS, military hospitals and other federal facilities

4. FTCA 101 Since 1992 Since 1992 Saves malpractice costs for FQHCs Saves malpractice costs for FQHCs Provides a degree of legal “immunity” to providers at FQHCs Provides a degree of legal “immunity” to providers at FQHCs

5. FTCA 101 How the game is played… Jane Doe decides that her chronic back pain is your fault Jane Doe decides that her chronic back pain is your fault Jane Doe calls a lawyer that she saw on daytime TV ad Jane Doe calls a lawyer that she saw on daytime TV ad Lawyer files suit in county or state court alleging malpractice Lawyer files suit in county or state court alleging malpractice

6. FTCA 101 How the game is played… Provider receives subpoena Provider receives subpoena Provider panics, cusses, etc… Provider panics, cusses, etc… Medical Director notified ASAP Medical Director notified ASAP Medical Director contacts FTCA guardian angels at US Department of Justice Medical Director contacts FTCA guardian angels at US Department of Justice

7. FTCA 101 How the game is played… FTCA coordinators contact local lawyer to clarify certain key issues… 1.Because the provider is covered by the FTCA, all suits must be filed in federal court 2.The provider is represented by the US Department of Justice… and they don’t look kindly upon frivolous lawsuits

8. FTCA 101 How the game is played… FTCA coordinators contact local lawyer to clarify certain key issues… 3.They can’t sue the provider or their family… The US government becomes the sole defendant. 4.An independent medical review board will consider the merit of the claim prior to any proceedings 5.If a case is filed and pursued, there will be no jury trial. A federal judge would hear the case. No jury = No sympathy card… and minimal damages for pain and suffering.

9. FTCA 101 Most frivolous lawsuits are dropped within the first week

10. FTCA 101 Even if it proceeds… And Uncle Sam loses or agrees to settle… Your personal assets are protected However… you’d still get a “ding” in the National Practitioner Data Base

11. Practical Advice on How to Avoid Getting Sued in the First Place

12. Cardiovascular Disease Chest pain should always be investigated. Chest pain should always be investigated. Assume that it is heart disease until proven otherwise. Assume that it is heart disease until proven otherwise. Document management of risk factors and adherence (or lack of) to treatment. Document management of risk factors and adherence (or lack of) to treatment. Maintain a high index of suspicion in patients with diabetes, the elderly and women. Maintain a high index of suspicion in patients with diabetes, the elderly and women.

13. Cardiovascular Disease Hypertension: enhanced emphasis in reaching goals for selected populations, i.e., diabetes, pre-existing heart disease. Hypertension: enhanced emphasis in reaching goals for selected populations, i.e., diabetes, pre-existing heart disease. Extremities: document pulses, look for infection in patients with diabetes and those who use tobacco (peripheral vascular disease). Extremities: document pulses, look for infection in patients with diabetes and those who use tobacco (peripheral vascular disease).

14. Medications Ask about allergies and the nature of the problem. Ask about allergies and the nature of the problem. Ask again and again (every visit). Ask again and again (every visit). Be alert to drug interactions and document your conversation with patients. Be alert to drug interactions and document your conversation with patients. Consider the use of an electronic source of pharmacologic information. Consider the use of an electronic source of pharmacologic information.

15. Medications Anticoagulants: risk of hemorrhage; drug interactions with antibiotics and others Anticoagulants: risk of hemorrhage; drug interactions with antibiotics and others Narcotics: sedation, risk of falls Narcotics: sedation, risk of falls Antibiotics: allergies Antibiotics: allergies Digoxin: check dose in the elderly, nausea Digoxin: check dose in the elderly, nausea Statins: obtain CPK and follow it, tell them about myositis and the symptoms Statins: obtain CPK and follow it, tell them about myositis and the symptoms

16. Medications Lithium: increased levels with dehydration, certain meds and renal failure Lithium: increased levels with dehydration, certain meds and renal failure Do not refill until you are sure of the dose. Do not refill until you are sure of the dose. Monitor for adverse effects (consider standing order for blood tests). Monitor for adverse effects (consider standing order for blood tests). Bring medications to every visit. Bring medications to every visit.

17. Abdominal Pain High index of suspicion, particularly in elderly. High index of suspicion, particularly in elderly. If not sure or severe, admit and obtain consultations. If not sure or severe, admit and obtain consultations. Think abscess, pancreatitis, gallstones, bowel ischemia, appendicitis Think abscess, pancreatitis, gallstones, bowel ischemia, appendicitis

18. Infections Urinary Tract Infections: think pyelonephritis/bacteremia-fever, flank pain, nausea, tachypnea, relative hypotension. Urinary Tract Infections: think pyelonephritis/bacteremia-fever, flank pain, nausea, tachypnea, relative hypotension. Look for skin lesions, respiratory rate and subtle evidence of severe disease (sepsis). Look for skin lesions, respiratory rate and subtle evidence of severe disease (sepsis). Skin infections: suspect deep involvement when pain is out of proportion to what you see. Skin infections: suspect deep involvement when pain is out of proportion to what you see. Look for clues that may dictate admission. Look for clues that may dictate admission.

19. Back Pain Look for alarm signals Look for alarm signals Recent trauma, history of cancer Recent trauma, history of cancer Bowel and/or urinary incontinence or retention (cauda equina) Bowel and/or urinary incontinence or retention (cauda equina) Fever (epidural abscess) Fever (epidural abscess) Cancer (epidural met and spinal compression) Cancer (epidural met and spinal compression) Weight loss (malignancy) Weight loss (malignancy)

20. Cancer Colon: bleeding, pain, change in bowel habits Colon: bleeding, pain, change in bowel habits Bladder: hematuria Bladder: hematuria Lung: lung nodule, never assume that it is benign unless you are sure; refer Lung: lung nodule, never assume that it is benign unless you are sure; refer Ovarian: abdominal enlargement, constipation Ovarian: abdominal enlargement, constipation Cervical: HSV, HPV Cervical: HSV, HPV

21. Breast Cancer Investigate all breast symptoms. Investigate all breast symptoms. Perform mammography. Perform mammography. Palpable lesions must be investigated even with a normal mammogram. Palpable lesions must be investigated even with a normal mammogram. Nonpalpable lesions with an abnormal mammogram should be investigated. Nonpalpable lesions with an abnormal mammogram should be investigated. Follow up and tracking if decide not to intervene. Follow up and tracking if decide not to intervene. Obtain consultations when in doubt. Obtain consultations when in doubt.

22. Pulmonary Evaluate shortness of breath; think of pulmonary embolism Evaluate shortness of breath; think of pulmonary embolism Treat acute asthma according to guidelines; early use of steroids, monitor, admit, if necessary Treat acute asthma according to guidelines; early use of steroids, monitor, admit, if necessary Follow up on abnormal chest x-rays, particularly in smokers or former smokers Follow up on abnormal chest x-rays, particularly in smokers or former smokers

23. CNS SAH: severe headache (never had it), neck pain; do CT and LP, if needed, neuro consultation SAH: severe headache (never had it), neck pain; do CT and LP, if needed, neuro consultation Headaches: alarm signals: new onset in elderly, progressive, cancer history, neuro signs, papilledema Headaches: alarm signals: new onset in elderly, progressive, cancer history, neuro signs, papilledema

24. Metabolic B12 deficiency (elevated methylmalonic acid with low-normal level): neuropathy, cognitive dysfunction, anemia B12 deficiency (elevated methylmalonic acid with low-normal level): neuropathy, cognitive dysfunction, anemia Anemia: look for iron deficiency and, if present, check for occult GI blood loss Anemia: look for iron deficiency and, if present, check for occult GI blood loss Electrolytes: diuretics (low sodium)-elderly females Electrolytes: diuretics (low sodium)-elderly females

25. Extremities Document your exam (neuro, vascular) during lacerations. Document your exam (neuro, vascular) during lacerations. If trauma and a lot of pain, think compartment syndrome. If trauma and a lot of pain, think compartment syndrome. If there is infection and a lot of pain, think necrotizing fasciitis. If there is infection and a lot of pain, think necrotizing fasciitis.

26. Extremities Trauma: Obtain x-rays to look for a foreign body Trauma: Obtain x-rays to look for a foreign body

27. Referrals Tracking to prevent lost reports or nonadherence to consultations. Tracking to prevent lost reports or nonadherence to consultations. Try to implement for x-rays, mammograms and labs. Try to implement for x-rays, mammograms and labs.

28. Patient Communication One of the most important factors. One of the most important factors. Call for follow up when ill and just seen. Call for follow up when ill and just seen. Call when new medications are started and you have a concern. Call when new medications are started and you have a concern. Express empathy and compassion. Express empathy and compassion. Do not make inappropriate or judgmental comments. Do not make inappropriate or judgmental comments. Become a good listener. Become a good listener. Do not blame for nonadherence to treatment. Do not blame for nonadherence to treatment.

29. Legibility All prescriptions and medical records must be legible. All prescriptions and medical records must be legible. Consider use of transcription or other electronic means. Consider use of transcription or other electronic means. The medical record is to document facts, not criticize other providers (bad idea). The medical record is to document facts, not criticize other providers (bad idea).

30. Office Environment Courtesy, respect of staff towards patients Courtesy, respect of staff towards patients Training and monitoring Training and monitoring Define unacceptable behaviors at the CHC (includes providers)-Performance Management Define unacceptable behaviors at the CHC (includes providers)-Performance Management Define disruptive behavior Define disruptive behavior

31. Preventive Strategies Communicate with patient. Communicate with patient. Show respect and courtesy. Show respect and courtesy. Alert them if they are going to wait more than 15-20 minutes. Alert them if they are going to wait more than 15-20 minutes. Develop referral tracking system. Develop referral tracking system. Do not make derogatory comments toward patients. Do not make derogatory comments toward patients.

32. Tracking Mammograms Mammograms Pap smears Pap smears PSA’s PSA’s Chest x-rays Chest x-rays CT scans CT scans MRI’s MRI’s Blood tests Blood tests

33. ER Develop good relationships with the ER to facilitate follow up. Develop good relationships with the ER to facilitate follow up. Develop protocols to obtain ER records of your patients. Develop protocols to obtain ER records of your patients. Do not make negative comments about the ER staff or the management. Do not make negative comments about the ER staff or the management.

34. Recommendations Read daily and develop high clinical knowledge. Read daily and develop high clinical knowledge. Maintain a high index of suspicion when dealing with certain situations. Maintain a high index of suspicion when dealing with certain situations. Call your patients when they are being treated. Call your patients when they are being treated. Develop referral tracking systems. Develop referral tracking systems. Write legibly. Write legibly. Do not make negative comments about others in the medical record. Do not make negative comments about others in the medical record. Keep in mind common high risk situations. Keep in mind common high risk situations.

35. Thanks