Dr Samantha KingMedical Protection Society

17:45 - 18:30 First Impressions Count

FIRST IMPRESSIONS COUNT

Dr Samantha King, MPS Medical Adviser

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Overview of today’s

session

▪ Getting things right -

1. First impressions

2. Dignity and respect

3. Communication

▪ Dealing with difficult patients

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1 September

2016-2017

MPS opened 1730 cases:

▪ 2 Vascular surgeons

▪ 5 Endocrinologists

▪ 11 Gastroenterologists

▪ 76 General Surgeons

▪ 76 Obstetricians/Gynaecologists.

How many GP cases?

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1 September

2016-2017

MPS opened 1730 cases:

▪ 872 General Practitioners

▪ GPs make up 23% of our membership

but 50% of our work.

HDC complaints

Getting Things Right

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Why get things right?

▪ We want to help people

▪ Improves the practice’s reputation

(word of mouth)

▪ Increases job satisfaction for staff

and improves team morale

▪ Patients are our customers - without

them we have no jobs

▪ Changing face of healthcare: funding

depends upon achieving good

outcomes.

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Royal New Zealand

College of General

Practitioners

General Practices need to show

compliance with all indicators and

criteria provided by the RNZCGP to be

accredited:

▪ 40 indicators

▪ Foundation criteria = required for

foundation accreditation

▪ Foundation + advanced criteria =

required for Cornerstone

accreditation

▪ Aspirational criteria = optional

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Getting things right

1. First impressions

2. Dignity and respect

3. Communication:

- non-verbal and verbal

- patient expectations

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1. Making a positive first impression

▪ It takes 3- 5 seconds to make a first impression

▪ First impressions need to be;

- Professional

- Polite

- Positive

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Case 1

I had had a night of vomiting and dry retching, decided I would come to the Health Centre at 8am. I

waited in my car until Radio NZ announced it was 3 minutes to 8, I then walked to the centre and

knocked on the door. Reception were just getting ready for the day, unfortunately my request was

meet by a Ms Smith, who stood at the front desk and held out her wrist pointing to her watch,

which she kept tapping, and waved for me to go away.

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Case 1

I knocked again and this time she pointed at the clock and waved again for me to go away I

indicated to her that I was very unwell, she finally activated the button to open the door. ( Must have

been, by this time, 8 am) Her verbal response was “What’s wrong with you” I replied I had very bad

nausea and needed to come in and lie down, and I thought I was going to be sick again, she then

threw a towel at me and said, “Well there is nobody here” I presume she meant the doctors. She

exuded hostility, anger and rudeness.

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Case 1

She then walked ahead of me towards the emergency rooms on the right

side of the building, I managed, just, to follow her, found the first room

free, and crawled onto the bed, Ms Smith did not offer me any help, not

even a glass of water, or assure me a Dr or Nurse would be called.

… I subsequently went to the Public Hospital by ambulance.

What’s your impression of the Medical Centre?

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Case 1

I have found it hard to understand that someone who works in a Medical

centre could not even offer me the basic help of one human being to

another, very distressed, human being. Her behaviour was reprehensible.

Thank you for the opportunity to bring these circumstances to your

attention, many of my friends and family who I have related this incident to

have suggested I should go to the press, that is not my way, however I

have given serious thought to approaching the Health and Disability

Commissioner, but wish to give you the right of first response, I look

forward to your acknowledgement of this letter and your reply in the very

near future.

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Case 1

A very apologetic and comprehensive response was written by the

practice manager.

The care from the doctor and nurse was excellent.

This complaint did not go any further.

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First impressions of your practice

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2. Dignity and respect

Code of Rights -

Right 3: Right to dignity and independence

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Dignity and respect

▪ Tone of voice

▪ Body language

▪ Courtesy

▪ Keeping people updated re wait times.

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Dignity and respect

In the treatment room:

▪ Privacy to converse, curtains.

▪ People coming and going.

Consult room:

▪ Offering chaperones.

▪ Curtains.

▪ Cover sheet.

▪ Tissues.

▪ Place to wash hands.

▪ Interruptions - receiving phone calls, cell

phones.

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Chaperones

▪ Should be offered for every

intimate examination.

▪ Signs in waiting room and in the

consultation rooms.

▪ Acknowledges a patient’s

vulnerability.

▪ Provides emotional comfort and

reassurance.

▪ Assists in the examination.

▪ Assists with undressing patients.

▪ Protects the clinician.

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3. Communication

▪ Code of Rights

Right 5: Right to effective communication.

▪ 70% of complaints are linked to poor

communication.

▪ It is a significant part of the patient’s overall

experience.

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Communication within

the practice team

▪ Practice meetings.

▪ Communications book.

▪ Set processes and policies about

communicating with other staff

- e.g. phone scripts

- Vicarious liability.

▪ Using the PMS to full effect.

▪ Tracking tasks.

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Communication with patients – key issues

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Non verbal communication

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Verbal communication

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Telephone skills

1. Adopt a standard greeting

2. Actively listen

3. Smile

4. Be polite

5. Try to respond positively

6. Consider speed of delivery

7. Reflect

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Different Interpretations

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Case 2

A woman came to the Medical Centre for help after crashing her car down a bank into a tree. She

flagged down a passing car and asked to be taken to the Medical Centre.

“On arrival I asked the receptionist for help stating that I had a swelling on my head and was afraid

that I might have concussion. The receptionist asked me if I was enrolled, I wasn’t. The

receptionist gave me a form to fill out and asked me to sit in the waiting room. I waited for 10

minutes and approached the front desk, asking to see a nurse and to contact the police about the

accident.

The receptionist responded that this was not an A&E, they had their own emergencies to deal with

and that I would be seen when someone was available. At no time did the receptionist ask what

had happened. The receptionist advised that I could call the police on my cell phone.

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Case 2

Realising that I was not going to get help quickly I started crying and asked the patients in the

waiting room where the police station was. I walked out of the clinic and happened upon an

ambulance. Once I explained to the ambulance officer what had happened he immediately took

action, taking me inside the ambulance, putting a blanket around me. I was taken to the A&E for an

examination.

I am writing to express my anger at the treatment I received from the receptionist.”

Was the patient treated appropriately?

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Case 2

The Medical Centre’s version:

The patient came into the surgery stating that she had been in an accident

and wanted to see a doctor straight away. The receptionist judged that

the head injury was not life threatening. She asked for the patient’s

details so that she could organise assistance. The nurses were busy and

no rooms were available. The patient appeared lucid enough to wait until

help was available. The patient was unhappy with this, became loud and

impatient. The receptionist reassured her that someone would be with her

shortly. Once the form was complete she came up to the counter and

slammed her fist on the counter. Again demanding a doctor straight away,

“what sort of place is this?” The patient left the building distressed, stating

“they refuse to help me here”.

Just then two nurses came to call the patient. Three staff members went

looking for the patient on the street.

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Case 2

▪ Patients can view things very differently. What is minor to us may be a

major concern to them.

▪ The patient’s expectations may not be reasonable. Resetting their

expectations if you can helps them and you.

▪ You can’t please everyone no matter how hard you try.

▪ Are the receptionists trained to know when to call for help urgently?

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Triage

• Case: Elderly patient developed what she thought was a heart attack. She was taken to their

doctors and asked to see a doctor urgently. The receptionist advised them that there were no

more appointments until late that day. The patients drove across town to another medical centre.

The patient was treated immediately and admitted to hospital where she died the next day.

• Who does triage?

• What training to receptionists have to recognise when patients need urgent attention?

• Not all patients know when they need urgent help. eg severe asthma in the waiting room

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Overview of today’s

session

• Getting things right

• Dealing with difficult patients

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Everyone is

different.

Different isn’t

bad.

Usually.

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Dealing with difficult

patients

▪ Aggressive, demanding, rude.

▪ Litigious.

▪ Don’t listen, refuse to take any

advice.

▪ Bring the list of 10 issues into a 15

minute consultation.

▪ Drug seekers.

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MPS Survey 2015

▪ MPS surveyed 254 GP members.

▪ 52% experience challenging interactions on a

weekly basis.

- 13% facing it daily.

▪ 75% experienced verbal abuse.

▪ 74% aggressive demands for treatment/drugs.

▪ 51% experienced violent or aggressive behaviour.

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Factors contributing to the

risk of conflict

▪ Circumstances.

▪ System and organisational problems.

▪ Environmental.

▪ Patient factors.

▪ Staff factors.

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Dealing with difficult patients

The human factor.

behaviours may include:

▪ Verbal reactions

▪ Physiological reactions

▪ Physical reactions.

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Aggressive demanding

and rude patients:

formulate a policy

▪ What is unacceptable behaviour?

▪ What process will you follow?

▪ Ensure you are not discriminating

against specific individuals.

Formulate a policy document

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Set boundaries

▪ As a rule call a meeting rather than

during a consultation.

▪ Support person for you and them.

▪ Be specific about the behaviour.

▪ What will happen if they breach the

boundaries.

▪ Be warm and conciliatory (you get

fewer complaints that way).

Start with a boundary setting

meeting:

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When you are feeling

threatened

▪ Have a clear plan that all staff are

aware of.

▪ Chaperone for the entire consult.

▪ End the consultation if it is getting out

of hand.

▪ Ask the patient to leave.

▪ If they don’t leave advise them that

you will call the police if they don’t

leave immediately.

▪ Call the police.

▪ Consider trespass order.

▪ Speak with your local police.

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Dealing with difficult

patients

▪ Be careful how you speak about

colleagues!

▪ Don’t be held to ransom

▪ Maintain very good communication

▪ Reset unrealistic expectations

▪ Do not advise them of their right to

complain to the HDC unless matters

remain unresolved. A complaint to

the practice or with Advocate are

appropriate first steps.

Litigious:

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Dealing with difficult

patients

▪ Discuss the importance of trust.

▪ Perhaps they need to find a doctor

whom they do trust.

Don’t listen, refuse to take any advice

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Dealing with difficult

patients

▪ Explain that they have a 15 minute

consultation.

▪ Explain how you intend to relate to

them:

- 30 minute booking

- Charge accordingly

- Show me the list and let’s

tackle the most important

ones

- In order to “thoroughly deal

with their presenting

symptoms…”

Bring the list of 10 issues into a 15

minute consultation

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Dealing with difficult

patients

▪ Start as you mean to continue

▪ What are the conditions where you

will prescribe?

▪ Set firm boundaries

▪ Talk about establishing the

relationship, getting to know each

other

▪ Stick to your boundaries!

Drug seekers

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Ending the doctor patient relationship

▪ It should not come as a surprise if at all possible.

▪ Some situations you have the right to dis-enrol immediately.

▪ Follow a good process: “We’re sorry but…”

- Meet with the patient (if appropriate) explaining why you will be

dis-enrolling them.

- Follow it up with a letter.

- Given them an appropriate time frame to find another doctor.

- You have no duty to find them another doctor.

- Continue to provide care as appropriate (which may be

emergency treatment only) until they are dis-enrolled.

- You cannot end the therapeutic relationship because of a

complaint.

- MCNZ website: mcnz.org.nz

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Summary

▪ Create a welcoming, professional environment.

▪ Treat patients with dignity and respect.

▪ Ensure all staff understand the importance of

effective communication skills.

▪ Difficult patients are a fact of life, you can feel

empowered to deal with them.

Any Questions?

MORE THAN DEFENCE

Medical Protection is the world’s leading protection

organisation for doctors and healthcare professionals

As a not-for-profit, mutual organisation, we protect and

support the professional interests of more than 300,000

members around the world

Membership provides access to expert advice and support together with the

right to request indemnity for complaints or claims arising from professional

practice

Our philosophy is to support safe practice in medicine

by helping to avert problems in the first place

Further support and information is offered on our website, in

addition to our publications, booklets, factsheets and case

studies.

medicalprotection.org

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