Medical directors play an integral role in the care of patients in the prehospital setting. Along with the ability to have a positive impact on the care of the patient goes the responsibility to strive for the best possible outcome. Medical directors must ensure that they carry out their roles with the due care which the law will impose on them. The failure to carefully carry out their roles may not only result in harm to the patient, but also to liability of the physician and the physician's employer.
Define the circumstances which must be present in order to form a physician-patient relationship.
List the components of the physician-patient relationship.
Identify whether a physician-patient relationship has been formed given a set of facts.
Discuss the nature of the physician-patient relationship when a physician responds to the field to assist with treatment.
Identify potential liability issues when a physician provides online and off-line medical direction.
Explain the roles of the physician in providing off-line medical direction
Describe ways in which EMS agencies can obtain useful feedback and detail a method for handling complaints.
DEFINE THE STANDARD MEANING OF PHYSICIAN-PATIENT RELATIONSHIP
In the United States, the physician-patient relationship is defined on a state-by-state basis through either judge made case law or state statute. As a result, the definition of this relationship varies from state to state. Physicians are generally not obligated to treat a patient unless they choose to do so or have assumed a duty to do so, although there are certainly exceptions to this rule. A patient-physician relationship is formed when a physician affirmatively acts on behalf of a patient by examining, diagnosing, or treating the patient or by agreeing to do so. Once the physician consensually enters into a relationship with a patient in any of these ways, a legal contract is frequently formed in which the physician owes a duty to that patient to continue to treat the patient until the relationship is actually and properly terminated.
The American Medical Association has commented on the physician-patient relationship as follows:
The practice of medicine, and its embodiment in the clinical encounter between a patient and a physician, is fundamentally a moral activity that arises from the imperative to care for patients and to alleviate suffering.
A patient-physician relationship exists when a physician serves a patient's medical needs, generally by mutual consent between physician and patient (or surrogate). In some instances the agreement is implied, such as in emergency care or when physicians provide services at the request of the treating physician. In rare instances, treatment without consent may be provided under court order…. Nevertheless, the physician's obligations to the patient remain intact.
The relationship between patient and physician is based on trust and gives rise to physicians' ethical obligations to place patients' welfare above their own self-interest and above obligations to other groups, and to advocate for their patients' welfare.
Within the patient-physician relationship, a physician is ethically required to use sound medical judgment, holding the best interests of the patient as paramount….
OPINION OF THE AMERICAN MEDICAL ASSOCIATION, E-10.015 (2001)
Attorneys may look at this relationship a bit differently. The physician-patient relationship is most often formed voluntarily with the mutual consent of the physician and the patient. The relationship involves an explicit or implied set of expectations between an individual and a physician which has reasonably imposed a duty of care on the physician to diagnose and/or treat the patient within the standard of care of the practice of medicine. The relationship relies on the actual or implied trust of the patient in the knowledge and/or skills of the physician. The formation of the relationship dictates that a physician has or should have the expectation that the patient is relying on the physician for present and/or future diagnosis, treatment, and/or evaluation.
The physician-patient relationship, once formed, imposes a duty on a physician to diagnose and treat a patient within the standard of care. The resulting relationship is one where a patient either explicitly or implicitly desires the physician to provide medical diagnosis and/or treatment. The goal of the relationship usually is for the physician to provide diagnoses of a condition, an answer to a question and a solution to a medical and/or health concern and issue. The relationship is based on the patient's trust in the physician to provide timely and accurate answers and/or solutions. Although not all medical conditions are capable of being treated to the point of remission or healing, the physician-patient relationship is one of an expectation by the patient that the physician is knowledgeable in the subject matter or will if necessary refer the patient to a physician capable of performing such a diagnosis and/or treatment.
However, a relationship is not formed simply because a patient has an expectation that the physician has become obligated to diagnose and/or treat the physician. The patient's expectations must be based on a reasonable set of circumstances which bind the physician to become bound to a duty of care to the patient. In determining whether a physician-patient relationship has been formed, courts frequently wrestle with the underlying facts of the alleged relationship between the physician and the individual.
Although in most instances determining whether such a relationship has been formed is not difficult, persons who have come in contact with a physician in some manner frequently allege that they have earned a duty for care from a physician to be treated as a patient. Not all physicians will agree that the level of contact they have had with an individual resulted in a duty of care owed to that individual as a patient.
Certain state statutes and judge made law impose only limited physician-patient relationships in various instances, such as when a physician is required to evaluate a patient's medical condition in order for the court to make certain findings on the patient's physical or mental well-being or when an individual is required to have a physical and/or mental examination prior to employment. These situations are discussed more in detail below.
Numerous courts have engaged in fact-finding missions of whether a physician's contact with an individual rose to the level of a physician-patient relationship.
Questions which could arise in the emergency medical services industry are ever abundant. Some potentially common situations are as follows:
A physician provides medical control over the phone or radio, instructing or confirming the administration of a treatment or medication to a patient in an ambulance.
A physician responds directly to a scene of an accident to assist with the treatment of a patient, such as by removing a limb in order to extricate the patient from a vehicle.
A member of a fire department or ambulance services asks what seems like an innocuous medical question of their medical director as to the member's own medical or health issues.
A paramedic is permitted to operate “under the license” or “under the supervision” of a physician, and the physician oversees the competency of the paramedic.
A physician reviews the care of emergency medical service providers under quality control, and permits the providers to operate in the field, having deemed them “competent” providers with adequate knowledge and skills.
A physician in his or her off time happens upon the scene of an accident or medical emergency, and (a) provides advice to the emergency medical service provider, (b) actually provides instructions to the emergency medical service provider, or (c) actually treats the patient.
Although the creation of a physician-patient relationship is generally easy to determine, as the patient usually seeks out the physician, and the physician then accepts the patient as a client, the relationship is not always clearly established. More difficult questions of whether such a relationship has been formed are, for example:
A physician with no relationship to the emergency medical service happens upon a scene of a medical emergency and asks a paramedic if he or she needs assistance with treating a patient, and the paramedic refuses assistance or alternatively accepts assistance.
A physician offers advice to a treating paramedic, which the paramedic utilizes in its treatment.
A physician with no relationship to the emergency medical service happens upon a scene of an accident, but offers no medical advice to the patient or the paramedic, but simply assists the paramedic in carrying out a manual task such as intubation or application of a splint.
A physician directly treats the patient, but the patient is unconscious and unaware of the treatment.
As stated above, the relationship is often a voluntary relationship where the physician can choose to accept the individual as a patient or choose not to do so. Most frequently, physicians can refuse to accept an individual as a patient for almost any nondiscriminatory reason (such as gender, race, sexual preference).
In some instances, physicians have waived the right to accept patients, such as physicians who work in emergency rooms and are presented with patients in potentially emergency situations, or physicians who are under a contract with a private or government insurance program to accept patients.
Additionally, some states impose duties of care on all individuals to take reasonable action, for example, Minnesota, Vermont, Hawaii, Rhode Island, and Wisconsin. What defines an action to be reasonable or unreasonable is a matter of case law. In these few states, however, the failure of a physician or emergency medical technician to render care within the scope of their authorized practice may be deemed a violation of the state statutes.
Physicians may choose to refuse to take on individuals as patients for a variety of reasons, including but not limited to:
The treatment request is beyond the physician's competence.
The treatment request is scientifically or medically invalid or unnecessary.
The treatment request is incompatible with the physician's personal beliefs.
PHYSICIAN-PATIENT RELATIONSHIP IN CLINICAL AND HOSPITAL PRACTICES
As stated, states vary in how they define a patient-physician relationship. However, a patient-physician relationship is generally formed when a physician affirmatively acts in a patient's case by examining, diagnosing, treating, or agreeing to do so. Once the physician enters into a relationship with a patient by providing an examination, diagnosis, and/or treatment, or simply agrees to do any of these actions, a legal contract is likely formed in which the physician owes a duty to that patient to continue to treat or properly terminate the relationship.
Broken into its parts, the relationship frequently requires the following components:
A request, either expressly or implicitly, by the individual to the physician to provide a diagnosis and/or treatment
An acceptance by the physician or a preexisting legal obligation of the physician diagnose and/or treat the physician
Not all states require that there be an actual agreement between the physician and the patient in every instance. In Oregon a court held that “in the absence of an express agreement by the physician to treat a patient, a physician's assent to a physician-patient relationship can be inferred when the physician takes an affirmative action with regard to the care of the patient.” A patient-physician relationship was formed because the physician took an affirmative action in rendering an opinion on the course of the patient's care.1
States commonly recognize that a physician who actually treats a patient has a duty of care toward that patient.2 In limited situations, courts have held that diagnosing patients does not necessarily create a physician-patient relationship.
Even though physicians may not form a physician-patient relationship with certain individuals, the physician may still owe the individual a limited duty of care.
For example, physicians also engage persons in other situations, such as to perform preemployment screening or “fit for duty” evaluations. Courts have generally held that no physician-patient relationship exists when a physician merely examines a patient on behalf of the patient's employer. However, if the physician treats the patient for any condition, such a relationship has been formed (see article for cases).
Courts have found that a physician has a limited duty to a patient to conduct the diagnostic tests accurately.
Although a physician-patient relationship might not exist in certain circumstances, a physician may still acquire a legal duty to a patient to advise the patient of a dangerous health situation discovered during an examination. For example, if a blood test reveals that an individual he or she examines is HIV positive or has a life-threatening heart condition, the physician may be deemed to owe the individual a limited duty to advise him or her of the condition. Some states have enacted statutes and/or regulations requiring such disclosure by the physician.
In hospital settings, the relationship is often formed in ways different from that of a private office setting.
The Emergency Room Patient
The Emergency Medical Treatment and Labor Act (EMTALA) was first enacted in June 1994. EMTALA applies to all hospitals which accept Medicare (so, almost all hospitals except Shriners Hospitals). The purpose of EMTALA is to prevent hospitals from rejecting patients, refusing to treat them, or transferring them to “charity hospitals” or “county hospitals” because they are unable to pay or are covered under the Medicare or Medicaid programs. It is therefore called the Antidumping Act.
EMTALA requires that no patient who presents to a hospital with an emergency medical condition and who is unable to pay may be treated differently than patients who are covered by health insurance. Any patient who “comes to the emergency department” requesting “examination or treatment for a medical condition” must be provided with “an appropriate medical screening examination” to determine if he or she is suffering from an “emergency medical condition.” If so, then the hospital is obligated to either provide the patient with treatment until the patient is stable or to transfer patient to another hospital in conformance with EMTALA's directives.
EMTALA imposes an obligation on the part of the hospital to provide an appropriate medical screening examination within the capabilities of the emergency department for the purpose of determining whether an “emergency medical condition” exists. EMTALA further imposes an obligation upon the hospital to institute treatment if an “emergency medical condition” does exist. The statute further imposes restrictions on transfers of persons who exhibit an “emergency medical condition or are in active labor”. One critical restriction is that the decision to transfer may not be made based upon the patient's ability to pay or the source of their income. A pregnant woman who presents in active labor must be admitted and treated until delivery is completed, unless a transfer under the statute is appropriate. The statute explicitly provides that this must include delivery of the placenta.
EMTALA applies to all persons entering the hospital campus within 250 yards of the emergency room. The 250-yard rule comes from the definition of “campus,” which is generally defined as the physical area immediately adjacent to the provider's main buildings, and other areas and structures that are not strictly contiguous to the main buildings but are located within 250 yards of the main buildings.
If the patient does not have an “emergency medical condition,” the statute imposes no further obligation on the hospital.
In the event that the hospital owns and operates its own ambulance service, the patient has been deemed to have entered the emergency room as soon as they are placed in the care of the emergency medical technicians staffing such ambulance. However, if the ambulance transports the patient to a different hospital pursuant to community-wide policies which direct the patient to a different hospital, the patient will be deemed the patient of that receiving hospital. Of course, while the patient is within that ambulance, the medical director of such ambulance (and its employer) may still remain liable for all acts and omissions of the emergency medical technicians.
PHYSICIAN-PATIENT RELATIONSHIP WHEN A PHYSICIAN RESPONDS TO THE FIELD
Physicians have become integral components of the emergency medical services industry. Physicians are no longer confined to the internal boundaries of a hospital setting, and instead are often called upon to respond to the location of a patient. In these instances, it is not a patient who requests the services of a physician, but is more frequently an emergency medical technician or fire chief who requests the presence of the physician at the scene. This scenario presents very complex questions on whether a physician-patient relationship has been formed. Since the questions are based on state case law or statute, the answers could vary. However, important factors which will be considered by a court are as follows:
Did the physician actively treat the patient, provide advice or orders to an emergency medical technician, or diagnose the patient?
Did the physician communicate with the patient? Did the physician give the patient a reason to rely on the physician? Did the physician ask questions of the patient in order to be able to diagnose and/or treat the patient?
Did the physician advise the patient to continue seeing the physician at a later date?
A court has stated that “a physician is not to be held liable for arbitrarily refusing to respond to a call of a person even urgently in need of medical…assistance provided that the relation of physician and patient does not exist.”3
VARIATIONS IN LIABILITY ASSOCIATED WITH FIELD CARE BY A PHYSICIAN (GOOD SAMARITAN, VOLUNTEER VERSUS PAID, DUTY TO ACT)
Many states have created laws which are designed to encourage physicians and other emergency care providers to provide assistance in unanticipated emergency situations. The laws can generally be divided into two categories: those that impose a duty to act and those that protect an individual when they have voluntarily acted.
Some states require that a person, including a physician, provide assistance to those in an emergency. The statutes stop short of imposing a burden to provide medical assistance, but do require “reasonable care.” These statutes create numerous issues in their applications, such as determining what a “reasonable” action is for a physician.
Some state statutes provide protection specifically for medical directors who volunteer their time with an emergency medical service agency, but limit their protection to medical directors who receive no remuneration for their services. Medical directors should evaluate whether the compensation they receive is worth the loss of protection they might receive. Alternatively, prospective medical directors should demand that the ambulance service indemnify them for their acts and/or omissions. Of course, providing this indemnification imposes a burden on the emergency medical service agency to ensure that the medical director is diligently performing its own duties. The contract with the medical director should ensure that the medical director's responsibilities are stated clearly.
“Good Samaritan” statutes provides varying degrees of immunity for physicians when they choose to provide medical assistance outside their scope of employment. Most commonly, these statutes require that the medical assistance is not offered in exchange for any type of remuneration. The law then provides either a full immunity or a partial immunity, called “qualified immunity.” Full immunity provides absolute protection to a physician for their acts and omissions. This is less typical.
More common is that a statute provides a qualified immunity to the physician for any negligent care, being care that does not meet the standard of care. The limit on the immunity is that no immunity is extended to the physician for assistance rendered in an intentionally harmful way or a manner which is reckless or is likely to cause injury.
The patient must not have already assumed a duty to the patient through another means, such as performing such services through their employment requirement.
Under these statutes, the physician is not required to render any specific amount of care or advice, but is simply encouraged to do so with the grant of the limited immunity.
One problem that may exist for the physician is that of insurance and defense coverage. Many insurance policies only insure the physician for acts performed within the scope of his or her employment. Some employment agreements limit the scope of employment to within the physical boundaries of the workplace, thereby excluding coverage to the physician when acting in an emergency situation. Thus, some physicians may be immune or partially immune from liability for their acts and omissions, but will not have insurance coverage to provide them costs for attorneys to defend them, or insurance coverage in case they lose a lawsuit. Thus, whether such a statute actually encourages someone to become involved in an emergency situation is questionable.
It is important to note that Good Samaritan laws do not always provide absolute protection for an emergency medical service or a physician. Although these statutes frequently provide absolute or partial immunity for negligent care, their immunities do not always extend to negligent supervision or training of the emergency medical service providers. Said another way, while an emergency medical service may successfully defend a lawsuit for its negligent treatment, it may lose the same lawsuit on the theory that the treatment would not have been negligent had the medical director ensured that each provider was properly trained, evaluated, and supervised.
As discussed above, a physician-patient relationship is most commonly formed when a physician assumes a duty to act on behalf of a patient and provides medical treatment as opposed to simply a diagnosis. Both situations occur with online medical control. In the online medical control situation, a patient does not request the assistance of a physician. At best, a patient or a third party called 9-1-1 and requested an ambulance. The patient has no relationship with the physician and in fact may never meet the physician providing medical control.
In some instances, the patient will be brought to the hospital at which the physician is employed. In other instances the physician is at another location separate and apart from the receiving facility.
The physician becomes directly involved with the diagnosis and treatment of the patient through the words and acts of another, being the paramedic or emergency medical technician.
OFF-LINE MEDICAL DIRECTION
Off-line medical direction generally occurs when a physician issues standing orders to an emergency medical services provider to utilize a drug or procedure in the field without the direct supervision of the physician and without having to make a request of the physician. The standing orders are only initiated upon the determination that a condition exists which warrants the use of such drugs or procedure.
In some states, the medical directors do not issue the list of drugs which may be administered or the care that may be rendered while in others the medical directors have more control over these decisions. Frequently, the medical director “signs-off” on the use of such drugs and skills by the agency, even limiting the rights which are granted by the state or region.
Generally, an agency which receives permission from a physician to provide advanced emergency medical care is viewed to be working “under the license” of the medical director. Thus, the medical director becomes obligated to review the skills of the emergency medical service providers and to ensure that they are properly trained in the use of such drugs and procedures. Without the permission of the medical director, the agency may not utilize such drugs and/or procedures. This oversight creates a duty of supervision and thus it is more accurate to state that the EMS providers are providing care “under the supervision of the licensed physician.” (A discussion on EMS provider certification versus licensure is detailed in Chapter 21.)
The liability from off-line medical direction arises from the supervisory relationship between the physician and the emergency medical service provider. The physician is responsible for ensuring that clear and medically appropriate advanced medical orders are issued to the provider, and that the provider possesses the knowledge and skills to carry out the advance orders in the appropriate medical situations. If an injury was caused by the improper administration of the drug or procedure, or the failure to utilize such drug or procedure, the lawsuit may focus on the acts and/or omissions of the medical director in training, supervising, and evaluating the skills of each of the emergency medical service providers. Medical directors are not always required to directly train, evaluate, and supervise each provider, but they must be involved in the evaluation and administration of the program used to do so. The lack of medical oversight by the physician may lead to a determination of negligence on the part of the emergency medical service or the agency itself.
In one filed lawsuit in Washington, DC, the mother of a deceased 2-year old sued on behalf of her child who died after EMTs failed to transport the child. The EMTs advised the mother to place the child in a steaming shower, instead of transporting the child to the hospital. The mother called back a few hours later, but it was too late to save the child. The lawsuit alleges that, among other reasons alleging liability, the ambulance corps failed to properly train and supervise the EMTs and that such lack of training and supervision leads to the negligent decisions of the EMT.4 In Washington, DC, a state statute imposes liability on the medical director personally if the liability results from the gross negligence of the medical director.
LIABILITY CONCERNS FOR TRANSFERRING AND ACCEPTING PHYSICIANS, AND INTERFACILITY TRANSPORT PROGRAMS
Emergency room physicians are governed by the Emergency Medical Treatment and Labor Act with regard to their actions of and consequences for accepting, evaluating, and transferring patients from the emergency room. A more complete discussion of this federal law appears above.
Generally, physicians cannot discharge or transfer a patient unless they are stable. EMTALA was designed to prevent “patient dumping” when the hospital did not want to care for the patient due to payment concerns.
That said, there are certainly times when a patient has to be transferred simply because the transferring hospital cannot adequately treat the patient. For example, some hospitals may not be able to perform the necessary surgery on a patient that came into their care. So long as the patient understands the risks of being transferred and is adequately advised of such risks, and so long as the patient is stabilized as much as possible, the transferring physician should not encounter actual liability for harm encountered by the patient during transfer.
The receiving physician must have agreed to accept the patient and must agree to offer the necessary care. A transfer cannot be safely undertaken without such an agreement. “Blind transfers” will no doubt lead to violations of EMTALA and are simply unsafe for the patient.
LAWSUITS AGAINST EMS MEDICAL DIRECTORS
Lawsuits against medical directors are less common then lawsuits against the emergency medical service itself. Common allegations against the medical director involve:
Negligent diagnosis of the patient, either directly on-scene or through the questioning of the emergency medical technicians
Negligent treatment of the patient, either directly on-scene or by giving harmful instructions and/or orders to the emergency medical technicians
Negligent supervision and/or training of the emergency medical service providers
Since many states or governing municipalities provide standing orders to paramedics and emergency medical technicians for the drugs and procedures they can render, physicians are not always directly involved in the actual care provided.
However, medical directors are frequently tied into the lawsuit through the allegation that the medical director failed to properly supervise and/or train the care providers. These lawsuits allege that the medical director failed to carry out his or her role. Thus, the question of what role the medical director was required to play is important. The role of the medical director can be defined by state law, a local municipal law, or a contract between the emergency medical service agency and the physician.
In the event that a lawsuit directly or indirectly implicates the acts or omissions of the medical director, the medical director must evaluate his or her exposure and course of action. If the medical director was an employee of the agency, the medical director will likely be defended and indemnified by the ambulance service. However, if the medical director was an independent contractor, the medical director may be sued directly by the patient or even brought in by the emergency medical service itself. In either event, the medical director will want to notify his or her insurance carrier.
There should always be some sort of agreement between a medical director and an emergency medical service agency which addresses at least the following:
The roles and responsibilities of the medical director
Which party is responsible for providing insurance coverage
Whether the medical director and/or the agency will defend and/or indemnify the other
Emergency medical services agencies will always be targets for lawsuits. Common lawsuits against EMS agencies involve allegations of more than negligent care and treatment, but also negligent hiring, training, and supervision, as well as many other underlying allegations.
Some lawsuits may be prevented by addressing concerns of patients and their families. Addressing a patient/family complaint may prevent the same issue from reoccurring in the future and may uncover provider issues which might lead to a lawsuit in the future with a different patient. Thus, EMS agencies need to provide a method to receive, address, and resolve complaints. At the same time, EMS agencies maintain valid concerns to protect themselves from potential lawsuits.
One important step that an emergency medical service can take to uncover problems and address concerns is to solicit and receive patient feedback. Unfortunately, agencies frequently do not view themselves as a “customer service.” However, patients and their families have unique views of the actions of emergency medical care providers.
Consider this scenario: Ambulance service responds to a combative patient. The family states that the patient is disoriented and has a history of low blood sugar. The patient flails its arms at the emergency medical service providers. In an attempt to start to administer medications through an IV, the emergency medical technicians restrain the patient for his own safety. The EMS provider misses the vein initially, and continues with the struggling patient, resulting in black and blue marks on the patient's arm. There is no other harm to the patient.
What the family believes occurred may be quite different from the view of the emergency medical service providers. The patient's family saw two individuals physically restrain their loved one and repeatedly plunge a large needle in his harm, causing black and blue marks. The family was scared for their loved one and did not know what was occurring. Instead of having any contact with the emergency medical service to express their concerns or obtain an explanation, they turn to the television lawyer soliciting clients of medical abuse. The attorney, having no better understanding of what occurred than the family, turns to the courts to receive an explanation and compensation for the alleged assault.
Some emergency medical services mistakenly believe that if the patient or their family had a concern, they would simply pick up the phone and call. That attitude only further exacerbates the situation and causes the patient's concerns to escalate.
Emergency medical service agencies should consider providing an easy method of reaching out to the patient and soliciting their feedback. There are numerous methods of communicating with a patient, including:
Providing a form to the patient to return to the agency after they are released from the hospital
Providing a Web site with a survey page
Mailing a follow-up card to the patient
Feedback should also be solicited from employees, as well as from entities such as nursing homes and hospitals, whose staff had the opportunity to observe the attitudes and treatment rendered by the emergency medical providers.
Sometimes, asking “how did we do” is enough to prevent the patient from increasing their anger over what they believe may have occurred. For-profit services always stand a better chance of maintaining contracts with nursing homes, hospitals, and other facilities by requesting feedback about their service.
More important, however, is that receiving, evaluating, and addressing complaints provide a method to uncover problematic caregivers. Repeated complaints by multiple patients about the attitude or care of an emergency medical technician could permit the agency to correct a problem before a more serious issue arises.
The feedback solicited should track the core values of the emergency medical service agency. The patient can evaluate whether the agency is achieving its mission and adhering to its core values.
Questions which can be asked include, but are not limited to:
Do you have any questions or concerns about the treatment rendered?
Are you satisfied by the care received?
Were the staff members courteous?
Would you like a call back from a member of the emergency medical service?
Like all customer-based businesses, soliciting feedback also provides employees with an incentive to be careful of their actions and attitudes, as they know that the employer is requesting feedback about them.
Emergency room physicians and nurses are frequently the source of the more significant reports of misconduct and negligence. Hospitals should easily be able to report such concerns to the ambulance company, and should be given direct access to a supervisor to quickly and easily make such a report. Otherwise, the hospital staff may contact the municipal agency which oversees the licensing of the ambulance service or discuss its concerns with the patient's family.
Emergency medical service agencies must understand that hospitals and physicians also have a need to protect themselves. Thus, ensuring that the blame for a poor outcome lies with the correct provider may be of vital concern to the hospital. Open lines of communication with a hospital are simply paramount to running a successful EMS program.
Of course, providers should also be a direct source of reports. Providers will not want to report their own errors, but they must be instructed that the failure to report a potential or actual issue can result in discipline to them. They should also be comforted that the self-reporting of an error will may be met with additional training and oversight in lieu of discipline whereas covering up such acts or omissions will be dealt with harshly. Partners and supervisors should also be encouraged to make reports, even if the report could result in bad relations with the other provider.
The routine method of monitoring the quality of care, being Quality Improvement and Quality Assurance programs, is only part of a comprehensive program to detect quality issues. Coupled with the above programs, however, a QI/QA program can be effective.
EMS agencies should be aware that not all quality assurance and quality improvement (QA/QI) proceedings are confidential. For example, in New York State, although the QI/QA process is generally protected from disclosure in lawsuits and public information inquiries, New York State law provides that if a person who is or later becomes a defendant in a lawsuit, the individual's testimony before the QA/QI process is discoverable.
An emergency medical service agency should openly solicit and address feedback on the care provided to patients. Such programs will pay significant dividends by not only addressing concerns after they occur, but preventing systemic problems before they cause real harm to a patient and the agency itself.
The establishment of a physician-patient relationship for EMS physicians may be less clear in legal terms than that of hospital-based physicians.
Liability for EMS physicians/medical directors lies primarily in three potential areas: negligent diagnosis/assessment, negligent treatment, and negligent supervision or training of prehospital providers.
Three potential ways to gather important patient feedback include providing a feedback form, offering a Web site with survey page, mailing out a follow-up card.
Feedback on quality of care should also include self-assessment and peer review.
Mead v Adler, 231 Or App 451, 220 P3d 118 (Or 2009).
Dallas-Stephenson v. Waisman, 39 A.D.3d 303, 307, 833 N.Y.S.2d 89 (1st Dep't 2007).
Childs v Weis, 440 SW2d 104 (Ct Civ App Tx 1969).
Stephanie Stephens v. Geoffrey Mount-Varner, MD.