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
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
ETHICS

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
(Advocacy)
Balance
Excellence
(Tension)
(Quality)
Jim Rohack, MD, Medical Director SWHP
Efficiency
(Stewardship)
Reasons for Conflict

Non-adherence
Mental Health & Substance Abuse Issues
Cultural & Racial Issues
Complex Environment
Communication Difficulties
10
Role of Network in grievances

Be objective
Hear all sides
Gather information
Facilitate resolution
Make a determination
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…
Number
Beneficiary/Representative Contacts
Category by Quarter for 2013
10
9
8
7
6
5
4
3
2
1
0
9
A total of 84
patient /family
contacts
7
5
5
3
00
2
1
1
Jan-March
00
April-June
July-Sept
Oct-Dec
Trending Involuntary Discharge
2008 to 2013

2013
19
2012
42
2011
42
2010
42
0
10
20
30
40
Maintaining a steady number is not good enough!
50
January-April, 2013
Number of all Involuntary Discharges by Type
Number =
19

Non-Payment
6
Severe Immediate Threat
10
Physician Termination
1
Ongoing Disruptive/Abusive
Behavior
2
0
5
10
15

How does Professionalism
&
Working with Difficult Patients
fit together?
Relationships:
Personal vs. Professional

Purpose
Balance of Power
Focus
Challenging situations
are often the delayed
result of professional
boundary violations.
Common Problems:
Boundaries Crossed

 Becoming personally involved
 Gifts
 Showing favoritism
 Dual relationships
Becoming Personally Involved
 Sharing that shifts
FOCUS from pt to
professional
 Lose ability to respond
objectively
 React emotionally

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
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
Dual Relationships

 Exchange of goods or services
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

1. Ethical, Legal,
7. Tip Sheets
Regulatory Statement 8. “Top Ten” Responses
2. Poster
9. Interactive Web-Based
3. Brochure
Training
4. Pocket Card
10. Training Modules
5. Bibliography
11. QI Tracking Tool
6. Taxonomy & Glossary
Toolbox Contents
cont.

 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 L-Look for Solutions
O-Open Yourself to
I-Implement Change
Understanding
N-Need A Nonjudgmental
C-Continue to
Approach
Communicate
F-Focus on the Issue
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”
Open Yourself to Understanding Others

“When addressing a
conflict, it is important
to acknowledge the
perspective and
feelings of the other
individual(s)
involved”
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.”
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.”
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.”
Continue To Communicate

“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.”
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.”
Tools to help you use the Conflict
Resolution Model

 DPC Brochure: “Decreasing
Conflict & Building Bridges”
 DPC CONFLICT Poster
 DPC CONFLICT Pocket Guide
Heart-Head-Heart Communication:
Two Sides to a Satisfying Service
Experience
Heart
Head
Feelings, personal
attention, caring
Information, tasks
We’re so busy the heart
messages get lost.
Dialysis is so full of
tasks
Caring Communication Hints

1. Acknowledge patients likely feeling.
2. Share your good intentions: How are
your actions for the customer’s sake?
3. Ask open-ended, not yes-no questions.
4. Use the words “for you.”
5. Express appreciation to the person.
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.
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
46
Additional ideas to
consider

 Patient Care Conference (PCC)
 Behavior Agreements
 Patient Advocacy Meetings
 Professionalism Trainings
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