Ethics and compliance I have to do what? Denise A. Atwood, Esq., R.N.

Transcription

1 Ethics and compliance I have to do what? Denise A. Atwood, Esq., R.N. Denise.atwood@slfhc.org

2 Learning Objectives Develop a basic understanding of ethical principles. Utilize a framework for ethical decision making. Gain a basic understanding of HRSA guidelines and compliance. Gain a basic understanding of FTCA guidelines and compliance. DISCLAIMER: this presentation does not constitute legal advice, but information & education only

3 Let s begin

4 Ethical Principles in Healthcare These may sound familiar: Autonomy Beneficence Non-maleficence Veracity/Fidelity Justice/Fairness

5 Ethics General Discussion Not going to address all ethical theories today, however in general - difficult right and wrong decision making Traditionally divided into three fields which may NOT sound so familiar: 1. Meta-ethics* 2. Normative ethics* 3. Applied ethics** Reference: Brown University

6 Applied Ethics Examples? Obligatory: right to do it and wrong not to do it * Impermissible: wrong to do it and right not to do it * Permissible: neither right nor wrong to do it * Supererogatory: it is right to do, but not wrong if you don t do it * Reference: Brown University

7 Ethics Considerations in Healthcare Intersection of ethics/ethical principles and 1. Personal morals? 2. Standard of Care or Scope of Practice issues? 3. Unprofessional conduct? 4. Compliance concerns? (and HRSA) 5. Risk mitigation? (and FTCA) 6. Law/legal issues? (and FTCA)

8 Ethical Dilemmas Personal Morals 2012 Medscape/WebMD survey of 24,000 physicians* INSURANCE: would you drop a longtime patient if their insurance did not pay well? YES 27% NO 41% IT DEPENDS 33% DEFENSIVE MEDICINE: is it acceptable to perform unnecessary procedures defensively because of malpractice concerns? YES 23% NO 55% IT DEPENDS 22%

9 Unprofessional Conduct, Ethics and the Law For a Doctor of Osteopathy which of these are unprofessional/unethical* Misdemeanor involving moral turpitude?* Charging a fee for services not rendered or dividing a professional fee for patient referrals? Failing to establish and maintain adequate records on a patient? Signing a blank, undated or predated prescription form? Engaging in sexual conduct with a current patient or former patient within 3 months after the last medical consultation?* Disruptive behavior in a professional setting?* Failing to disclose a licensee s license number and the board s address and phone number if you provide medical care by computer?** Reference Arizona Revised Statutes

10 Ethical Decisions - Framework My recommended framework for sound ethical decisions based on a practiced approach: 1. What is the real ethics issue 2. Gut 3. It depends do any duties or exceptions apply? 4. Options & desired outcome 5. Available resources patient & you/your organization 6. Justify your decision (meta-ethics) if needed 2016 Denise Atwood PLLC

11 Ethical Framework applied to Case Studies

12 Ethics Case Study Standard of care Dr. G. is the only physician at RURAL HOSPITAL that performs colonoscopies. The nurses who assist Dr. G. observe that he rarely reaches the cecum which would be the standard of care. The nurses, feeling the procedure is incomplete, sought intervention from the hospital administrator - who seems hesitant to intervene. After two years of not getting assistance from the administrator, the nurses announce they will no longer assist Dr. G. during colonoscopies. What is the hospital s / administrator s ethical obligation?

13 Ethics Case Study Refusal of Care At Mr. K s 1 st appointment, he tells you he has gained 50 pounds in the past year (after quitting smoking) and has shortness of breath when walking up an incline. Mr. K. is 40 years old, weighs 310 pounds and is pale. Clinically the N.P. thinks Mr. K. has nephrotic syndrome and maybe a potential kidney malignancy. Mr. K. states he has no insurance so he does not wish to pursue further testing. Mr. K. does not want to be a charity case and is refusing to let you talk to Mrs. K. What do you do at the administrator? What are some exceptions to patient confidentiality?

14 Ethics Case Study Refusal of Testing At her follow up appt. 70 y.o. Mrs. C. is refusing recommended diagnostic evaluation for cancer. The doctor informed you that Mrs. C s refusal at this point will impact her future treatment decisions and options. She is able to articulate the information given to her, but she is unwilling to proceed and does not want her son to know her medical condition. Mrs. C. appears to have decision-making capacity and states she does not want to spend her last days being treated for cancer. Should the Medical Director override Mrs. C s decision not to undergo further evaluation by talking with her son? What is the hospital s / administrator s ethical obligation?

15 Switch gears

16 HRSA and FTCA - Overview What does FTCA stand for? Why is it important for a Federally Qualified Health Center (FQHC) and its providers? References / Resources at then end of the slide deck The following discussion DOES NOT address exceptions for Health Care for the Homeless or Public Housing Primary Care Programs

17 HRSA, FQHC and FTCA The Connection FQHCs may be granted malpractice liability protection with the Federal government acting as their primary insurance coverage (grants immunity). FQHCs must submit an initial deeming application to the HRSA and must meet certain requirements to attain deemed status. Renewal applications for redeeming must be submitted on an annual basis. A deemed FQHC, its employees, and eligible contractors working within the approved scope of project are considered federal employees and are immune from lawsuits for medical malpractice.

18 HRSA, FQHC and FTCA The Connection So, a patient who alleges acts of malpractice by a deemed FQHC cannot sue the FQHC or provider(s) directly, but must file the claim against the U. S. Government. If the case is accepted, the Federal government assumes responsibility for costs related to a claim resulting from the performance of a medical, surgical, dental, or related function. There is no cost to a participating health center or its providers. These claims are reviewed and/or litigated by the U.S. Department of Health and Human Services, Office of the General Counsel and the Department of Justice according to FTCA requirements.

19 HRSA and FTCA - Overview How many HRSA Health Center Program Requirements are there? Overview to follow with detail on several requirements from a compliance perspective. References / Resources at then end of the slide deck The following discussion DOES NOT address exceptions for Health Care for the Homeless or Public Housing Primary Care Programs

20 HRSA Health Center (HC) Program Requirements 1. Needs Assessment: HC demonstrates & documents needs of its target population and service area 2. Required and Additional Services: HC provides all required primary, preventive, enabling health services and additional health services as appropriate and necessary, either directly or through established written arrangements. 3. Staffing Requirement: HC maintains a core staff as necessary to carry out all required primary, preventive, enabling health services and additional health services as appropriate and necessary, either directly or through established arrangements and referrals. Staff must be appropriately licensed, credentialed and privileged. 4. Accessible Hours of Operation/Locations: HC provides services at times and locations that assure accessibility and meet the needs of the population to be served. 5. After Hours Coverage: HC provides professional coverage for medical emergencies during hours when the center is closed. 6. Hospital Admitting Privileges and Continuum of Care: HC physicians have admitting privileges or other arrangement to endure continuity of care 7. Sliding Fee Discounts: HC has a system in place to determine eligibility for patient discounts adjusted on the basis of the patient s ability to pay.

21 HRSA Health Center (HC) Program Requirements 8. Quality Improvement/Assurance Plan: HC has an ongoing QI/QA program that includes clinical services and management and that maintains confidentiality of patient records. 9. Key Management Staff: HC maintains a fully staffed HC management team as appropriate for the size and needs of the center. Prior approval by HRSA of change in the Project Director/Executive Director/CEO position is required. 10. Contractual/Affiliation Agreements: HC exercises appropriate oversight and authority over all contracted services, including assuring subrecipient(s) meets HC program requirements. 11. Collaborative Relationships: HC establish and maintain collaborative relationships with other HC providers, including health centers in the service area of the center. HC secures letter(s) of support from existing HC. 12. Financial Management and Control Policies: HC follows generally accepted accounting principles (GAAP) and assures an annual independent financial audit is performed. 13. Billing and Collections: HC has systems in place to maximize collections and reimbursement for its costs including written billing, credit, and collection policies. 14. Budget: HC has a budget that reflects the costs of operations, expenses, and revenues.

22 HRSA Health Center (HC) Program Requirements 15. Program Data Reporting Systems: HC has systems which collect and organize data for program reporting and which support management decision making. 16. Scope of Project: HC maintains its funded scope of project. 17. Board Authority 18. Board Composition 19. Conflict of Interest Policy: HC bylaws or written corporate board approved policy include provisions that prohibit conflict of interest by board members, employees, consultants, and those who furnish goods or services to the HC. NO board member shall be an employee of the HC or an immediate family member of an employee. The Chief Executive may serve only as a non-voting ex-officio member of the board* (*recommended but not required)

23 HRSA - Compliance Required and Additional Services established through written arrangements.

24 HRSA & FTCA - Compliance 1. Staffing Requirement: Staff must be appropriately licensed, credentialed and privileged. 2. FTCA deeming requirements 3. State law requirements 4. Health center policy requirements 5. Accreditation requirements*

25 HRSA & FTCA - Compliance Quality Improvement/Assurance Plan: HC has an ongoing QI/QA program that includes clinical services and management and that maintains confidentiality of patient records. FTCA deeming requirements State licensing requirements Accreditation requirements

26 HRSA - Compliance Contractual/Affiliation Agreements: HC exercises appropriate oversight and authority over all contracted services, including assuring subrecipient(s) meets HC program requirements.

27 HRSA - Compliance Conflict of Interest Policy: HC bylaws or written corporate board approved policy include provisions that prohibit conflict of interest by board members, employees, consultants, and those who furnish goods or services to the HC. Define conflict of interest? Potential ethical implications?

28 HRSA Quality/Compliance Tools We are always happy to share! If you would like copies of the Sun Life Quality Agenda or Dashboard template or Credentialing/Privileging audit tool, please denise.atwood@slfhc.org

29 Ethics references / resources Bonde, S., et. al. (2013, May). A framework for making ethical decisions. Brown University. Retrieved from College of Medicine, Center for medical ethics and health policy online at Geisel School of Medicine, Handbook for rural health care ethics. A practical guide for professionals online at Stanford Medicine, Center for biomedical ethics online at

30 HRSA references / resources HRSA, (2014, February). Health Center Program Requirements. HRSA, (n.d.). About the Federal Torts Claims Act. HRSA, (CY 2017). FTCA Deeming Application Evaluation Self Checklist. HRSA, (n.d.). Conflict of Interest. emanual/chapter13.html

31 Questions?