A hidden danger


A hidden danger

Recognizing and reducing the risk of sexual abuse in healthcare settings is a challenge, but one that should not be ignored,writes Michelle Foster Earle, president of OmniSure Consulting Group.

Social service organizations, religious institutions, and schools are very familiar with sexual abuse liability insurance. When making risk and insurance decisions, highly publicized claims such as those involving the Catholic Church, Penn State Coach Jerry Sandusky, and teachers caught up in scandalous relationships with students make it easy for brokers to explain why such protection is necessary.

Schools, youth organizations, and churches are highly trusted institutions focused on equipping and helping people who are in their formative years or who are seeking guidance. That’s why most people are happy to submit to a series of criminal background checks before working with the babies in the nursery at church, leading a group at girls’ camp, or volunteering at a child’s school. No one wants to make it easy for predators to gain access to vulnerable children by way of an influential position in a trusted institution.

Children are not the only ones perceived as easy targets because of their vulnerability and powerlessness. In the past 10 years, attention has turned to the elderly, whose physical limitations, medical conditions, and communication difficulties make them easy targets as well. Not only are nursing homes required to conduct background checks on workers because the elderly are at high risk of being abused, but nursing homes in some states are also required to perform background checks on new or potential clients.

Advocacy groups have created websites dedicated to exposing sexual predators living in long term care settings and to educating consumers about the dangers and signs of potential abuse. It is common for people to check the sex offender registry in their area to protect both children and vulnerable adults.

However, when was the last time you heard of a consumer checking the sex offender registry or asking precautionary questions before seeking medical care at a hospital, medical facility, or clinic? Better yet, when was the last time your healthcare organization took a look at its own policies, procedures, processes, and protocols to prevent sexual abuse and molestation at your facility?

The healthcare setting

What sets the stage for the risk of sexual abuse and liability in a healthcare setting? We can start with patient vulnerability, therapeutic expectations, fiduciary duty of the provider to the patient, imbalance of power, professional boundaries, and professional codes of conduct.

Here are a just a few recent headlines involving sexual abuse or misconduct with patients:

  • A physician is sentenced to 14 years for sexually assaulting patients. 
  • Johns Hopkins Health System offers a $190 million settlement to more than 8,000 women whose bodies may have been videotaped or photographed by a gynecologist using a pen-like camera during pelvic exams. 
  • A top pediatric cancer doctor is sentenced for child pornography.
  • A paramedic admits to sexually assaulting an unconscious woman strapped to a stretcher.
  • A radiology tech performs an unauthorized vaginal exam following a pelvic ultrasound. 
  • An employee describes constant sexual misconduct and assaults at an Arizona state mental hospital. 
  • A dentist is charged with third-degree sexual assault of a 19-year-old patient. 
  • A prison guard is accused of sexually assaulting a female inmate in a hospital room where she was taken to have her appendix removed. 
  • A surgeon slaps sedated patients’ buttocks, uses derogatory terms. 
  • A psychologist calls it touch therapy, but patients call it sexual assault. 

In most of these cases, alleged or actual perpetrators are accused of taking advantage of their positions of power to sexually abuse vulnerable patients who seek medical care and treatment. These scenarios are especially serious in the public’s opinion. Instead of a masked perpetrator armed with a gun, the offenders are trusted professionals wearing medical scrubs or lab coats armed with medical instruments, but the offense can still can cause the kind of harm, pain, and losses that come from other types of assault, and the betrayal of trust and resulting publicity can be much more damaging to an organization’s reputation. 

Manage the risk

According to patient safety and risk management specialists, one of the best things a healthcare organization can do to reduce risk in all areas of patient safety is to implement a strong quality assessment and performance improvement (QAPI) program. Well-run QAPI programs identify and address issues or trends that could adversely affect patient safety, care quality, or security.

As part of the QAPI program, conduct an internal assessment using a checklist or guidelines for assessing and reducing sexual abuse liability risks. Below are a few tips from the Sexual Abuse Liability Risk Assessment Tool developed by OmniSure Consulting Group that will help jumpstart the process.

Assess the patient intake and education process

Some patients are at higher risk than others due to prior victimization, poor boundaries, or risky behavior. Make sure you have established intake and admission criteria specific to the types of services provided at your facility. Assess the patient’s or client’s needs, mental health concerns, and social background for issues related to criminal conduct, likelihood of sexual aggression, or risk of victimization.

Make a written record of capabilities and significant limitations, and outline conditions under which a patient may be discontinued from service or involuntarily discharged. In counseling situations, educate patients about therapeutic boundaries, referencing the appropriate professional code of conduct and making clear some things are never acceptable.

In settings such as mental or behavioral health, assisted living, and youth residential treatment centers, check the sex offender registry for new patients or clients.

Review the employee screening and selection process

Employment applications should not only question whether applicants have ever been convicted of a crime, including physical, sexual, or child abuse, they should also include a self-disclosure statement for sanctions or other issues with licensing or certification boards in any state where the applicant has worked. They should also authorize the organization to complete reference and criminal background checks.

Make sure outsourced agency or independent contractors comply with and duplicate company practices. Ask volunteers to complete a modified application that includes questions about criminal history and sexual misconduct.

Update orientation and training practices

Prior to allowing employees to treat or work with patients, provide orientation programs with training on ethical, clinical, and legal issues surrounding boundary violations and sexual misconduct. Discuss ethics, law, risk factors, vulnerability, accountability, stages of boundary crossing versus boundary violation, warning signs, and examples of slippery slope scenarios. 

Employee handbooks should clearly prohibit unprofessional relationships with clients and outline rules for reporting dual relationships, conflicts of interest, suspicious behavior, compliance concerns, incidents, disruptive physicians or providers, and allegations of abuse.

Require appropriate procedures and supervision

Make sure to establish procedures for patient interactions with clinicians or staff that are supported by applicable guidelines. Staff ratios should comply with federal and state regulations so that all applicable private exams or treatments are supervised or occur in the presence of a chaperone or appropriate observer.

When possible, set up procedures so that unsupervised individual communications of a confidential nature occur in open, visible spaces, or in closed spaces with unobstructed windows in view of others.

Audit documentation

First, inform patients of the nature, risks, and benefits of care and treatment, and gain their consent in writing. Second, take progress notes that document significant interactions arising during or directly related to care, including any deviations from normal practice or boundary crossings.

For example, if during an interaction a patient begins sobbing about the loss of a loved one, a clinician might give the patient a brief hug followed by a hand on his shoulder. Even if the hug were intended simply as a gesture of sympathy, it is not standard practice, and it could potentially be misconstrued by the patient as arising from something other than therapeutic intention.

In cases where a deviation from normal care is therapeutically indicated, be sure to document the clinical reasoning. For example, a patient who begins feeling anxious in the exam room is then walked to the physician’s office to continue a discussion about care.

Improve incident management

For an incident management and complaint resolution process to be effective, the concept known as ‘just culture’ must be openly infused into the culture of the organization. Empower and encourage employees to report incidents and near misses without fear of reprisal.

Punish openly reckless and intentionally harmful behaviors, and encourage staff and volunteers to speak up about disruptive behaviors at every level of authority. Analyze honest mistakes for the opportunity to change systems or processes to prevent harm in the future.

If an allegation of sexual abuse occurs, employees should already know and have acknowledged their requirement to report incidents immediately to the to the appropriate authorities, maintaining the required confidentiality of the patient and involved parties per company procedures. Initiate a prompt investigation following written investigation procedures. 

Measure patient satisfaction and conduct employee exit interviews

An organization that collects patient satisfaction surveys at the time of discharge and follows up on identified concerns can actively solicit information and act on issues before they have had time to escalate. Annual staff satisfaction surveys and exit interviews can also provide an opportunity to address concerns about potential abuse or high-risk behavior.

About Michelle Foster Earle

Michelle Foster Earle is the president of OmniSure Consulting Group, a risk management firm contracted by some of the nation’s leading medical professional liability insurance companies to help medical practices, hospitals, healthcare facilities, and providers of healthcare and social services nationwide reduce risk, improve performance, and avoid lawsuits. She has earned designations in healthcare management, is a licensed General Lines Property and Casualty agent in Texas, and is an Associate in Risk Management. Foster Earle would like to credit Gail Normandin-Carpio, RN, CCHP, for her significant research and contribution to OmniSure’s Sexual Abuse Liability Risk Assessment Tool, from which much of the information in this article is obtained. She can be contacted at michellef@omnisure.com

Further information

American Medical Association’s Code of Medical Ethics

Federation of State Medical Boards. Addressing Sexual Boundaries: Guidelines for State Medical Boards

National Prison Rape Elimination Act (PREA) Resource Center Website (for confinement settings)

Patient Safety and the Just Culture: A Primer for Health Care Executives

National Sex Offender Public Website

OmniSure Consulting Group, Michelle Foster Earle