The goals of Healthy People 2020 include increasing to 71.7 percent the proportion of cancer survivors who live 5 years or more after diagnosis. Achieving this will certainly require the development and application of effective therapies, but hand in hand with those should be clear communication between patients and their oncology professionals. Research and malpractice claims data show that sharing information makes a difference in outcomes in the clinic and in the courtroom.
A recent study published in the Journal of the National Comprehensive Cancer Network found that some women don't return for recommended screening after surgery for early-stage breast cancer due to geographic issues (2018;16(7):829-837). This study did not identify the reasons why these women did not access recommended follow-up care, but common reasons for lack of follow-up are transportation, cost, and poor understanding of the need for additional care. This latter reason is perhaps the most solvable.
"The importance of communication cannot be overstated," said Kerin Torpey Bashaw, MPH, BSN, RN, Senior Vice President of Patient Safety and Risk Management for The Doctors Company, the nation's largest physician-owned medical malpractice insurer. "When physicians take time to listen to what patients are saying and engage them in a dialogue, it makes a difference."
Data Tell the Story
Bashaw recently spoke with Oncology Times about best practices for communication and avoiding malpractice claims in oncology settings. The Doctors Company studies these issues and others on an ongoing basis, utilizing data from its 79,000 members as well as other sources.
"In breast cancer care, a person's insurance, how far away they live from treatment resources, and their financial status all impact their aftercare," Bashaw said. "If a physician misses a key element in communicating the importance of follow-up care, and in understanding a patient's challenges to receive that care, a poor outcome may result."
An analysis by The Doctors Company and CRICO Strategies bears this out. In 2015, they collaborated to perform a detailed analysis of 562 medical malpractice claims involving breast cancer filed between 2009 and 2014. CRICO is the medical malpractice insurer for the Harvard University medical community, and its database contains more than 300,000 medical malpractice claims from more than 500 hospitals and 165,000 physicians across the country.
This analysis, published in Patient Safety & Quality Healthcare, identified two points at which harm occurred: 1) during the initial diagnosis of breast cancer and 2) during the management or treatment of breast cancer. Key findings were that 71 percent of the malpractice claims involved diagnosis, 28 percent involved communication (between patients and providers or communication among providers), and 19 percent involved patient factors (nonadherence to follow-up or nonadherence to treatment plan). In essence, communication and patient behaviors-which can often be influenced by communication-contributed to malpractice claims in nearly half the cases examined.
"Cancer is complex because there are many more tests, many more appointments, many more consultations," Bashaw said. "Without tight operational processes, the opportunity for error is expanded." She noted that the development of standard operating procedures-including communication methods-is essential for every oncology practice. "When you look at root causes for errors, usually there are not standard processes in place. ... If you have a practice and you don't have tight policies and procedures for vulnerable areas, you can be in line for error."
The Doctors Company has developed a free interactive guide for office practices to help ensure patient safety. Access it here: https://www.thedoctors.com/siteassets/pdfs/risk-management/interactive-guides/In.
Recommendations
Based on malpractice data and on Bashaw's extensive experience in patient safety, she offered the following recommendations for reducing risk and improve patient outcomes and experiences.
1. Establish infrastructure. Hire a practice management team that understands how practice procedures impact patient outcomes. Establish an infrastructure for the practice that ensures recommended procedures are followed to prevent errors. Once a year, assess the practice to determine whether the procedures are being followed and errors are being prevented. This step should be first and foremost, Bashaw said.
2. Perform comprehensive assessment and follow up. Make sure that for each patient, a detailed, comprehensive assessment is performed. The assessment should specify next steps and include reminders or intervals for follow-up. This encompasses the ordering of tests, referral to consultant providers, and making sure clear processes are in place for communicating laboratory test results. "Make sure consults that are ordered actually get referred," she added. "Establish a loop closure mechanism that makes sure consultative notes get back to the provider."
3. Coordinate care. Even rural practices should establish access points to medical centers with cancer resources. Cancer navigators have emerged as advocates for the patient and family as they confront the complexity of cancer care. "I recommend that small practices tap into community resources such as nonprofits to meet the needs of patients," Bashaw said.
4. Implement clear communication on all fronts. The need for clear communication is pressing in all realms of practice, from staff correspondence to patient education. Bashaw advises establishing clear ways for staff members to communicate with each other, with the treating provider, and with patients."This includes conveying the importance of keeping appointments and providing ample opportunity for discussion," she said. "Allow patients to communicate freely and honestly. Define the communication processes in writing so that the physician's team is clear about how communication needs to happen at all stages. Clarity is the key. Make sure the patient understands how the practice is going to communicate with him or her."
5. Make appointments a priority. The medical record should contain evidence of all communications with every patient, including discussions about appointments. "It's also important to have a mechanism for when appointments are missed," she said. "Attempt to reach out to the patient and document that you did so. There are claims related to patients not understanding their appointments and never showing up. Then a different scenario develops because intervention didn't happen."
Michelle Perron is a contributing writer.