Terry Salz

In a perfect world, all physicians are perfect, all patients are perfect, and all doctor-patient relationships are perfect. But in the real world, this is not always the case. Patients can be a problem, and as a physician, you have a right to terminate your relationship with them. 

Once a physician-patient relationship is established, the doctor has an ongoing responsibility to the patient until that relationship is terminated. Patient abandonment occurs when a physician fails to provide the necessary medical care to a current patient without adequate justification. Therefore, a protocol for patient termination is absolutely necessary.  

Warning signs that a relationship with a patient is significantly challenged or consistently devalued include failure by the patient to comply with a recommended plan of care, including subsequent appointments, and consistent no-shows. Physicians can discharge a patient for several reasons, including continual no-shows for appointments, nonadherence with a prescribed treatment regimen, threatening behavior, and nonpayment for services rendered. 

 No-shows create a loss of revenue, but when they become a chronic issue, taking action is critical. If the patient continues to schedule appointments and fails to show up, you also may put your malpractice insurance carrier on notice when you initiate patient dismissal. If this patient has a serious medical problem in the future, you do not want a lawsuit claiming abandonment. 

Training your staff and having an emergency response plan in place is your best defense against violent events should they occur. Staff members should be able to judge whether a situation has escalated and then be trained to call 911 immediately. Remember, a false alarm is better than a tragedy. Should you or your staff ever believe that your lives are at risk, leave immediately. Dismissal of these patients should be handled with immediate notifications to the proper authorities and your malpractice insurance carrier. 

 A patient's failure to pay a bill can occur for several reasons. Nonpayment is often an early warning sign that a patient is unsatisfied with his or her outcome, or it can simply be evidence of lack of funds. Always consider both options, and always try to determine why the patient has not paid. Doing so can be a difficult and uncomfortable process and therefore should always be handled by a staff member with excellent communication skills.  

Patients experiencing financial hardship will appreciate the opportunity to make arrangements to honor their financial obligations. Patients voicing an issue regarding care via nonpayment always should be  referred to the physician, who should then seek risk management assistance from a professional liability carrier. 

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All physicians are perfect, and all patients are perfect, right? Wrong. When the doctor-patient relationship goes south, you have the right to terminate your involvement, just so long as you follow these rules.

Carefully discharge difficult patients

Competitive organizations fully understand the importance of trust to the success of their business. They know how to earn and keep the trust of their employees and-perhaps most importantly-they understand the ramifications of having little or no trust. No organization can afford a decrease in morale and lack of respect for management. Once these occur, stress levels rise, productivity plummets, absenteeism rates soar, and damaged customer relations occur. 

Because stress occurs daily in the work place, you want your employees to feel secure. Increasing the levels of trust with employees will reduce turnover, increase employee productivity, create a more positive work environment, and motivate employees truly to care about your organization.  

The consequences of relationships lacking in trust frequently include diminished performance and profits. Positive motivation creates trust when employees are treated as if they and their quality of life matter. Recognition of this fact is free yet priceless. In this economy of rapid changes and restructuring, employees need to feel secure and compensated for their dedication and productivity. When employees only hear promises and unattainable goals, the result is low or no trust.  

Organizational trust refers to employees' faith in goal attainment and to the belief that, ultimately, this faith will prove beneficial. Employees treat their customers as they are treated. Have you ever walked into an office and the first person you see is rude and annoyed at your arrival, and all you hear is complaining during your stay? I can assure you that office is not bringing in all of the revenue it could and actually is losing money.   

If you have employees who are consumed with complaining about their work environment, you are breeding dysfunction. These employees are toxic and can and should be replaced for the sake of your business. Just as employees need to be able to trust management, you need to be able to trust your employees.  

When employees aren't involved in toxic behavior but see you tolerating it from others, it translates into a lack of trust in you as a manager, in your commitment to your staff and their choices, and in your commitment to the success of the business. Lack of employee trust may reduce productivity and cause good employees to depart. Remember, just as customers abandon companies they don't trust, so will employees.   

With this in mind, organizations with little or no employee trust can look forward to high costs related to hiring and training and rehiring and retraining. With so much time spent on finding and keeping employees, productivity will continue to suffer.  

Acknowledge when change is needed, make the change, and watch it increase your revenue. Make this the year that you implement a plan. Do not become consumed with changes you cannot control, but realize that employee/employer trust is a factor over which you 

If you own a medical practice, you have a responsibility to your employees and patients to develop a successful and efficient practice. Building trust with all the members of your staff plays a huge role in accomplishing this. Here are a few steps that you, as an employer, can take to ensure the creation and promotion of trusting relationships with your employees: 

 As an employer, make predictability and accuracy in measuring and paying for performance your ultimate goals. In the end, these qualities will help maintain the employee efficiency and productivity every practice needs to prosper in these difficult economic times.  

 Being clear with staff about your expectations, and then acknowledging your staff members when they meet those expectations, will lead to confidence and consistency in management. Praise someone individually when he or she fulfills responsibilities. Doing so provides employees with positive feedback and acknowledges your appreciation of their work. 

 Boundaries are important, but they must be well defined if they are to promote connection rather than separation. Boundaries allow staff members to work within their departments, have an obvious delegation of assignments, and know with whom they can interact and where they can seek guidance. 

 Your staff members need to realize that their word is the most simple, yet crucial, way to develop and maintain trust. Should management or the organization as a whole consider agreements trivial, then trust will never be a word associated with your organization. Your reputation and your value for staff members will be affected. If you don't know whether you can keep a promise, don't make it. 

Percentage of employee turnover reported by respondents to the Medical Group Management Association Cost Survey for Multispeciality Practices: 2011 Report Based on 2010 Data: 
• Receptionist and medical records staff:

				
• Nursing and clinical support staff:

				
• Billing/collections and data entry:

*Answers to the survey are voluntary and the data are based on respondents to the survey (549 groups).

The author is chief executive officer of International Medical Billing Management & Consulting Inc., Punta Gorda Florida. Send your feedback to 

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Times are difficult, people are stressed, and employers are worried. What can you do, as an employer, to build a successful practice with efficient, friendly, motivated staff? The answer is simple.

Author | Terry Salz

Articles

Carefully discharge difficult patients

Employee trust key to a strong practice