Advanced Risk Management

Transcription

1 Description Advanced Risk Management Review ethically based risk management principles. Samuel Knapp, Ed.D., ABPP Summer 2017 Look at processes of risk management. Applications and examples Learning Objectives The participants will be able to: 1. apply risk management principles and 2. teach risk management principles to others. Overview Basics of Risk Management Effective Quality Enhancement Strategies Self Awareness/Self Monitoring Examples I. Basics of Risk Management Assumptions False Risk Management Principles Sources of Complaints Higher Risk Situations and Patients Assumptions 1. Risk management (RM) should not focus exclusively on facts (laws, ethical standards, disciplinary procedures). 2. RM should focus more on self awareness and self monitoring. 3. Fear is of limited value in RM. 4. The best RM principle is to provide and document good care. 1

2 Basic principle The fundamental risk management principle is to provide and document good service. What Do You Do? Take a minute and write down at least three steps that you have taken recently to improve the quality of your services. RM = Quality Service What Do You Do? Now take a minute and write down how you have improved the quality of services that other psychologists (or other health care professionals) provide? CAUTION Avoid false risk management principles: Any purported risk management principle that tells a psychologist to do something that appears to harm a patient or violates a moral principle needs to be reconsidered. Knapp et al., 2013, p. 32 Examples of False Risk Management Principles 1. Always get a safety contract signed. 2. Never keep detailed records. 3. Never self disclose to or touch a patient. 4. Informed consent consists only of getting patients to sign a form. 5. Risk management is only concerned with keeping psychotherapists from being disciplined by an oversight body. Common Sources of Founded Complaints Boundaries Incompetent practice Breaches of confidentiality Fee disputes Premature termination Failure to get CE 2

3 Processes Licensing board complaints Malpractice courts must show harm Ethics committees Others: criminal violations, data bank Practitioner Characteristics Older/male Isolated Stressed Areas of practice Forensic work Areas of Practice Evaluations with consequences High conflict families Any time there are inadequate resources for particular patient (skill, time, energy, backup) Patient Factors Complex problems, e.g., difficult social relationships, lack of insight Use litigation as a means to address conflicts Lack of insight as to how they create or maintain problems Not limited to any one diagnosis Early Screening Extensive psychiatric history II. Effective Quality Enhancement Involved in litigation At risk factors: childhood abuse, criminal record, troubled work history, impaired relationships Consultation Empowered Collaboration Documentation Redundant Protections 3

4 Ethical Foundations of Quality Enhancement Strategies Strategy Salient Moral Principles Consultation Empowered collaboration (informed consent) Beneficence, nonmaleficence Respect for patient autonomy Evidence Base for Quality Enhancement Strategies Consultation: Look at diagnosis, treatment choice, relationship quality. Documentation Redundant protection Beneficence Beneficence Empower collaboration: Agree on treatment goal, legitimate patient preferences. Redundant protection: Routinely monitor patient progress. Quality Enhancing Strategies As the legal risks, possibility of treatment failure, or patient complexity increases, greater attention should be given to quality enhancing strategies. Consultation Has a foundation on beneficence and nonmaleficence Reduces stress and isolation Benefits of Consultation Technique oriented information Emotional reactions (countertransference) Reduction of emotional turmoil Empowered Collaboration Respect for patient autonomy Evidence based relationship: agreement on treatment goal accommodating reasonable preferences Thinking through solution together 4

5 Empowered Collaboration (2) Empowered collaboration builds upon informed consent and attempts to maximize patient involvement in treatment. The patients become more actively involved in the process of psychotherapy. Greater commitment leads to better outcomes. Documentation: Legal Purposes Beneficence/ Nonmaleficence Required by insurers, State Board of Psychology, APA Ethics Code A record of treatment for future providers Useful risk management tool Documentation: Quality Enhancing Monitoring Progress Dialogue between self and patient regarding process and goals of treatment Means to identify pertinent clinical issues A procedure to document response to treatment Beneficence/Nonmaleficence Additional source of information for a difficult patient Routine procedure with high risk patients Four Session Rule If, at the end of four sessions, you do not have a good working relationship with the patient OR the patient is not improving, for no obvious reason, Prompt List 1. Rethink diagnosis and goals: Do you need a consultation? 2. Discuss issues with patients. 3. Are there second sources of data to explore? then you need to rethink therapy. 5

6 Prompt List: Additional Reflections Do YOU think you and the patient have a good working relationship? Is your assessment of the patient adequate? Are there unresolved ethical issues? Do unresolved clinical issues impede treatment? What does your System I say about the patient? System II? III. Self Awareness/Reflection Professionalism Risks of self awareness gaps Self reflection activities Professionalism Looking at many definitions of professionalism, Wilkinson summarized them as a commitment to self monitor and improve (2009, p. 551). Common Problem Areas Overestimating abilities Bias/prejudice Cognitive errors Overestimating Abilities Walfish, et al (2012) found that, among 129 mental health professionals, 25% placed themselves in the top 10% of competence and no one placed themselves in the bottom 50% of competence. The mean ranking was 80 th percentile and the modal ranking was 75 th percentile. Overestimating Abilities (2) On the average, clinicians believed that 3.6% of their patients deteriorated during treatment, although Castonguay, Boswell, Constantino, Goldfried, and Hill (2010) reported that deterioration rates ranged between 5% and 10%. (Caution: Better psychotherapists may have self selected into the study.) 6

7 Better than Average Effect Also called Dunning Krueger effect, found widely among other professionals in the West, less so in non European cultures Dangers of the Better Than Average Effect Although a little self inflation may be harmless, Davis et al. (2006) found a subset of physicians with very low ability who ranked themselves very high. Do We Get Better with Age? Most psychotherapists think they get better with age (Orlinsky et al. 1999). We Do Not Necessarily Get Better with Age Choudhry, Fletcher, and Soumerai (2005) found that the quality of performance of physicians was poorer for those who had been practicing longer, compared to more recent graduates. Of course it is not entirely clear if the behavior of the older physicians had declined or whether the newer physicians were better trained. We Do Not Necessarily Get Better with Age (2) Goldberg et al. (2016): Outcomes of more experienced therapists declined slightly as a group, although some individual psychotherapists improved. Huppert et al. (2001): Therapy experience had a small association with outcomes using cognitive behavioral therapy with panic attacks. Interpretation Some psychologists get better with age, many stay the same, others deteriorate. SJK Spengler et al. (2015): The accuracy of clinical judgments was enhanced as a result of experience, although not by much (effect size d = 0.12) (p. 221). 7

8 Do We Harbor Prejudices Outside of Our Awareness? Banaji and Greenwald, Implicit Association Test and uncomfortable egalitarians Constantine & Ladany, 2000) found a gap between self reported multicultural competence of psychotherapists and their actual behavior in clinical practice. Other Prejudices LaChapelle et al. (2014): underestimate pain, overestimate psychosocial resources of attractive patients De Ruddere et al. (2011): underestimate pain of patients they did not like Pascal & Kurpius (2007): negative characteristics when the client was overweight Vulnerable to Cognitive Biases Such as fundamental attribution error or confirmation bias (Rogerson et al., 2011) The most common reason for misdiagnosis in an urban hospital was confirmation bias (Sanders, 2009). Professionalism? Step One: Acknowledge need for self awareness as: not a static state that, once achieved at the point of licensure, requires no further attention, distinguished from rumination, or the unproductive dwelling on negative aspects of oneself, one s outcomes and moods (Stein & Grant, 2014, p. 507). Self Awareness Take a minute to write down three things you do to ensure adequate self awareness (or to avoid pitfalls of overestimating ability, biases, or cognitive errors). Getting to Self Reflection Better if planned and deliberative aspect of one s professional life. Be open minded and reflective in all professional activities. Which activity, conducted by which professional, under what circumstances, will result in what kind of self knowledge? Activities may be synergistic. 8

9 Supervision Feedback Orchowski et al. (2010) ways supervisors increase self reflection: modeling self reflection themselves, creating conditions of warmth, empathy, and genuineness, asking open ended and nonjudgmental questions, being sensitive to supervisee defensiveness or negative self talk, structuring self reflection activities (e.g., tapes with reflective prompts, questions such as, How did you feel? ). Increasing Self Awareness Patient feedback Personal therapy Balint groups Literature/reflective writing Mindfulness Competent community Patient Feedback Being receptive to patient feedback can be a source of self reflection. Balint Groups Although developed for physicians to help them handle relationships with patients, it has been tried with other professionals. Evidence has methodological limitations, but suggests that it leads to more empathy toward patients (Airagnes, Consli, DeMorlhon, Galliot, Lemogne & Juary 2014). Personal Psychotherapy Norcross (2005) reported that, among those who had psychotherapy, 90% stated they benefited from it. Almost half believed it helped make them better psychologists (Norcross, 2005). Reduce stress, socialized into patient role, etc. Reading and Literature Reading good literature may also help reduce prejudice (Chung and Bemak, 2013; Johnson, Jaspar, Huffman & Griffin, 2013). 9

10 Reflective Writing Many examples, e.g.. Nicholas and Gillett (1997) had medical students review a story from the standpoint of the patient, the patient s family, the physician, or others involved. This approach alerts us to how our institutional and professional practices are experienced by both health care provider and by patients or consumer (1997, p. 299). Mindfulness An intervention that emphasizes the nonevaluative, nonelaborative attention to and awareness of one s current experience (Carlson, 2013, p. 125). Teaching Mindfulness Improved physicians self reported mood, empathy, conscientiousness, and emotional stability (Krasner et al., 2009). Among staff at an inpatient psychiatric unit, led to improvements in self reported patient satisfaction and reduced the number of safety events (patient falls, patient aggression, and medication errors; Brady et al. 2012) IV. Competent Community How do others help improve the quality of your services? What do you do to improve the quality of services of other psychologists? Competent Community Johnson, Barnett, Elman, Forrest, and Kaslow (2012) called this the competent community, or a network of colleagues who help provide continual feedback and monitoring. Competent Community (2) Numerous examples could be cited from the sports world of teams with extremely talented individuals falling short of their potential and of teams composed of less talented individuals excelling as a team. The same undoubtedly applies in clinical settings and medical practices (Williams, 2008, ). 10

11 What Is Your Competent Community? Resources for: day to day functioning up to date treatment literature quality of interpersonal relationships ethical/legal resources Competent Community and Risk Management Consider your responses to Slide 8 (ways you improve the quality of your services), Slide 9 (how you help others), and Slide 47 (ways you increase self awareness). Are any of these linked to a competent community? What Can You Do to Upgrade? What concrete steps can you take to upgrade your competent community? Who Are You? Are you part of a competent community for anyone else? Do you watch over them? Help them keep up to date? Gauge their emotional well being and give them feedback? Help them with ethics or law? Case One You conducted an evaluation on an applicant for a municipal police force. You conducted a very thorough examination and concluded she should not be a police officer. She has a background of being litigious. What can you do to reduce your risk? Thoughts for Case One? Are you aware of your ability levels? (Do you have a general idea what to do or where to go for complex cases?) Can you identify problem clients early? Are you using relevant quality enhancement strategies (e.g., focusing a lot on informed consent)? 11

12 Thoughts for Case One, continued Does the client trigger any biases on your part? Can for compensate for or be aware of cognitive biases? Are you sensitive to your emotional reactions to clients or patients? Case Two You were treating a depressed young woman who is not responding to treatment and you believe she needs a higher level of care. She reminds you that you once said, I will always be there for you, and now accuses you of backing out of your commitment. What do you do? Case Three The new employee you just hired reported to you that he has just seen his third patient this week who has Complex PTSD caused by RSA (ritualized Satanic abuse), but you have only seen one case of suspected SRA in your 15 years of practice. Is this a problem? If so, how do you handle it? Case Four Your adolescent client tells you he hates the reunification therapist assigned by the court and asks you to write a letter stating that the reunification therapy is harming his mental health. How do you respond? Case Five A 16 year old patient reports to you that she has been smoking pot while driving. Although she keeps saying, This was the last time, she continues to drive and smoke. What should you do? Case Six Your supervisee just told you one of his patients has just joined the church that he and his wife have attended for the last 10 years (and feel very attached to). It is possible that the patient and the supervisee may have incidental contact in some social or religious gatherings sponsored by the church. What do you do? 12

13 Case Seven A patient enters therapy with major depression. He reported to you but says Don t tell my physician, who is prescribing anti depressants that he is taking a large quantity of an herbal remedy. The literature says sometimes this herbal remedy interacts with psychotropic medication. What do you do? Case Eight A highly depressed young man has not been improving for the last three months. He has been missing appointments and when he comes in, he often comes in late. The patient has brief, fleeting thoughts of suicide, but denies he would act on them. He refuses to make an appointment with a psychiatrist, even though you have strongly recommended it. His wealthy parents are paying for the treatment. What do you do? Case Nine During an intake, a patient reveals strong suicidal ideation and has a plan (and the means) to kill himself. Baseline and dynamic data suggest he is at high risk to die from a suicide. He does not want to go to the hospital and has done nothing that would warrant an involuntary psychiatric hospitalization. What do you do? Questions, answers and more discussion References References (2) Airagnes, G., Consli, S. M., DeMorlhon, O., Galliot, A. M., Lemogne, C., & Jaury, P. (2014). Appropriate training based on Balint groups can improve the empathic abilities of medical students: A preliminary study. Journal of Psychosomatic Research, 76, Association of State and Provincial Psychology Boards. (n.d.). ASPPB Competencies expected of psychologists at the point of licensure. Expected.pdf Banaji, M., & Greenwald, A. (2013). Blindspot. New York: Delacorte Press. Brady, S., O Connor, NB., Burgermeister, D., & Hanson, P. (2011). The impact of mindfulness meditation in promoting a culture of safety on an acute psychiatric unit. Perspectives in Psychiatric Care, 48, Carlson, E. N. (2013). Overcoming the barriers to self knowledge: Mindfulness as a tool to seeing yourself as you really are. Perspectives on Psychological Science, 8, Castonguay, L. G., et al. (2010). Training implications of harmful effects of psychological interventions. American Psychologist, 65, Chung, R. C. Y., & Bemak, F. (2013). Use of ethnographic fiction in social justice graduate counselor training. Counselor Education and Supervision, 52, Davis, D. A., et al. (2006). Accuracy of physician selfassessment compared with observed measures of competence: A systematic review. JAMA, 296, Constantine, M. G., & Ladany, N. (2000). Self report multicultural counseling competence scales: Their relation to social desirability attitudes and multicultural case conceptualization ability. Journal of Counseling Psychology, 47, Cullari, S. (2009 June). Analysis of board of psychology disciplinary actions, PA Board of Psychology Newsletter, 1 2. De Ruddere, L., et al. (2011). When you dislike patients, pain is taken less seriously. Pain, 152, Elman, N., Illfelder Kaye, J., & Robiner, W. (2005). Professional development: Training for professionalism as a foundation for competent practice in psychology. Professional Psychology: Research and Practice, 36, Goldberg, S. B., et al. (2016). Do psychotherapists improve with time and experience? A longitudinal analysis of outcomes in a clinical setting. Journal of Counseling Psychology, 63, Huppert, J. D., et al. (2001). Therapies, therapists variables, and cognitive behavioral therapy outcomes in a multicenter trial for panic disorder. Journal of Consulting and Clinical Psychology, 69, Johnson, W. B., et al. (2012). The competence community: Toward a vital reformulation of professional practice. The American Psychologist, 67,

14 . References (3) References (4) Johnson, D., et al., (2013). Reading narrative fiction reduces Arab Muslim prejudices and offers a safe haven from intergroup anxiety. Social Cognition, 31, Khoury, B., et al., (2013). Mindfulness based therapy: A comprehensive meta analysis. Clinical Psychology Review, 33, Krasnser, M. S., et al. (2009). Association of an education program in mindful communication with burnout, empathy, and attitudes among primary care physicians. Journal of the American Medical Association, 302, LaChapelle, D. L., et., (2014). Attractiveness, diagnostic ambiguity, and disability cues impact perceptions of women with pain. Rehabilitation Psychology, 59, Lynch, D. C., Surdyk, P. M., Eiser, A. R. (2004). Assessing professionalism: A review of the literature. Medical Teaching, 26, Nicholas, B., & Gillett, G. (1997). Doctors stories, patients stories: A narrative approach to teaching medical ethics. Journal of Medical Ethics, 23, Norcross, J. C., & Guy, J. D. (2005). The prevalence and parameters of personal therapy in the United States. In J. D. Geller, J. C. Norcross, & D. E. Orlinsky (Eds.), The psychotherapist s own psychotherapy: Patient and clinician perspectives (pp ). New York: Oxford University Press(pp ). New York: Oxford University Press. Orlinsky, D., et al., (1999). Psychotherapists assessment of their development at different career levels. Psychotherapy, 36, Pascal, B., & Kurpius, S. E. R. (2012). Perceptions of clients: Influences of client weight and job status. Professional Psychology: Research & Practice, 43, Rogerson, M. D., et al., (2011). Nonrational processes in ethical decision making. American Psychologist, 66, Sanders, L. (2009). Every patient tells a story. New York: Random House. Spengler, P. M., et al. (2009). The Meta Analysis of Clinical Judgment Project: effects of experience on judgment accuracy. The Counseling Psychologist, 37, Stein, D., & Grant, A. M. (2014). Disentangling the relationship among self reflection, insight, and subjective well being: the role of dysfunctional attitudes and core self evaluations. The Journal of Psychology, 148, Walfish, S., et al. (2012). An investigation of self assessment bias in mental health providers. Psychological Reports, 110, Wilkinson, T., et al. (2009). A blueprint to assess professionalism: Results of a systematic review, Academic Medicine, 84,