Professionalism & Working with Difficult Patients The ESRD Network of Texas, Inc.

Our Patients “Patients with renal disease are challenged by many stressors, including loss of biochemical and physiologic kidney functions, development of digestive and neurological disorders, bone disease and anemia, inability to function in the family and to maintain one’s occupation, decreased mobility, decreased physical and cognitive competence, and loss of sexual function” Kimmel, MD & Peterson, MD Seminars in Dialysis, 2005

It’s not an easy life Sometimes this causes denial, anger and behavior issues

What Do We Know? That facilities are desperately seeking ways to work with challenging patients. That resources are few That there are no concrete answers That each individual patient represents a new challenge #3 Therefore best practices are extremely important as well as treatment team collaboration.

From CMS…. “we believe that every dialysis facility has the resources and responsibility to work with every patient, including patients perceived to be disruptive or challenging” -Conditions of Coverage

MAIN GUIDING PRINCIPLE FOR ALL PROFESSIONAL ETHICS IS? DO NO HARM!

What is needed? More compassion More understanding More staff education How to work with mentally challenged individuals In many cases PCT’s have limited training on working with difficult patients More support for staff and patients

Patients want from staff Kindness Recognition Comfort Emotional support This requires Caring Communications

Compassion Balance Excellence Efficiency (Advocacy) (Tension) (Quality) Efficiency (Stewardship) The Network has found when there is a balance of these three components facilities run more efficiently and patients are satisfied with their care. Jim Rohack, MD, Medical Director SWHP

Reasons for Conflict Non-adherence Mental Health & Substance Abuse Issues Cultural & Racial Issues Complex Environment Communication Difficulties Patient are often in denial or have a feeling of invincibility even after they have been hospitalized Many mental health issues go undiagnosed and or untreated. With some patients there is just a refusal to receive treatment often due to severity of their current condition. Respecting patients cultural traditions is a major challenge in Western medicine and in many cases the patient is left in internal conflict between right and wrong with in their values system. Very few people enjoy coming to an environment that poses stress and or discomfort. Therefore, its important that staff attempt to make the dialysis center a place that is harmonious. First starting with their attitudes. Everyone has different communication styles, its important to assess patients various ways of communicating and adjusting to their needs in an effort to illicit trust and building rapport this understanding how they communicate their needs. If patients feel that they are just another body in the chair, there will always be distance and the perception of poor quality of care.

Role of Network in grievances Be objective Hear all sides Gather information Facilitate resolution Make a determination

What do we see at the Networks?

Growing Number of Involuntary Dismissals nationally Tantamount to DEATH SENTENCE? “We have no other choice” “Our back is against the wall on this” “We have tried everything else” Some Will Die…

Beneficiary/Representative Contacts Category by Quarter for 2013 This graph does not include “other” category which indicates a 4 case total difference. QOC =127 *******Look at Discharge – What were the reasons in the 4quarter for d/c’s********

Trending Involuntary Discharge 2008 to 2013 Comparison Maintaining a steady number is not good enough!

January-April, 2013 Number of all Involuntary Discharges by Type IVD must be decreased by 1 or 5% per quarter

How does Professionalism & Working with Difficult Patients fit together? The work that we do every day impacts the lives of others. Usually the impact comes from an inability to build a healthy professional relationship with our patients.

Relationships: Personal vs. Professional Purpose Balance of Power Focus Differences: PURPOSE Personal: for both is emotional Professional: pt=> services professional=> $$$, service delivery BALANCE OF POWER Personal: both are = Professional: , prof>power, pt dependent FOCUS Personal:  Professional: =>pt, pt’s best interest is always the main concern

Challenging situations are often the delayed result of professional boundary violations. Familiarity- long-term/3Xweek Grievances are often about professionalism—one of most common patient complaint

Common Problems: Boundaries Crossed Becoming personally involved Gifts Showing favoritism Dual relationships Healthcare workers are often nurturing and sensitive, thus susceptible to the formation of intense personal relationships.

Becoming Personally Involved Sharing that shifts FOCUS from pt to professional Lose ability to respond objectively React emotionally Approp: Names, ages, activities of children Inapprop: concerns that teen does drugs A: conversation at grocery store I: going out for dinner, dating A: Encourage pt to call unit when no ride I: giving pt a ride Establishing expectation that we will continue to respond in that manner and that other staff will also. Case 1: Well-liked pt becomes involved in personal lives of staff. Not invited to party. Feels hurt and rejected. Becomes withdrawn and depressed. Acts out. Labeled as difficult. Case 2: Pt refusing to have tech put him on because she’s going through a nasty divorce and he’s afraid she won’t concentrate on his arm.

Gifts Unit policy against giving/receiving of gifts Federal regulations against giving to patients Protects pts from feeling that they need to pay extra for quality Protects staff from feeling they need to give extra attention Case 3: Pt buys lunch regularly to show appreciation. Staff become overwhelmed with amount of work it takes to keep the pt happy. Expectations develop and feelings can be hurt or insulted when expectations are not met.

Showing Favoritism Show that you favor one pt over another, or facilitate a pt favoring you over other staff Creates expectation that it will be done again Expectation that other staff will do the same Distrust of other staff Case 4: Pt always early for tx. Someone starts putting pt on early. Next staff person doesn’t and pt becomes angry feeling they are being put on late.

Dual Relationships Exchange of goods or services Case 5: Pt. Moving, needs storage. Staff offers us of garage. 3 months and no move. Case 6: Pt. Works on staff’s car. Car messes up. Pt blamed. Pt’s arm infiltrated by staff. Case 7: Buy from one pt and not another (Avon, GS cookies, Kid’s School Sales)

SEXUAL MISCONDUCT Demeaning to the patient It is usually intentional It is a breach of TRUST Long-term effects can be devastating but may not be readily apparent THE BREACH OF TRUST IS USUALLY FAR MORE SERIOUS THAN THE ACTUAL SEXUAL CONTACT

TOOLS TO HELP Decreasing Dialysis Patient- Provider Conflict Toolkit Caring Communications Tips

DPC Toolbox IG-”At the time of publication of these rules, each facility had received a copy of an interactive program developed by the ESRD Networks on Decreasing Dialysis Patient Provider Conflict (DPC) that addresses proactive techniques to resolve such issues before progression to involuntary discharge.”

Toolbox Contents Ethical, Legal, Regulatory Statement Poster Brochure Pocket Card Bibliography Taxonomy & Glossary Tip Sheets “Top Ten” Responses Interactive Web-Based Training Training Modules QI Tracking Tool

Toolbox Contents cont. Clips of “real life” situations Critical thinking algorithms and video Clips of “real life” situations Use of Taxonomy & Glossary Use of conflict resolution techniques Sent to each facility in US Interactive educational software

DPC “CONFLICT” Resolution Model 9 step program

“CONFLICT” Resolution Model C-Create a Calm Environment O-Open Yourself to Understanding N-Need A Nonjudgmental Approach F-Focus on the Issue L-Look for Solutions I-Implement Change C-Continue to Communicate T-Take Another Look

Create A Calm Environment “In order to effectively address a conflict, you need to be aware of the physical surroundings, as well as the thoughts and feelings you are experiencing because of the conflict” Staff must maintain a professional stance, this attitude should be one that includes caring and the provision of comfort.

Open Yourself to Understanding Others “When addressing a conflict, it is important to acknowledge the perspective and feelings of the other individual(s) involved” When we care about people we are willing to listen to their concerns and investigate ways to meet the needs of all involved. We do not attack first. We avoid a defensive presence.

Need A Nonjudgmental Approach “As a dialysis professional, it is important for you to maintain an objective and professional approach as you address the conflict. Keep in mind that words exchanged in the heat of an argument are often not intended as personal attacks.” We maintain an objective and professional approach as we address the conflicts. We must remember that the words used by patients are not meant to be taken personal. They are just angry. We must remember that not everyone has learned to handle conflict in the same manner.

Focus On The Issue “When conflict occurs, there is a tendency to lose sight of the issue that started the disagreement. What starts out as a concern about starting dialysis on time can quickly become a disagreement about the facility staff, the clinic operations, or the physician care.” Often times during a meeting with a patient, one of the parties involved tries to focus on several concerns at one time and many times the incidents happened months prior. It is recommended that a designated person assists with keeping the participates on the matter at hand with a focus on positive outcomes.

Look For Solutions “Not all conflicts can be resolved nor are all conflicts based on valid complaints. But working in collaboration with the patient will improve the likelihood of a positive outcome.”

Implement Agreement “If you take the time to work through the conflict, it is likely that you will reach a stage of agreement when changes will need to be put into action.” Contracts are a thought of the past, respectable adults work towards an agreement. Showing respect for your fellow person helps the process go a long way and lessen the opportunity for a position of defense.

Continue To Communicate How's it working out? “Effective resolution of a conflict requires follow up communication. This allows you to monitor the progress being made. And demonstrates to the patient your commitment to resolving the conflict.” Follow up is extremely important. Follow up should be encourage to be made by the patient as well as the team. the patient can be encourage to provide feedback regarding improvement identified by a set date.

Take Another Look “Handling a conflict, like successfully performing dialysis related tasks, requires practice, understanding, education, and monitoring. Regardless of whether a conflict is minor or major, reviewing the steps used in addressing the conflict will be beneficial.” Revisiting the matter occasionally is a good way to prevent future reoccurrences, it is important that this follow up be made with preserving the dignity and respect for the patient. Lets be proactive instead of reactive at times.

Tools to help you use the Conflict Resolution Model DPC Brochure: “Decreasing Conflict & Building Bridges” DPC CONFLICT Poster DPC CONFLICT Pocket Guide

Feelings, personal attention, caring Information, tasks Heart-Head-Heart Communication: Two Sides to a Satisfying Service Experience Heart Head People desire to be cared about. We want to know that we are not just another number or person sitting in a seat. Remember the Heart Head Heart communication: Show a level of caring while making difficult decisions Take time to let the patient know that you are not too busy for them. Feelings, personal attention, caring We’re so busy the heart messages get lost. Information, tasks Dialysis is so full of tasks

Caring Communication Hints Acknowledge patients likely feeling. Share your good intentions: How are your actions for the customer’s sake? Ask open-ended, not yes-no questions. Use the words “for you.” Express appreciation to the person. Take time to explain to a patient what your positive intensions are and how you hope the patient will benefit. For example teach staff to show compassion and empathy when they observe a patient in pain. How many times have patients observed a blank stare from staff when trying to describe their situation?

Messages Key to Patient Satisfaction You are not a number. YOU, uniquely YOU matter to me. I respect your thoughts and feelings. I want you to feel my support. Yes, I’m here to care for you. And, I also care ABOUT you. The use of both verbal and nonverbal communication allows patients to see that you understand what they are saying: Respond in a respectful way as oppose to a discerning and matter of fact way. Show that you are trying to be supportive and that you care about what they have to say! It is also important to remember that patient satisfaction increases a patients perception of their over all quality of care, therefore patients are less likely to want to transfer from your facility.

When the team is struggling with a patient… Educate their staff about caring communications tips Contact the Network as soon as possible Suggestions, tips, ideas Objective party

Additional ideas to consider Patient Care Conference (PCC) Behavior Agreements Patient Advocacy Meetings Professionalism Trainings PCC with the Network involved Use agreements in stead of contracts, less chance for defensiveness Be proactive, have quarterly patients meetings and provide time for patients to discuss concerns Regularly professionalism training (for some clinics 2 times per year) It takes 6-10 times to hear something to learn it and use it over 21 days to change a behavior.

How to handle a situation… If the patient is an actual and immediate danger to others Weapons Striking others CALL 911 Immediate Discharge IG- An "immediate severe threat" is a threat of physical harm. For example, if a patient has a gun or a knife or is making credible threats of physical harm, this would be considered an "immediate severe threat."

The Renal Professional You Make A Difference

ESRD Network of Texas, Inc. Thank you for your participation For assistance contact the Patient Services Department : Treneva Butler 469-916-3808 Ron Davis 469-916-3810 Maria Bustamante 972-503-3215 ex 344