Many smaller local governments
Has Veto power
2/3 majority vote can override a veto
State/Prosecutor has BOP in Criminal cases
BOP is proving propondence of evidence in civil
beyond a reasonable doubt in criminal
Bill Of Rights- Freedoms- Prevents governments from interferring with our individual rights
False statements about a person
Duty of care- Fail to exercise reasonable care that results in harm
Based on decisions made by judges
Based on decisions made by judges
• all types of hospitals (medical, psychiatric, long-term care, etc.)
• managed care oranizations (like HMOs)
• VNAs (visiting nurse associations)
• clinical laboratores
This would include:
• the diagnosis
• the risks and potential consequences of treatment
• the expected benefits of the treatment or procedure
• potential alternative treatments
• prognosis if no treatment is received
• that an acceptable standard of care is followed
• the costs, including the amount of expected pain
• Determine the prerequisites for licensure.
• Forbid the practice of medicine without a license.
• Specify the conditions for license renewal, suspension, and revocation.
• Endorsement—This is an approval or sanction granting a license by endorsement
to applicants who have successfully passed the National Board of Medical
• Reciprocity—A license to practice medicine may be granted by a state that
accepts a medical license granted by another state.
Medicaid fraud, rape, murder, larceny, narcotics conviction, and the inappropriate
use of drugs and alcohol.
for a professional, such as a physician, to practice.
Certification is granted by a certification board and means that a person has
met the special requirements, such as additional education and training,
of the certifying board.
begins to run at the time the injury is discovered or when the patient should
have known of the injury.
is responsible for the actions of the employee.
p. 60 – If a physician continues to practice medicine without renewal of his or her license, under the law it is considered practicing medicine without a license.
p. 61 – The term “reasonable” is a broad, flexible word to make sure the decision is based on the facts of a particular situation rather than on abstract legal principles. It can mean fair, rational, or moderate. Reasonable care has been defined as “that degree of care a person of ordinary prudence would exercise in similar circumstances”.
p. 63 – Do not discuss anything relating to a patient within earshot of others.
p. 63 – The statute of limitations is a state law that varies by state.
p. 64 – The Good Samaritan laws do not protect physicians or their employees from liability while practicing their profession in their work environment. The laws are meant to encourage medical professionals to assist with emergencies outside of the work setting. Always check the coverage of the Good Samaritan Law in your own state.
p. 65 – Even though the doctrine of respondeat superior mainly refers to the employer, in all states both the physician and the employee may be liable.
p. 66 – Healthcare workers have a duty to be assertive and question those orders that they believe are erroneous or appear to be harmful to the patient. They also have a duty to refuse to carry out orders that violate their own practice acts.
p. 67 – All employees must understand that there are limits to their authority when it comes to healthcare decisions. The ultimate decision always rests with the physician, provided it does not violate their professional practice.
p. 68 – Everyone in a healthcare institution – not just the risk manager – is responsible for risk management.
• requirements for licensure
• duties of the licensed physician
• grounds on which the license may be revoked
• reports that must be made to the government
• define penalties for practicing without a license
• continuing medical education, measured in CME units (typically 75 hours in a 3 year period). This can be done through workshops, courses, seminars, self-instruction modules, teaching, reading approved medical literature.
• no information can be shared without the patient’s consent
• no information can be given over the phone without consent
• no records an be given to another person or physician without the patient’s written permission (unless subpoenaed).
• information should be shared only on a need-to-know basis
FLEX – Federal Licensing Examination
USMLE – U.S. Medical Licensing Examination
• a out-of-state physician providing emergency care
• physician waiting to qualify for residency
• research physician who does not practice patient-based medicine
• military physicians at military hospitals
• Denial (the most frequently used defense)
• Assumption of risk
• Contributory negligence
• Comparative negligence
• Borrowed servant
• Statute of limitations
• Good Samaritan laws
Using arbitration, mediation or a combination (med-arb) for deciding a civil case can same time and money.
this can be time consuming because both parties must agree on the choice of arbitrator. Then both parties must agree to abide by the arbitrator’s decision.
Patients should be asked to sign an authorization for all procedures indicating that they understand the risks involved, accept those risks, and give their consent for treatment.
The employer is not liable for any negligence caused by the employee while in the service of the temporary employer.
In some states, where there is no cap, malpractice insurance have risen to a point where some physicians have had to leave their practices.
It is important with this type of insurance to file reports in a timely manner, especially by the time of the policy’s year end.
Payment for the actual loss of income, emotional pain and suffering, or injury suffered. The losses are past, current, and future and include lost wages and profits.
p. 136 & 138
Patients seek recovery, or compensation, for a variety of damages:
• Permanent physical disability
• Permanent mental disability
• Loss of enjoyment of life
• Personal injuries
• Past and future loss of earnings
• Medical and hospital expenses
• Pain and suffering
The result is patients have to undergo additional tests and procedures and the cost of healthcare increases. The over use of specialist can negatively impact the relationship with the PCP.
Defensive medicine becomes problematic if a physician becomes reluctant to attempt more risky, but potentially effective procedure for fear of a lawsuit.
Studies show that physicians with good bedside manner (talking unhurriedly, sitting on the bedside, holding the patient’s hand) were much less likely to be sued (regardless of skill). This extends to all healthcare professionals and is why physicians hire employees who project a warm and caring attitude toward
(or proximate cause)
p. 136 & 137
Proximate cause means there were no intervening forces between the defendant’s action(s) and the plaintiff’s injury — hence, a cause-and-effect relationship.
Proximate cause refers to the last negligent act that contributed to a patient’s injury, without which the injury would not have resulted.
Illegal billing, referral kickbacks, dishonesty when conducting medical research, embezzlement, and the illegal sale of drugs are all forms of fraud.
Frequently cited areas of medical related fraud are on p. 141.
In order to protect the physician/employer from liability for negligence under the doctrine of respondeat superior, the healthcare professional should:
• Have a written job description that clearly defines the responsibilities, duties and skills necessary for the job.
• Use extreme care when performing his or her job
• Carry out only those procedures for which he or she is trained
• Be honest about any errors or inability to perform a procedure
Medical personnel must be especially aware of malfeasance when they offer advice such as “Try giving your child aspirin to bring down the fever.”
A physician is held to a different but not higher standard of care than a nurse, medical assistant, physician assistant, or phlebotomist.
Medication errors are one of the leading types of medical errors.
The mediator lists to both sides of the dispute and assists the parties in finding a solution.
Occurs when poor technique is used; such as when a phlebotomist performs veinipuncture and the patient suffers nerve damage.
An example would be when a patient collapses in the office and a nurse trained in CPR fails to administer it.
With this type of insurance it is important to clearly documetn when an event took place.
p. 134 – When a person is injured they are sue under tort law (“a wrongful act against another person”). The unintentional tort of negligence is the most often cause of lawsuits for healthcare professionals.
p. 134 – Not everyone will perform reasonable skill in the same way. However, unreasonable lack of skill is unacceptable
because it shows lack of skill or carelessness.
p. 135 – The best solution is to avoid errors is to always double-check all orders and healthcare decisions that physicians and other healthcare professionals make. Electronic prescriptions has eliminated many medication errors. Most important, never perform a procedure for which you are not trained.
p. 135 – You can be sued even if you are right. Patients can be injured though no fault of the medical personnel.
p. 136 – The determination of duty in the court room is the responsibility of the judge, not the jury.
p. 137 – Proximate cause refers to the last negligent act that contributed to a patient’s injury, without which the injury would not have resulted.
p. 137 – To have preponderance of evidence to find in favor of the plaintiff, the jury believes that it is at least 51 percent likely that the defendant caused the injury.
p. 141 – Filing a false claim for programs such as Medicare or Medicaid is a federal crime. The employee’s physician could be severely fined and even lose his or her license for this type of fraudulent act.
p. 142 – Every person has the right to say “no” when asked to perform an activity that is unethical, illegal, or against his or her own value system.
p. 143 – It is easier to prevent negligence that to defend it.
p. 144 – The physician is solely responsible for explaining the risks of treatment or procedure. If a they delegate this function to a nurse, medical assistant, or physician assistant, the physician still retains overall responsibility.
p. 144 – Instructions given to the patient should always be noted in the patient’s record.
p. 145 – Healthcare professionals should have an understanding of what is right and wrong under the law. Arguing that a negligent act was unintentional is not a defense, nor is ignorance of the law.
p. 146 – Medical personnel must listen to and respect the patient’s wishes.
p. 146 – Every staff remember must take responsibility for reporting and correcting defects (to the physical condition of the premises) that could cause injury.
p. 147 – Be alert for indications of drug use among coworkers. Reporting abuse is necessary in order to get help for the abuser and to protect patients and the reputation of the facility.
p. 147 – A comment made to a patient such as “I’m sure you will be fine.” could be taken as a verbal contract.
p. 148 – Never completely obliterate any notation on a chart. If a note is placed in the wrong chart, cross through the notation with one line and write “Incorrect Chart” and you name.
p. 148 – Never alter a medical record
p. 150 – There is no law that states, ” If you didn’t document it, you didn’t do it,” however, it is difficult to defend a practice that is not documented.
p. 152 – Medical assistants can be named and prosecuted in lawsuits.
p. 152 – The public often assumes anyone in a white uniform is a nurse. Unless they are an R.N. the healthcare professional must correct the patient.
p. 154 – Healthcare professionals must only practice within the scope of their training. There are times when a healthcare professional must refuse to perform a task.
Duty – takes place when there is an obligation established between the physician and the patient
Dereliction of duty – the physician or healthcare provider failed to provide a correct standard of care to the patient and therefore, has not met the duty.
Direct or proximate cause – the dereliction or breach of duty was the direct cause of the patient’s injury
Damages – injuries caused by the defendant for which compensation (financial or otherwise) is due.
The plaintiff must prove that it is more likely than not that the defendant, (physician), has caused the injury.
The burden of proof is on the plaintiff.
(also called Res ipsa loquitur or RIL)
Under res ipsa, an exception to the burden of proof rule occurs, and the burden of proof now falls to the defendant. A judge decides if a case can be tried under ris ipsa; to do so three conditions must be present:
1. The injury could not have occurred without negligence.
2. The defendant had total and direct control over the cause of the injury, and the duty was within the scope of the duty owed to the patient or injured party.
3. The patient did not, and could not, contribute to the cause of injury.
In order to have a civil malpractice lawsuit, the plaintiff (patient) must show that:
1. A relationship had been established
2. The relationship established a duty of the physician to the patient.
3. The duty required the physician to perform at a particular standard of care.
4. The duty was breached by the physician.
5. The patient received an injury as a result of the physician’s breach of duty.
6. The physician’s breach of duty was the proximate cause of injury to the patient.
• Special compensatory or exemplary damages
A plaintiff in a wrongful-death suit does not have to prove that he or she was completely dependent on the deceased person for support.
The plaintiff must prove that the defendant’s actions were the “proximate,” or immediate cause of death.
This office was created to protect programs under the Department of Health and Human Services (HHS) such as Medicare and Medicaid.
The OIG reports problems to the Secretary of State and Congress makes recommendations on how to correct them.
• Represents the OIG in civil cases tried under the False Claims Act.
• Imposes money penalties on healthcare providers found guilty of fraud.
• Issues fraud alerts
1. Additional costs to federal healthcare programs
2. Quality of patient care
3. Access to care
4. Freedom of choice
6. Healthcare provider’s abuse of professional judgement
• A claim using a diagnosis code other than the true diagnosis code to obtain reimbursement for services
• A claim indicating a higher level of service that that which was provided.
• A claim for a service that the provider knew was not necessary
• A claim for services provided by an unlicensed individual
(under Civil Liability Cases)
Lawsuits involving the physical condition of medical facilities have involved cases such as broken steps, malfunctioning elevators and doors, and defective carpets.
A comment made to a patient such as “I’m sure you will be fine.” could be taken as a verbal contract.
Never completely obliterate any notation on a chart. If a note is placed in the wrong chart, cross through the notation with one line and write “Incorrect Chart” and you name.
It is poor technique to leave spaces on the chart so that another person can add statements later.
Deliberate attempts to alter or hide a chart can result in losing a negligence case, even weeks after the case is over (if the chart has been changed since last checked.)
There are two major types of liability insurance:
• Claims-made insurance
• Occurrence (or claims-incurred) insurance
When done once per shift, does not always convey exactly what was done for the patient. To a judge, it may appear as “lack of monitoring.” It is different to defend a practice that is not documented.
• When nurses exceed their scope of practice, they violate their nursing license.
• Nursing supervisors have been found negligent for not establishing procedures for the nursing staff that are designed to protect patients.
• Most states have statutes that provide civil immunity for paramedics who provide emergency life-saving care.
• All healthcare professionals are required to report unusual situations to their supervisors.
• It is wise to talk to risk management about the need to complete an incident report whenever an unusual situation occurs. The report accurately reflects the time, date, and facts of the situation. It can be subpoenaed by the court in the even of a lawsuit.
(or Malpractice Reform)
• Follow safety practices and OSHA guidelines
• Communicate clearly and within HIPAA
• Document accurately and completely
• Be positive
• Write clearly and concisely
• Don’t use overblown or empty words to describe your abilities
• Be truthful
• Emphasize your skills as a team player
• Incorporate specialized terminology
• Research the organization
• Read the letter aloud
Be concise, articulate, and convincing.
See p. 158
Courts may mandate that affirmative action programs be implemented if there is evidence that an employer has intentionally discriminated against a particular minority group.
• Applies to employers who have 20 or more employees.
• Does not apply if the older employee does not have the ability to perform the job
• The employer must be able to show in writing why the younger job applicant was hired over the older one.
• Mandatory retirement is prohibited under this law except for certain exempt executives.
• People over 40 are protected by ADEA and Title VII.
• There are 43 million disabled persons in the U.S.
• Persons with AIDS are also covered under this act.
• Employers must make reasonable accommodations to make the work environment accessible to their disabled employees.
• Exceptions occur if making the accommodations would put undue hardship for the employer.
• The vagueness of term “undue hardship” has caused problems interpreting this law.
• Employers have a 2 years to implement the accommodations.
• Patients are also protected under this statute.
As long as a person is competent, he or she has the right to make their own decisions.
Bioethical and legal issues arise when a person is called upon to make decisions based upon his or her own religious beliefs, for another person such as a child or incompetent adult.
Guardianship may have to be established by the courts so the best interested of the patient are observed.
p. 191 & 196
• Prior to this amendment only compensatory damages were awarded
• Wrongful discharge suits fall under this law.
• Hospitals cannot discriminate against employees and employees cannot discriminate against patients.
• The federal government requires all clinical laboratories that test human specimens must be controlled.
• 1992 – mandate written policies and procedures for a comprehensive quality assurance program
• most tests are regulated except simple ones that would not negatively impact a patient if the result were erroneous
• The FDA is responsible for categorizing the tests and allowing the waiver of testing
• Tests performed at home are general waived but the manufacturer must request the waiver
• Tests that use a microscope, calculations, or a judgement call are not waived
• A complete list of waived tests is on hcfa.gov/medicaid/clia and www.cola.org
• This is an important act because it has helped decrease the number of uninsured Americans.
• A company with 25 or more employees must provide extended healthcare insurance to terminated employees for up to 18 months – usually at the employee’s expense.
• COBRA also contains an amendment called EMTALA which prohibits “patient dumping”
• Drug-using employees are expensive in terms of decreased productivity, workplace, accidents, and increased healthcare costs.
• To prevent abuse some organizations require drug testing as a condition of employment.
• Patients must be stabilized before transfer or sent to a regional trauma center if they cannot be stabilized
• A person reporting patient dumping may not be peanalized
• Hospitals can be fined or have their Medicare agreements dropped
• The patient can sue the hospital
• A physician can be penalized if he/she misrepresents a patient’s condition
• EMTALA does not apply to HMOs, private clinics, or private phusician’s offices.
p. 194 & 206
• ERISA requires employers to earmark money that can only be used to pay future benefits.
• Guarantees vesting of pension plans
• Under ERISA, employees who stay with a company for 10 years are entitled to 50 percent of the employer’s retirement plan even if they leave the company and take another job.
• The employee is entitled to 100% of the employer’s pension contribution after fifteen years of employment when he or she becomes fully vested.
• ERISA protects employees from being laid off just before they become vested.
This does not apply if there is a contract between the employer and employee that defines the duration of the employment.
This concept is beginning to lose favor as wrongful-discharge lawsuits rise.
p. 193 & 197
• EEOC monitors Title VII and the Justice Department enforces the statute.
• If a patient is denied credit based on a poor credit rating from a credit agency, the patient must be notified of this fact and given the name and address of the reporting agency.
• The agency must disclose the information to the consumer and correct any outdated or erroneous information.
• The FCC issued guidelines for specific times that credit collection phone calls can be made (8 a.m. – 9 p.m.)
• It prohibits harassment and threats
• Guidelines on page 209
• Billing and collections personnel must have a full understanding of the laws regulating the collection process
• This is the main statute regulating employee benefits.
• Over time must be provided at time and a half if over 40 hours are worked each week
• Hospitals are an exception when they make an agreement with their employed to establish a work period of 14 days. Overtime then starts at 80 hours.
• This law affects only full-time, hourly employees.
• Salaried, management, part-timers, and time-sharers usually do not benefit from this law.
• The employees job, or an equivalent position, must be held.
• In most cases the leave is without pay.
• FMLA also allows an employee to take 12 weeks for a family members medical situation (birth, death, adoption).
• The employees heath coverage must be maintained
• Accumulated employee benefits cannot be lost
• The oldest act relating to compensation.
• Employers are required to contribute to Social Security plans for their employees.
• Severe fines ensue if the employer does not pay on time.
• Detailed documentation of the employer’s payments are necessary
The Wagner Act
• OSHA regulations preempt all other state and local regulations regarding employee safety and health, meaning that states may not pass any laws concerning the working environment.
• Right-to-know laws
• Employers and office managers should become familiar with OSHA regulations as they apply to their specific fields. This protects employees and avoids fines for OSHA violations which can be severe.
• Poor publicity from OSHA violations can damage an office or company’s reputation.
• It is better to err on the side of being to cautious when implementing OSHA regulations.
• An employer cannot force a woman to quit her job because she is pregnant
• A woman cannot be refused a job because she has had an abortion
• The employer’s medical plan must cover pregnancy the same way it covers medical conditions.
• The woman is entitled to sick leave the same as other employees
• This act prohibits discrimination based on disability in any institution that receives federal financial assistance. (e.g., a hospital that receives Medicare or Medicaid reimbursement must comply with this law).
• This act had a major influence on the Americans with Disabilities Act of 1990 because it included a broad definition of “handicapped” (people with physical or mental impalement)
• This act give legal basis for claims challenging denial for employment because of physical or mental reasons.
• This act laid the groundwork for unemployment compensation in the United States.
• Social Security is paid by the employer and the employee in equal payroll taxes and Medicare participant premiums.
• Social Security is composed of different but related programs:
– Medicare health benefits
• The amount paid to the beneficiary is calculated based on the worker’s average wages earned during his/her working lifetime.
• This proposal from the Kennedy administration is considered one of the most important pieces of all legislation.
• This act applies to all organizations that have 20 or more employees working 20 or more weeks a year.
• Some of the most frequent violations in the healthcare employment field are related to Title VII issues.
• Title VII also makes sexual harassment a form of unlawful sex discrimination.
Regulation Z of the Consumer Protection Act
• Installment payments are often used for orthodontia, obstetrical care, and surgical treatment.
• It is legal to include a finance charge, however, few physicians and dentists require the charge.
• In order to receive unemployment insurance, the employee must have worked for an employer who has paid, or was required to pay, unemployment compensation taxes.
• Exemptions apply for religious, educational, or charitable organizations.
• Employees who are fired for a good cause cannot collect unemployment benefits.
• Employers typically pay into a fund to help cover costs when a worker is hurt during the course of employment.
• The goal of worker’s compensation is to get the worker pack to work as soon as possible.
• COBRA may allow for a retraining opportunity if the injury results in permanent inability to work the same job
• If the employee has only worked at the job a few months, the former employer may have to pay worker’s compensation.
• Some medical practices specialize in worker’s compensation cases
• Worker’s Compensation is completely administered at the state level
• The employee must submit written notice of the injury to the employer
• Worker’s Compensation pays a fraction of the normal salary, such as 2/3.
• Available even if the employee is at fault for the injury, except employees who violate hospital policy
• An employee who is injured by a nonemployee can collect Workman’s Compensation and sue the nonemployee for damages.
Clinical Laboratory and Improvement Act (CLIA) of 1988, 1992—The federal government now requires that all clinical laboratories that test human specimens must be controlled. These standards mandate written policies and procedures for a comprehensive quality assurance program to evaluate the overall quality of the laboratory testing process.
Health Maintenance Organization (HMO) Act of 1973—This act requires any company with at least 25 employees to provide an HMO alternative to regular group insurance for their employees if an HMO is available in the area.
Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985—Under COBRA, a company with 20 or more employees must provide extended healthcare insurance to terminated employees for as long as 18 months—usually, but not always, at the employee’s expense.
Drug-Free Workplace Act of 1988—Under this act, employers contracting to provide goods or services to the federal government must certify that they maintain a drug-free workplace.
Fair Labor Standards Act (FLSA) of 1938—This is the main statute regulating benefits. It establishes the minimum wage, requires payment for overtime work, and sets the maximum hours employees covered by the act may work.
Equal Pay Act of 1963—This act makes it illegal for an employer to discriminate on the basis of gender in the payment to men and women who are performing the same job.
Unemployment Compensation—The unemployment compensation laws provide for temporary weekly payments for the unemployed worker.
Federal Insurance Contribution Act (FICA) of 1935—Under this law, employers are required to contribute to Social Security plans for their employees.
Workers’ Compensation Act—This statute protects workers and their families from financial problems resulting from employment-related injury, disease, and even death.
Employee Retirement Income Security Act (ERISA) of 1974—ERISA regulates employee benefits and pension plans.
Family and Medical Leave Act (FMLA) of 1994—This law allows both parents to take a leave of absence of up to 12 weeks in any 12-month period when a baby is born. The employees’ jobs, or equivalent ones, must be available when both return to work. The FMLA also requires employers
to provide unpaid leave for up to 12 weeks to employees who request leave for their own or a family member’s medical or family-related situation, such as birth, death, or adoption.
• Fair Credit Reporting Act of 1971—This act establishes guidelines for use of an individual’s credit information.
• Equal Credit Opportunity Act of 1975—This act prohibits businesses, including hospitals and medical offices, from denying credit based on the applicant’s race or gender—an unfair treatment referred to as discrimination.
• Truth in Lending Act (Regulation Z) of 1969—This act requires a full written disclosure about interest rates or finance charges concerning the payment of any fee that will be collected in more than four installments.
• Fair Debt Collection Practices Act of 1978—This act prohibits unfair collection practices by creditors.
• Federal Wage Garnishment Law—This law restricts the amount of the employee’s
paycheck that can be used to pay off a debt (garnishment).
• Inclined ramps into buildings and over curbs in parking lots
• Elevator floor numbers accessible to wheelchair-bound persons
• Handicapped accessible bathrooms with handrails
• Hallways with 36 inches of clearance for a wheelchair
• Desks and counters that accommodate a wheelchair
• Telephone adapters for the hearing impaired
a. Age—Only legal to ask if he or she is between 17 and 70; if the person’s age falls outside this boundary, then it is legal to ask only the birth date.
b. Birthplace—Legal, but inadvisable to ask where the applicants, their parents, spouse, or children were born. It is illegal to ask about their national heritage or nationality or that of their spouse.
c. Address—Legal to ask, along with how long applicant has lived there.
d. Married/Maiden Name—Legal, but inadvisable.
e. Citizenship—Legal to ask, “Are you a citizen of the United States?”
f. Organizations person belongs to—Legal to ask if applicant belongs to any organizations.
g. Languages—Legal to ask what language a person can speak and write, but can be perceived as discriminatory and a method to determine a person’s national origin.
h. Military experience—Legal to ask if person was a member of the armed forces and when he or she was discharged. Cannot ask what type of discharge was received.
i. If ever convicted of a crime—legal.
a. Age—Cannot ask for the applicant’s specific age if it falls between 17 and 70.
b. National heritage or that of applicant’s spouse.
c. If applicant rents or owns home.
d. If applicant has children.
e. Height and weight.
f. Race or color.
g. Religion or creed.
h. If applicant has ever been arrested.
i. Any handicaps.
j. Memberships in any specific organizations.
k. What type of military discharge.
b. Effectively screen backgrounds.
c. State in writing that the employee handbook is not a contract.
d. Use a two-tier interview screening process.
e. Carefully assess the applicant’s skill level.
f. Develop an application form that provides accurate information about the applicant’s qualifications.
g. Provide a job description for every position.
h. Develop a progressive disciplinary procedure and make this policy known to all employees and supervisors.
i. Provide in-service training to supervisors on how to conduct job interviews and how to motivate and discipline employees.
j. Become familiar with the legal and illegal employment interview
p. Employees should receive a 30 minute lunch break and 2 two 15 minute breaks during each 8-hour work day. The exact policy is established by individual states by the Department of Labor.
Keep one’s opinions about he use of deodorants, clean clothing, and frequent bathing to oneself, unless the patient’s health is suffering as a result of poor hygiene conditions.
Communication is a challenge for non-English speakers. The nods for “yes” and “no” may be switched.Non-English-speaking-patients need brochures, and handouts in their own language. An interpreter must be available when explaining important information.
• Learn as much as you can about other cultures, races, and nationalities.
• Be sensitive to the feelings of others
• Evaluate all information before accepting it as belief
• Always avoid ethnic jokes. Walk away if a co-worker is telling ethnic or disrespectful joke
• Be open to differences in other people
• Bioethical and legal issues arise when a person is called upon to make decisions based upon his or her own religious beliefs, for another person such as a child or incompetent adult.
• Guardianship may have to be established by the courts so the best interested of the patient are observed.
• It is never appropriate to judge, either with verbal or nonverbal criticism, another person’s religious customs and beliefs. A exception occurs when there is evidence of abuse as a result of a religious practice.
• There are some beliefs that do not allow a person to receive a blood transfusion. When the patient is a child, a court order is needed for the transfusion to proceed against the objections of the parents.
• Employers has a legal obligation under the Civil rights Act to make accommodations so that employees can practice their religious observations.
• Employees should be allowed to see, comment on, or copy anything affecting them in written review and personnel file memos.
• Healthcare facilities must remain current on regulations affecting employment practices such as health, safety, compensations, worker’s compensation, unions, and discrimination laws.
• In general federal law usually applies to organizations that employ a declared number of employees and who work a minimum number of weeks in the year.
• Usually, federal law preempts state laws. An exceptions occur when:
– there is no federal law on the topic
– the state law does not conflict with the federal law
– Congress prohibits states from regulating a certain law by complete preemption
• employee health and safety
• compensation and benefits regulations
• consumer protection and collection practices
• federal labor acts
• pay plans
The basis of the law is that people must be judged primarily by their job performance.
• All healthcare workers have occupational exposure
• OSHA standards mandate that each employee with occupational exposure must be offered the hepatitis B vaccination at the expense of the employer. An employee may decline, in writing, to receive the vaccine.
• The OSHA standard refer to urine, stool, sputum, nasal secretions, vomitus, adn sweat only if there is visible evidence of blood.
• OSHA compliance checklist for medical facilities includes:
– eyewash stations
– fire extingishers
– first-aid kits
– written training programs
– labels for chemical and hazardous waste
– sharps containers
– exit signs
– spill kits
– accident report forms
– chemical inventory lists
• OSHA guidelines are available from the U.S. Department of Labor, Washington, D.C.
• MSDS must be posted wherever hazardous materials are used.
• Employees are instructed to read the sheets and know how to handle the materials.
These laws influence the compensation (salary) and benefits provided to employees.
• These can be saved up and used when the employee has to take time off for an illness or surgery.
• Sick days are not part of earned vacation days. They cannot be used except for sickness.
• Once a debtor files for bankruptcy, a creditor (such as a physician who is owed an outstanding debt) may no longer seek payment from the patient, but must instead file a claim in bankruptcy court at a later date.
• A creditor who fails to comply with bankruptcy laws, such as harassing the debtor, can be cited for contempt of court.
• Follow up with bill collection to avoid the impression that the physician was at fault in the patient’s death
• The probate department of the superior court in the county that is handling the estate can provide information on the time limits and also name the administrator of the estate.
• The time limit varies from state to state
• Consult with an attorney
• If an aging account is more than three years old, the creditior should investigate the state’s statute of limitations before investing time, effort , and money to collect the debt.
• Avoid issues by collecting debts as soon as possible
• Physicians accused of unethical behavior can be issued a warning or censure by the AMA.
allocation of scarce health resources
determination of death
euthanasia: active and passive
fetal tissue research
harvesting of embryos
HIV, AIDS, and ARC
organ donation and transplantation
random clinical trials
stem cell research
withholding lifesaving treatment
• Ethics (a branch of philosophy) in healthcare are applied ethics.
• Ethics requires critical-thinking approach that examines important considerations such as fairness for all consumers, the impact on society, and future implications of the decision.
• The dignity of the individual, whether it is the patient, employee,or physician must always be of paramount concern when discussing ethics and bioethics.
• Bioethics concerns ethical issues discussed in the context of advanced medical technology.
• An illegal act is almost always unethical. However, an unethical act may not be illegal.
• The same principles are found in the AMA’s code of ethics.
• Physicians accused of unethical behavior can be issued a warning or censure by the AMA.
• The AMA Board of Examiners may recommend the expulsion or suspension of a physician from the AMA, but it does not have authority to bring legal action against a physician.
• The AMA is required to report to the state licensing board or governmental agency if someone alleges that a physician has committed a criminal act.
• Violation and conviction may result in a fine, imprisonment, or revocation of the physician’s license.
• Serious cases of fraud require the loss of a physician’s license.
• Codes of Ethics or statements of intent are developed by professional organizations to summarize the the principles of behavior they expect of their practitioners.
• The Nuremberg Code was developed in response to a wartime medical ethic atrocities; it outlines the basic ethical principles that must be followed when conducting medical research
• The first AMA Code of Ethics was developed in 1847. Since then the AMA has taken a leadership role in setting such standards.
• Know the code of ethics that relates to your professional practice. Many healthcare professionals keep a framed copy near their place of work to remind them of this responsibility.
Principles of Medical Ethics
• Human dignity
• Responsibility to society
• The need for continued study
• Patient autonomy
• Responsibility of the physician to improve the community
• Responsibility to the patient
• Access to medical care
Every healthcare professional who interacts with patients (even medical receptionists) must be familiar with the Principles of the AMA.
• Accepting patients
• Allocations of health resources
• Confidential care of minors
• Fee splitting
• Financial incentives for organ donation
• Gene therapy
• Ghost surgery
• HIV testing
• Mandatory parental consent to abortion
• Physician-assisted suicide
• Quality of life
• Withholding or withdrawing life-prolonging treatment
AAMA – American Association of Medical Assistants
ADA – American Dietetic Association
AHIMA – American health Information Management Association
ASMT – American Society for Medical Technology
ASRT – American Society of Radiologic Technologitst
• The most commonly donated are corneas, heart, kidneys, skin, bone marrow, blood, liver, and lungs. The long bones of the body (tibia, fibula, femur, humerus, radius, and ulna) can also be transplanted.
• Some organs and tissues can be donated by a living person, such as, blood, bone marrow, and kidneys.
• A U.S. law prohibits the sale of organs. Payment to cover the medical cost for the donor is allowed.
• UNOS contains a database relating to every organ donation and transplant in the U.S. since 1986.
• UNOS uses a formula that gives half the weight to considerations of medical untility or need and half to considerations of justice.
• An estimated 400,000 people are waiting for transplant in the U.S.
• There are 106,000 people listed on the UNOS waiting list (many are for kidneys)
• Severe shortages of organs leaves patients to take desperate measures to find organs on their own
• One issue is the extreme expense involved for the procedure and continued immune suppression therapy
• The criteria for rationing are controversial.
• The United States and Great Britain are committed to the donation model for organs; organs may be harvested only with the consent of the donor or the donor’s surrogate representative.
• All U.S. states have adopted the Uniform Anatomical Gift Act, permits competent adults to either allow or forbid the posthumous use of their organs though some type of written document, including a donor card.
• The social utility method of allocation determines the allocation of organs based on who will benefit the most through careful matching and estimated survival rate.
• Another approach is the justice method, which gives everyone an equal change at the available organs.
• Other methods include seniority (first come, first serve) basis and the lottery method. Both of these methods cause concern because they may result in a person in lesser need receiving an organ first. The lottery method may result in a patient with little chance of recovery, receiving a scarce organ.
• Other selection criteria, such as age, social status, projected ability to give back to the community raise concerns that this is not a just system for all persons.
• A combination approach using medical suitability first and then seniority basis second is the most often used method.
• National Organ Transplant Law of 1984 forbids the sale of organs and addresses the matter of finding donor organs close to recipients locations.
• Financial incentives for cadavers is generally frowned upon
• Medicare has been expanded to fully fund kidney transplants and most insurance will cover heart transplants.
• Lessons learned from the Oregon case are:
– Medical resources are limited in all states
– The need for acute care, such as for transplants, is more visible than preventative care, such as prenatal care
– New medical discoveries and treatments, with their enormous costs, are likely targets for cost containment rather than older, more basic medical treatments.
– For new treatments to be funded, they must replace older, ineffective treatments
• The preference should be stated before hiring takes place.
• If the healthcare providers reasons jeopardize the health and safety of the patient it may be necessary for them to resign.
• The ethics of the employer must be in agreement with the ethics of the healthcare professional.
– the relief of pain and suffering
– the restoration of body functions and health
– the prevention of disability and death
• Human experimentation is considered necessary for medical progress to occur
• Medical research carries some degree of risk and patients must be willing, informed participants, especially in nontherapeutic research
• The justification for all research is that the benefits must outweigh the risks.
• This utilitarian (benefit/cost) approach is considered a good model for research.
• Increasing knowledge is not considered justification for risking human life
• Medical researches must abide by the code of ethics established by their professional organizations
• HHS implements government standards for research. They require all institutions that receive federal research funds to establish an Institutional Review Board (IRB) to oversee any human research.
• Patients must be informed about the risks and they type of research design that is used. Such as:
– Control group
– Randomized study in which the subjects is assigned at random to either the control or experimental treatment group
– Placebo group in which an inactive substance or an alternative type of treatment is given
• Research can help determine the which course of treatment is best
• Physicians are responsible for explaining the risks involved in a research project, however, other healthcare professionals have a duty to covey information the patient tells them to the doctor.
• Physicians should not engage in drug trials for drugs made by companies that they own stock in.
• Race based control groups create another ethical dilemma because people of a certain race may not receive treatment
• However, race based control groups are necessary when researching a condition that only affects that particular race
• Arguments against human cloning is the effect it might have on human dignity.If we control the creation of human beings, then we can eliminate the creation of imperfect human beings.
• Three more oppositions to cloning are:
– health risks from mutated genes
– emotional risks
– the risk of abusing technology
• Also,since therapeutic cloning destroys a 4-d-ay-old embryo, many anti-abortionists are against it.
• This could cure some diseases but there are unanswered questions such as:
– Should gene therapy be used to create healthier fetuses?
– Should companies develop tests to predict mental illness?
– Could gene therapies, designed to save lives, end up being a way to choose the traits we want our children to have?
• The controversy revolves around the moral implications of using human embryos to obtain stem cells.
• Embryos are grown in the lab, in-vitro fertilization left overs and from abortions.
• Congress has banned all federal funding of stem cell research
• The FDA has little jurisdiction over embryonic research
• States have widely opposing views
• The ban on stem cell research was lifted in 2009
• Research using stem cells from sources other than embryos is less controversial.
• Some fear there are dangers of starting a practice that is ethically questionable
• Exhaust all other channels for correcting the situation within the organization
• Have documented evidence that would convince an impartial and reasonable observer.
• Have a good reason to believe that by “blowing the whistle” and going public the necessary changes will be made to prevent harm and injury.
► Anonymous complaints can be made to reulatory agencies like the EPA or OSHA.
►The Occupational Safety and Health Act of 1970, the Solid Waste Disposal Act and the FDA prohibits retaliation against an employee who files a complaint with them. Federal workers are protected from losing their jobs.
►Whisteblowing is used as a last resort when all other methods for warning about a dangerous situation have failed.
• Illness has been linked to 50 percent of all personal bankruptcies in the U.S. Often the person starts out owning a home and having health insurance, but once they get sick and can no longer work, they lose their health insurance and then their homes. With out a law to protect them, they may be denied new insurance because of their preexisting condition.
• Physicians no longer provide as much free care as they used to.
• Medical office personnel must treat all patients with the same consideration for the patient’s dignity no matter what their ability to pay.
• Another cause of rising medical cost is the physicians need to practice defensive medicine to avoid potential lawsuits.
• Rationing of medical resources to keep costs down but often makes patients unhappy
Health Reform 3590
• A provision that allows individuals who already have healthcare coverage to retain their coverage if desired
• A provision also applies to employers who currently offer coverage.
• Patients who are not eligible under Medicare and Medicaid will be required to maintain minimum coverage beginning after 2013. There will be a fine for failing to retain coverage.
• A tax credit and reduced cost sharing, on a sliding scale, for qualified individuals.
• An expansion of Medicaid
• The act does not require employers to provide healthcare coverage, However, if they do not, they may be liable for an additional tax.
• Hospitals would be required to conduct periodic community health needs assessments.