1. ESRD Network 6 5 Diamond Patient Safety Program Taking Time Out: Working with Non-Compliant Patients Updated 2/5/09

2. Objectives Identify the problem of non-compliance in the dialysis unit Specify the causes for non-compliance Identify interventions to address non- compliance

3. What is Non-Compliance? Failure to conform - failure of a competent adult patient and/or staff member to adhere to the policies and procedures of the facility

5. Involuntary Discharge Survey Network 5 - 74% of discharges due to non-compliance; nationally 49% Federal regulations Ethical considerations

6. Reasons for Non-Compliance Medical problems Technical problems Life task Transportation Patient decisions Women - skip more because of technical problems Men, younger, HTN - skip more because of life tasks African Americans skip more because of transportation problems

7. Reasons for Non-Compliance Psychiatric conditions Hostility toward authority Depression and memory impairment Financial problems Impaired mobility Language/ethnic barriers

8. Prevention of Non-Compliance Communication –Active listening –“I”statements –Non-judgmental Set limits Be consistent Offer positive choices Empower - let patients own the problem Taking care of yourself

9. Prevention of Non-Compliance Staff education Appropriate use of staff Develop written policy and follow consistently Establish a committee to review difficult cases Ongoing CQI with use of QAPI Work to eliminate discomforts caused by dialysis

10. Reactions to Non-Compliance Team –CQI/QAPI –Quantify the problem –Identify a staff person whom patient trusts Determine if a clinical problem contributes to the behavior Assess whether or not patient understands the consequences of non-compliance Identify barriers

11. Reactions to Non-Compliance Patient –Involve patient and family Clear up any differences in expectations, review Rights and Responsibilities Directly ask patient the reason for non-compliance, Externalize the problem - focus on the behavior Identify any changes that have occurred in patient’s environment –Clinical –Psychological/psychiatric

12. Reactions to Non-Compliance –Identify Barriers Patient’s ability to understand Socially isolated Potential psychiatric diagnosis or substance abuse Financial problems Employment Inappropriate treatment modality –Home care –Self-care –Withdrawal

13. Reactions to Non-Compliance Other things to consider: –Offer peer counseling –Send letter of concern –Refer to an ethics committee –Refer to Adult Protective Services –Behavior agreement Mutual Consequences Realistic