Addressing management issues

Drawing blood without orders from a physician, and
helping the hearing impaired in your audiences

Drawing blood without orders
from a physician

Q:
We have a practice in our lab of drawing patients who have no orders from their physician and holding the blood until we do get an order. This is a rural hospital. Some of our patients travel a long way to get here, only to find that their doctor has not sent the orders. Is this an acceptable practice, or should we discontinue doing this?

A:
There are some differences in the
panelists advice about how to handle this challenge. Each panelist reminds you, however, to make certain that you are following the federal, state and local laws that apply to your facility regarding this issue.

Larry Crolla advises, The answer really depends upon state regulations. Some states allow direct access, in which a patient can order his own tests, while other states say, with the power of the law, that only an authorized person (authorized by the law in that state) can order tests. In your situation, the pathologist, if he is agreeable, can order the tests to possibly fulfill the legal issues until you get the order. You can also call the patients physician and get the order faxed to you. I think for patient satisfaction, you need to find a solution that allows you to draw the blood and run the tests.

According to Alton Sturtevant, This seems to fall under the category of good customer service, but should be reviewed for compliance with hospital policy, state and federal regulations and the hospitals accrediting body. Review of the College of American Pathologists website did not reveal a specific answer to the question using the query of physician orders. It did, however, state all specimens should be accompanied by a valid requisition, including the following information:

• adequate patient identification information (for example, name, registration number and location, or a unique confidential specimen code, if an alternative audit trail exists);
• name and address (if different than the receiving laboratory) of physician or legally authorized person ordering the test;
• tests or assays requested;
• time and date of specimen collection, when appropriate;
• source of specimen, when appropriate; and
• clinical information, when appropriate.

The Office of the Inspector General stipulates that each laboratory must have written policies, procedures and standards of conduct.

Dr. Sturtevant adds, It is clear from the above that you must have written procedures for standards of conduct and orders from an appropriately authorized person before you can perform tests on a patient. I cannot find a general prohibition for collecting specimens that anticipate the physicians orders. You would be on firmer ground to have a written hospital policy to permit you to perform this procedure that allows for proper collection and preservation of the patients specimen(s). There are practical matters that may prevent you from providing this service with assurance that you will always be providing good service to your patients and medical staff. They include considerations of patient preparation (i.e., fasting, proper specimens for all test orders, correct collection of an Advanced Beneficiary Notification from patients, etc.). Your facility should give you its final guidance with regard to this service to ensure that all parties are served properly.

Marti Bailey points out, Unless your state allows patients to order laboratory tests on themselves, you are really putting your hospital at risk. If you have no test order, then you certainly do not have any diagnosis information, all of which is needed in order to bill Medicare appropriately. So, if your hospital or office receives federal dollars because of participation in the Medicare program, the fact that you are not following Medicares billing guidelines puts you in a very risky position, indeed. I understand the need and desire to provide good patient care, but the fact is that no one can afford to ignore state laws or payer regulations to prevent inconvenience to patients and physicians. The truth is that as long as we allow physicians and patients to receive services without the documentation required by law and by our payers, things are never going to get better. The longer we persist in this service-at-any-cost mentality, your hospitals or offices loss due to unbillable services will continue to grow.

Ms. Bailey recommends, I hate to advise you to persist in this risky practice even one day longer, but since it has been your policy, I feel that you need to give advance warning to both your patients and ordering physicians. Post a large notice in your blood-collection area advising patients that as of a specific date, blood will no longer be collected without an order. For any patients who come to your lab with no order in the interim, be sure to point out the new policy to them specifically. In addition, call the office of any referring physicians who fail to give an order to patients who come to you for collection, and let them know of the policy, as well. After the new policy takes effect, make an effort to call physicians offices and try to get them to fax an order if you do not receive one. If you cannot get one, then do not provide services for something that you do not have an order to do.

Bottom line. Make certain that you are following the federal, state and local laws that apply to your facility. Then apply the best customer service you can to keep from inconveniencing the patients and physicians. This is another opportunity to think outside the box in order to provide great customer service.

Helping hearing impaired
in your audiences

Q:
I have recently found that some of the people in my continuing education sessions at the hospital and patient diabetes education sessions are hearing impaired. Any suggestions from the panel about how to make my sessions heard by the hearing impaired?

A:
There are numerous things you
can do to address this opportunity to meet the needs of your customer. Arrange to have several reserved signs for seats up front for the hearing impaired. Ask the person in charge of the meeting to seat the hearing impaired in the front seats upon arrival. Now, the focus is off of trying to deal with them during your presentation. Consider using these practical tips:

• If you are not using a handout, give them a copy of your notes or outline before you start the session. This will assist them in following the proceedings.
• Repeat important points.
• If you can identify a person who is having trouble hearing, stand closer to him while speaking.
• Do not talk with your back to the audience because those with impaired hearing use lip reading as a coping strategy.
• Speak a little slower. The faster you speak, the more difficult it is for the hearing impaired to understand you.
• During the break, ask the person if he would like to sit up front so he can hear you.