CLOSURE - the biggest missed opportunity for Risk Manangement, Patient Safety and Public Relations

Most discussions about risk management tend to focus on specific high risk scenarios, i.e.  chest pain, abdominal pain, missed foreign bodies, shift change confusion and similar fairly well identified risk scenarios. There are many sources that identify those scenarios and the physician or provider would be well served to be familiar best practices in handling those scenarios. But those articles and sources will focus on competent care as the cornerstone of risk avoidance. The importance of compassion and empathy will often also gain mention. 

Closure 3 C's stool

This discussion is more generic and applies to almost all patient encounters of patients who are discharged and many or most admitted patients. It will focus on what is often a tiny portion of the total time devoted to the patient's care, yet I maintain it is just as important. I will refer to this as "closure" and focus on appropriate closure, those last few minutes with the patient,  as the final common pathway to patient satisfaction, minimization of complaints and substantial risk reduction.

As a Department Chief in a medium sized community hospital for twenty-plus years, I was responsible for dealing with all manner of complaints or perceived lapses in standards of care. I was also involved, at least peripherally, in almost all legal and malpractice issues or complaints. Over those years, one of the most glaring facts confronting me was that almost every complaint I answered could have been adequately addressed, usually resulting in a satisfied patient (or parent or caregiver) with the investment of sufficient time and education. Rarely was there any deficiency in the medical care provided. What was missing was a similar investment of time and effort by the treating physician at the time of the visit. In a few cases, lawsuits were filed and although they were dropped during discovery, they represented substantial avoidable cost to the group. 

Even in the high risk scenarios already noted, missed diagnoses and inappropriate discharges can often be associated with satisfactory outcomes and legal action avoided with proper closure.

Many providers may read the preceding and think that appropriate closure is synonymous with, or fully accomplished by the provision of comprehensive discharge instructions. While good discharge instructions are important, they are insufficient as a substitute for proper closure.

At this point, it would be appropriate to look at the characteristics of a provider-patient interaction that encompasses optimal closure. Each will be discussed in detail.

  • The physician MUST clearly understand the expectations of the patient
  • The physician establishes and reinforces their role as the patient's advocate
  • The physician MUST address, in some manner, ALL of the patient concerns.
  • The physician MUST assure that all the issues of medical concern to the physician are discussed with the patient and the physician is satisfied the patient has the necessary level of understanding to assure proper follow up.   
  • The patient has an understanding of all the above issues. 
  • Patient has been given adequate opportunity to ask, and have answered, any and all questions.
  • Written instructions have been provided, that are consistent with the verbal instructions. 
  • The patient is SATISFIED (to a reasonable extent given the scenario)

Implicit from the forgoing description should be the obvious element that is often overlooked. Emergency department processes should be set up in such a way that a final patient-physician face-to-face MUST occur. Further, the physician must develop a very keen sense of reading body language and facial expression because absent in the above discussion is the one major obstacle to simply making policy and enjoying the fruits of your labor. That obstacle is lack of honesty and appropriate communication by the patient. This is not to say that patients deliberately lie to physicians, though they may, but rather that for many reasons patients fail to convey problems, questions, misunderstandings, etc., to physicians. They may not listen carefully, be distracted, be frustrated, feel foolish, overwhelmed, or believe they are too uneducated to bother trying to understand. Regardless, the physician must be able to fluently read: a confused look in their eye, the lack of satisfaction, the sense of being "brushed off" or not taken seriously, or any other concern. Often the single clue to a physician that a patient has unaddressed concerns will be a tentative look by the patient as it becomes apparent that the visit has ended and the physician is about to leave the bedside for the last time. 

Working against the physician will always be a set of uncontrollable factors that should be understood. Patients may have waited for long periods which can lead to frustration and conflict. Poor basic understanding of anatomy, physiology and pathology can make meaningful communication a challenge to a provider unwilling to spend the adequate time and effort providing necessary patient education. Limitations of patient resources, lack of insurance, transportation, or ability to fill prescriptions, can make formulation of a reasonable treatment plan a challenge. Absence of a primary provider to coordinate follow up can be a frequent issue. These are all issues that the patient may face but not openly discuss with the physician. The physician's challenge will be to elucidate and plan for each treatment obstacle.  

Let's examine each of the characteristics of proper closure in more detail.

The physician MUST clearly understand the expectations of the patient

In order to address the patients concerns, the physician must know what they are. Often this requires no more than asking a few simple questions. Most physicians will get a relatively good feel for why the patient has presented to the ED while obtaining the history of the present illness. However, some concerns remain hidden. The patient with abdominal pain may be concerned not just about ruling out appendicitis, but also a cancer similar to what just killed a relative. Parents of febrile children understand less of your concern to rule out serious bacterial infection, and more about your lack of antibiotic use for your final diagnosis of viral infection. The critical issue will the alignment of expectations with outcome. Satisfaction from the patient comes not from your appropriate treatment, but rather from your ability to adjust their expectations so that the treatment plan makes sense to them. 

The physician establishes and reinforces their role as the patient's advocate

Patients expect that the physician is there to help, at least when they arrive. However many visits end with the patient having a very different impression of the physician and their relationship with that physician. Appearing rushed, being unable to pinpoint a diagnosis, struggling with difficult obstacles to follow up, dealing with conditions with poor, or less than optimal, prognoses, can leave a patient feeling like they are bargaining with an adversary rather than conspiring with an ally. It is of critical importance that the physician consciously monitor conversations during closure to assure adversarial feelings do not emerge during the conversation. I have often felt that one of the most important characteristics (apart from competence) of the best physicians is the ability to convey the image of themselves as a "strong patient advocate". It is one thing to be the competent provider of health care that our patients seek, but it raises the physician to a whole new level to be seen as the advocate for the patient, who usually feels limited in their ability to deal with the system. 


The physician MUST address, in some manner, ALL of the patient concerns.

The obvious issue here is the physician must elucidate all the patient concerns if there is to be any hope of addressing them all. Concerns and expectations are closely intertwined, and the same issues and methods apply uncovering and addressing them. An appropriately obtained history of the present illness with open ended questions and adequate opportunity for the patient to convey concerns is only the first step. Appropriate Closure at the time of discharge provides a second opportunity of no less importance in filling in gaps, and developing a full picture with the benefit of new information from the visit, of the patient's needs and concerns. Each and every one should be specifically addressed, even if that only means reassurance that the problem is stable, not imminently dangerous, and more appropriately handled during follow up. 

Examples of patient questions and concerns that can be easily addressed:

“Will my doctor get the records?”: assure the records are forwarded appropriately. Your department should have a process that makes this easy. 

“It takes a month to get an appointment”: your department should have a system in place to assure time sensitive follow up. Perhaps a courtesy call to the physicians office. Perhaps just informing the patient that if they let the doctors office know that it is an ED referral, they will be seen quickly.

“It is getting hard to provide the care my mother needs”: add a social service referral to the disposition

“My doctor always puts me on antibiotics”: Oh you know this one. The proper answer here you need to spend the time to educate the patient (and probably leave the patients physician some “wiggle room” for political reasons). 

The physician MUST assure that all the issues of medical concern to the physician are discussed with the patient and the physician is satisfied the patient has the necessary level of understanding to assure proper follow up.   

Often during a visit, a secondary medical concern may arise. Previously undiagnosed hypertension or diabetes, or an abnormal imaging study requiring follow up are common examples. This is another area that is critical as the patient had no expectations or plans to deal with such an outcome. Historical experience tells us that such problems often do not receive the follow up they deserve. Patients arrive with symptoms of concern and concentrate on those issues. The new issues uncovered by the physician are often asymptomatic and not assigned much importance by the patient. Only the physicians efforts to educate the patient on the importance of the problem will change this and the likelihood of appropriate follow up. 

The patient has an understanding of all the above issues. 

Patient has been given adequate opportunity to ask, and have answered, any and all questions.

Adherence to each of the elements noted provides a solid foundation to build a solid closure. The final element is to assure that all the questions have been answered. Assuming the patient now has the necessary knowledge and understanding, It is reasonable to assume they can ask the appropriate questions and understand the answers. 

Written instructions have been provided, that are CLEAR and consistent with the verbal instructions. 

We spend considerable time educating our patients and arranging follow up. The discharge process also requires provision of written instructions. My personal impression is that many departments have given up trying to conquer this beast and just make do with whatever the hospital has purchased.  There are dozens of computerized discharge systems. Most suffer the same inadequacies. Customization is too cumbersome so patients go home with whatever comes off the printer with minimal changes.  Not infrequently they contain inconsistencies with the verbal instructions. The good news and the bad news here is the same, patients rarely read what we give them. Departments should strive to make instructions simple, straightforward and reliably consistent with practice protocols.  They should also be easily modified to patient needs. 

My own preference for discharge follows a simple formula with 4 specific elements: 

  1. Identify the diagnostic impression; 
  2. Outline the treatment prescribed with a brief rational or explanation as needed. This includes prescriptions, OTC recommendations. Diet & activity limitations or recommendations, wound care instructions, etc.
  3. Emergency precautions. In almost every visit there are some risks of bad outcomes related to inaccurate diagnoses, complications (expected or unexpected), lack of predicted response to treatment, etc. I favor a separately identifiable, clear and highlighted section for each discharge set that considers the possible bad outcomes and specifically identifies those early signs or symptoms, identifiable by the patient, that require immediate follow up. All these issues should have been covered in discussion outlined above. 
  4. The final area to be covered on the discharge instructions is non-emergent or routine follow up. This tells the patient who and where to follow up and what to do should there be any problems arranging the recommended follow up. If you subscribe to the need to disclaimers of any kind, they can also be put here. 

All on one page would be the goal, although additional pages are often necessary for required prescription drug information, secondary instructions, information or referrals. In this situation, it is best if the primary basics can be kept on a single first page. I believe if written instruction would follow this model, the instructions that we deem most important would be more likely to be read and followed. 

The patient is SATISFIED (to a reasonable extent given the scenario)

I add this just as a reminder that the final goal is to discharge a patient who is satisfied and feels positive about the interaction with the physician. A patient who leaves feeling positive is much more likely to be compliant, less likely to blame bad outcomes on the provider and therefore presents much lower risk to all involved. 

The physicians final face-to-face encounter with the patient is the last chance to make everything right. Time spent here will be well rewarded. The busy milieu of the ED, delays in treatment/testing/reporting, and prioritized care to more serious patients, may all have caused the physician-patient relationship to be strained. The physician should summarize the entire visit for the patient and provide appropriate patient education.  Done properly, this becomes the perfect platform to display the care, compassion and supportive advocacy role of the physician. Good medical care is imperative, unfortunately few patients have the ability to judge the true quality of care provided. Managing risk therefore involves assuring BOTH good quality care and a good perception of the physician providing care. 

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