Workplace Bullying and Its Cost to the Urgent Care Operation

™ MARCH 2012 VOLUME 6, NUMBER 6

THE JOURNAL OF URGENT CARE MEDICINE® www.jucm.com | T h e O f f i c i a l P u b l i c a t i o n o f t h e UCAOA and UCCOP

Also in this issue Practice Management 15 Buy or Lease Your Next Urgent Care Site? 22 Workplace Bullying and its Costs to the Urgent Care Operation Case Report 28 When Serious Pathology Masquerades as a Minor Injury PUBLICATION BRAVEHEART A ™

The Official Publication of the UCAOA and UCCOP March 2012

VOLUME 6, NUMBER 6

CLINICAL 9 Ureterolithiasis: Leaving No Stone Unturned Symptoms from stones in the ureter can mimic other conditions, making for a diagnostic dilemma in urgent care. Imaging is the key to accurate assessment and appropriate treatment. William Gluckman, DO, MBA, FACEP and Kate Aberger, MD

PRACTICE MANAGEMENT IN THE NEXT ISSUE OF JUCM Urinary tract infections (UTIs) are common in chil- Buy or Lease Your Next dren and a major source of morbidity. UTIs that 15 involve the kidney are of particular concern Urgent Care Site? because they can lead to permanent renal scarring After location, how to pay for an urgent care site is crucial in children. Next month’s cover story looks at the to your success. Here’s how to think it through. challenge of accurately diagnosing UTI in infants and children in the urgent care setting who may Michael Zelnik, CCIM not be able to communicate symptoms. We review methods of urinalysis, options for treatment, red flags for high-risk patients, indications for referral, 22 Workplace Bullying and its and considerations for special populations. Costs to the Urgent Care Operation 7 From the UCAOA More than one third of U.S. employees say they have been bullied in the workplace. Does your practice have a Executive Director policy in place to thwart this insidious problem? If not, it should. DEPARTMENT Alan A. Ayers, MBA, MAcc 19 Abstracts in Urgent Care 26 Health Law CASE REPORT 31 Insights in Images: 28 When Serious Pathology Clinical Challenges Masquerades as a Minor 35 Coding Q&A Injury 40 Developing Data The patient punctured his hand with a power screwdriver. CLASSIFIEDS It turned out to be the least of his problems. Frank Fannin, MD, EMT-P 37 Career Opportunities

www.jucm.com JUCM The Journal of Urgent Care Medicine | March 2012 3 JUCM EDITOR-IN-CHIEF Lee A. Resnick, MD Case Western Reserve University Department of Family Medicine EDITOR-IN-CHIEF Institute of Urgent Care Medicine Lee A. Resnick, MD [email protected] JUCM EDITORIAL BOARD JUCM ADVISORY BOARD EDITOR Judith Orvos, ELS Michelle H. Biros, MD, MS Jeffrey P. Collins, MD, MA [email protected] Harvard Medical School; University of Minnesota CONTRIBUTING EDITORS Massachusetts General Hospital Kenneth V. Iserson, MD, MBA, FACEP, Nahum Kovalski, BSc, MDCM Tanise Edwards, MD, FAAEM FAAEM John Shufeldt, MD, JD, MBA, FACEP Author/editor (Urgent Care Medicine) The University of Arizona David Stern, MD, CPC Gary M. Klein, MD, MPH, MBA, CHS-V, William Gluckman, DO, MBA, FACEP, CPE, CPC MANAGER, DIGITAL CONTENT FAADM Brandon Napolitano FastER Urgent Care mEDhealth advisors [email protected] Nahum Kovalski, BSc, MDCM Benson S. Munger, PhD ART DIRECTOR Terem Emergency Medical Centers The University of Arizona Tom DePrenda [email protected] Peter Lamelas, MD, MBA, FACEP, FAAEP Emory Petrack, MD, FAAP MD Now Urgent Care Medical Centers, Inc. Petrack Consulting, Inc.; Melvin Lee, MD Fairview Hospital Urgent Cares of America; Hillcrest Hospital Raleigh Urgent Care Networks Cleveland, OH 120 N. Central Avenue, Ste 1N Ramsey, NJ 07446 Genevieve M. Messick, MD Peter Rosen, MD Immediate Health Associates Harvard Medical School PUBLISHERS Peter Murphy Marc R. Salzberg, MD, FACEP David Rosenberg, MD, MPH University Hospitals Medical Practices [email protected] Stat Health Immediate Medical Care, PC Case Western Reserve University (201) 529-4020 John Shufeldt, MD, JD, MBA, FACEP School of Medicine Stuart Williams Shufeldt Consulting [email protected] Martin A. Samuels, MD, DSc (hon), FAAN, (201) 529-4004 Joseph Toscano, MD MACP San Ramon (CA) Regional Medical Center Harvard Medical School Classified and Recruitment Advertising Russell Johns Associates, LLC Urgent Care Center, Palo Alto (CA) Medical Kurt C. Stange, MD, PhD [email protected] Foundation Case Western Reserve University (800) 237-9851 Mark D. Wright, MD Robin M. Weinick, PhD Mission Statement The University of Arizona RAND JUCM The Journal of Urgent Care Medicine supports the evolution of urgent care medicine by creating content that addresses both the clinical practice of urgent care medicine and the practice man- UCAOA BOARD OF DIRECTORS agement challenges of keeping pace with an ever-changing health- Marc R. Salzberg, MD, FACEP, President care marketplace. As the Official Publication of the Urgent Care Association of America, JUCM seeks to provide a forum for the Nathan Newman, MD, FAAFP, Vice President exchange of ideas and to expand on the core competencies of urgent care medicine as they apply to physicians, physician assistants, Cindi Lang, RN, MS, Secretary and nurse practitioners. Laurel Stoimenoff, Treasurer JUCM The Journal of Urgent Care Medicine (JUCM) makes every effort to select authors who are knowledgeable in their fields. Howev- William Gluckman, DO, MBA, FACEP, CPE, CPC, Director er, JUCM does not warrant the expertise of any author in a par- Jimmy Hoppers, MD, Director ticular field, nor is it responsible for any statements by such authors. The opinions expressed in the articles and columns are those of Robert R. Kimball, MD, FCFP, Director the authors, do not imply endorsement of advertised products, and do not necessarily reflect the opinions or recommendations Don Dillahunty, DO, MPH, Director of Braveheart Publishing or the editors and staff of JUCM. Any pro- Roger Hicks, MD, Director cedures, medications, or other courses of diagnosis or treatment discussed or suggested by authors should not be used by clinicians Peter Lamelas, MD, MBA, Director without evaluation of their patients’ conditions and possible con- Steve Sellars, MBA, Director traindications or dangers in use, review of any applicable manu- facturer’s product information, and comparison with the recom- Lou Ellen Horwitz, MA, Executive Director mendations of other authorities. JUCM (ISSN 1938-002X) printed edition is published monthly except for August for $50.00 by Braveheart Group LLC, 120 N. Central JUCM The Journal of Urgent Care Medicine (www.jucm.com) is published through a partnership Avenue, Ste 1N, Ramsey NJ 07446. Periodical postage paid at Mah- between Braveheart Publishing (www.braveheart-group.com) and the Urgent Care Association of wah, NJ and at additional mailing offices. POSTMASTER: Send address changes to Braveheart Group LLC, 120 N. Central Avenue, America (www.ucaoa.org). Ste 1N, Ramsey, NJ 07446.

4 JUCM The Journal of Urgent Care Medicine | March 2012 www.jucm.com JUCM CONTRIBUTORS

reterolithiasis, or stones in the ureter, is a common cause of flank and abdom- inal pain that can be debilitating. Some 7% of adult females in the United UStates and 12% of adult men will develop stones at some time in their lives, and prevalence is rising. In our cover story this month, William Gluckman, DO, MBA, FACEP and Kate Aberger, MD, look at the etiology of stone formation, options for imaging, and ways to tailor treatment based on stone composition. Dr. Gluckman is President & CEO of FastER Urgent Care, Morris Plains, New Jersey, and a member of the JUCM editorial board. Dr. Aberger is an attend- The low cost provider of ing physician in the Department of Emergency Medicine at St. Joseph’s Regional Medical Center in Paterson, New Jersey, and at FastER Urgent Care in Mor- ris Plains, New Jersey - Low cost interpretations Hand injuries are common in urgent care, and in this month’s Case Report, Frank Fannin, MD EMT-P, reminds us how impor- - All modalities, 365 days, in tant a thorough, focused assessment is for these patients. The 50 states history can have a significant impact on direction of care. In this case, a potentially devastating outcome was avoided because the physician - Stat and routine turnaround took the time to build a complete picture of what happened after the 62-year- times old male punctured his hand. Dr. Fannin is Medical Director of Urgent Care Services at King’s Daughters Medical Center in Ashland, Kentucky. American based and Does your practice have an anti-bullying policy in place? If trained Radiologists. not, it should, according to Alan A. Ayers, MBA, MAcc, author of this month’s first practice management article, on prevent- - Typed reports are faxed ing workplace bullying. More than one-third of U.S. employees and available on-line. say they have been bullied in the workplace and the problem is four times more prevalent than illegal discriminatory harassment. - Reduce your medical Mr. Ayers is Content Advisor to Urgent Care Association of America and malpractice, have your Vice President of Concentra Urgent Care in Dallas Texas, and a frequent con- imaging read by our tributor to JUCM. In our second practice management article, Michael Zelnik, a real estate professional with more than 30 years’ experience, helps you think through the benefits and risks of leasing ver- sus purchasing a property for your practice. There is no right or wrong choice, but there are many factors to consider once you’ve identi- fied a geographic location and before you sign on the dotted line. Mr. Zelnik is President and Founder of the Zelnik Realty Group and the National UC Realty Division in Columbus, Ohio.

Also in this issue: John Shufeldt, MD, JD, MBA, FACEP, describes how to spot a “cancer” before it spreads. He’s not talking about a life-threatening disease in his Health Law column. Rather, Dr. Shulfeldt is referring to the “bad hire” that you need to avoid. Nahum Kovalski, BSc, MDCM, reviews new abstracts on current litera- ture germane to the urgent care clinician. In Coding Q&A, David Stern, MD, CPC, discusses codes for incision and drainage, R-codes and POS 20, and coding for a compression bandage. To get started, call today Our Developing Data end piece this month looks at patient flow according to average visits per month and per shift per day. ■ 480-339-5007 www.UrgentRad.com JUCM The Journal of Urgent Care Medicine | March 2012 5 [email protected] Practice Management Workplace Bullying and its Costs to the Urgent Care Operation

Urgent message: More than one third of U.S. employees say they have been bullied in the workplace. Does your practice have a policy in place to thwart this insidious problem? If not, it should.

ALAN A. AYERS, MBA, MACC

What is the Difference Between Diversity and Tolerance? ccording to one definition, diversity is anything that makes you different while tolerance is not persecuting peo- A ple who are different. Many urgent care operators strive for a unified team focused on building the practice and delivering an outstanding patient experience. An array of experiences, perspectives, and talents should thus strengthen their organizations. Yet in many work- places, honest, respectful communication gives way to politics, game playing, and power grabs, with the resulting behavior being “workplace bullying.” If you think that workplace bullying isn’t relevant to your urgent care operation, consider these facts: Ⅲ 37% of the U.S. workforce—54 million Ameri- cans—report repeated abusive behavior at work. Ⅲ 41% of Americans say they have been psycholog- ically harassed at work. Ⅲ 50% of all workers have missed time from work

because of harassing behavior directed at them. © Corbis.com Ⅲ 70% to 80% of Americans report recurring rudeness and incivility at work. Ⅲ 82% of individuals targeted for workplace harassment leave their jobs. Ⅲ Workplace bullying is four times more prevalent Alan A. Ayers is Content Advisor to Urgent Care Association of America than illegal discriminatory harassment. and Vice President of Concentra Urgent Care in Dallas, Texas. A frequent contributor to JUCM, his last article was Motivate Your Front-Line Staff Sources: Waitt Institute for Violence Prevention, American Psychological With Enlightened Leadership (January 2012) and is posted on the JUCM Association, the University of Manitoba, and National Institute for Occu- website. pational Safety and Health.

22 JUCM The Journal of Urgent Care Medicine | March 2012 www.jucm.com WORKPLACE BULLYING AND ITS COSTS TO THE URGENT CARE OPERATION

Table 1. Examples of Workplace Bullying • Intimidating a person through stated or implied threats. Who are Bullies and Their Targets? • Spreading malicious rumors or gossip that is not true. The vast majority of workplace bullies are • Excluding or isolating someone socially, such as routinely not including bosses (managers, supervisors and medical an individual for company events. directors) who are competitive and driven but • Being short, curt, or impatient with the intention of limiting lack emotional security. Bullies crave power communication. and control, have a sense of superiority due to • Undermining or deliberately impeding a person’s work, such as moving position but are often unsure of their own items around, “misplacing” documents, etc. abilities, resent the successes of others, and • Physically abusing, threatening abuse, or appearing to want to commit above all are threatened by a co-worker’s or abuse. employee’s show of independence. • Establishing impossible deadlines or requirements that will set up the While one might believe that the targets of person to fail. workplace bullying are the same as school- • Withholding training, resources, or time to develop the skills necessary to yard bullying—those who are loners, weak- complete a task. lings, or physically different—actually quite • Withholding information, omitting from important meetings, or giving the opposite is true. Targets tend to be the out wrong information. most skilled individual in a workgroup—the • Yelling, speaking sarcastically, or using profanity. “go to” people whose promotion, special • Critiquing a person persistently, either one-on-one or in front of others. recognition, or confidence create envy in • Making accusations of incompetence, despite a history of objective bullying supervisors. excellence. Moreover, targets typically refuse to be • Blocking applications for an individual’s training, transfers or promotions. subservient. This causes a problem for the • Enforcing “policies” inconsistently and creating multiple performance bully who seeks to separate vulnerable indi- standards that hold one person accountable but not others. viduals from the group and make them feel • Taking credit for someone else’s work. bad. When targets take steps to preserve their dignity—their right to be treated with Adapted from “Bullying vs. Harassment: Understanding the Physiological, Neurological and Strategic respect—bullies escalate their campaigns of Costs,” Scott Warrick, JD, 2011. hatred and intimidation, gossiping and cliquishness, to wrest control of the target’s work using shame, humiliation, and domi- Odds are workplace bullying has either occurred or neering behavior. has the potential to occur in your operation and the Rarely can bullies be effective on their own—they results can be devastating to employees, patients, and need the help of others in isolating a target and perpet- the long-term success of your practice. uating the bullying cycle. That’s why bully supervisors use other employees (called “cronies”) who will support What is Workplace Bullying? and build a positive image that the boss is actually a Workplace bullying is a form of repeated aggression by capable, compassionate leader and that the target someone or more “perpetrators” upon one or more “tar- how “deserves” the treatment received. gets.” Bullying is most often hierarchal (between a supervisor and employee) but can also be lateral (among Impact of Power Differentials in Urgent Care co-workers) and the bully’s actions can be obvious or Medical practices such as urgent care centers are partic- subtle, verbal or non-verbal .1 Bullying is driven by the ularly susceptible to bullying behavior because of their perpetrator’s need to control the targeted individual, hierarchical structure of authority. Not only does aca- perpetrators typically co-opt others (either voluntarily demic medical training reinforce a “survival of the or through coercion) in the bullying behavior, and the fittest” mindset—up to 70% of medical students expe- bully’s personal agenda takes precedence over actual rience workplace bullying while in medical school—it’s work and undermines legitimate business goals. Bully- also well established that senior nurses frequently “break ing manifests in the workplace as verbal abuse, offensive in” junior staff members.2 Of particular sensitivity to conduct or behavior, and work interference (sabotage). urgent care operators is the power differential between Table 1 provides some common examples. medical doctors and front-line staff:

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Table 2. How Workplace Bullying Creates an “Unhealthy” Workplace ple of a hospital patient who witnessed one • Increased stress resulting in increased absenteeism and turnover nurse insult another while administering med- • Increased body weight, incidence of heart disease and other ailments ication. The patient became afraid the nurse contributing to higher health care costs would retaliate if he complained about the inci- • Increased costs for recruiting, onboarding, and training dent, knowing that he would be returning for • Increased costs for employee assistance programs (EAPs) more treatments and had previously experi- • Increased risk of accidents/incidents enced a stressed-out nurse improperly inserting • Decreased productivity and motivation a needle. In this situation, not only was work- • Decreased morale and employee engagement place bullying taking place but it actually • Decreased customer service and diminished patient experience caused the patient to experience feelings sim- 3 • Decreased brand image, patient loyalty, and word-of-mouth referrals ilar to a target of workplace bullying.

Adapted from www.workplacebullying.org/2009/05/04/workplace-bullying-psychological-violence and How Does Workplace Bullying Affect other sources. Employees? Workplace bullying is very damaging because of its repetitive nature, with the aver- Ⅲ Medical doctors frequently earn 10 times the pay age duration of abuse being about 22 months.4 This of front-line staff. means that for a long period of time, targets, co-work- Ⅲ Medical doctors have significantly more education ers, and patients witness abuse, which leads to an over- than their team members. all unhealthy workplace. Ⅲ The doctor must approve all patient care and is Victims of repeated abusive behavior experience feel- thus the “final authority” (bottleneck) in service ings that include shock, anger, helplessness, and vulner- delivery. ability, as well as inability to sleep, loss of appetite, Ⅲ Medical doctors have greater social prestige, credibil- headaches, and general anxiety related to work. Longer- ity, and respect from the outside. term, workplace bullying leads to the same health consequences as post traumatic stress syndrome—including These discrepancies can create an environment in heart disease, weight gain, and diminished cognitive which employees are afraid to question, clarify, or cor- capacity. The target’s feelings of frustration often are rect a physician’s request. Patient safety is severely brought home, affecting enjoyment of family and social affected by workplace bullying as almost half of all relationships. Victims become withdrawn, take frequent medical support staff surveyed by the Institute for Safe or extended leaves of absence from work, quit their jobs, Medication Practices said they would rather keep silent or in the most severe cases—commit workplace violence than confront a hostile physician.3 Bullying compro- or suicide. mises the ability of workers to function as a team, As illustrated in Table 2, workplace bullying not only diminishes the quality of patient care, and unnecessar- has a direct negative effect on the target but it also has ily risks patient wellbeing—which could contribute to a negative effect on the overall operation. Job turnover malpractice lawsuits even further raising the costs of bul- can cost 100% to 150% of an employee’s annual salary lying in the workplace. as a result of expenses related to recruiting, onboarding Workplace bullying affects patients in the health care and training, service delivery disruption, and the loss of setting as attention shifts from delivering services to intellectual capital to competitors. Costs for existing worrying about how one fits in with co-workers, the employees escalate as absenteeism and health insurance value placed on one’s job by superiors, whether one is claims increase and productivity and morale decrease. compensated or evaluated fairly, and one’s future within Because patients are able to notice changes in employ- or outside the organization. This means when bullying ees, the practice’s image also suffers—reducing the like- is present, not only does a charge entry specialist have lihood of repeat business and positive word-of-mouth. to worry about accurately coding the patient visit, but Managers need to know exactly what’s occurring on she has to worry whether her boss will berate her work the operation’s front-line, but witnesses to workplace bul- or he/she is gossiping about her in the break room. lying start avoiding abusive bosses and forego any com- Even worse is when bullying behavior occurs in the munication that may bring a “shoot the messenger” open—within view of patients. One study cited an exam- response. To avoid standing out—and becoming targets

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themselves—employees buy-in to a “yes Table 3. Typical Employer’s Response man” culture that questions nothing and There is little a target can do to stand up to the bully on their own. Yet, agrees to everything regardless of how detri- sadly, the most common response of employers is that they ignore the mental to the organization’s long-term success. problem. That could be because 40% of bullied employees never report it Managers begin to lose touch with the day-to- to their employers and only 3% file lawsuits. day business, leading to decisions made based • Everything the bully does is arbitrary and capricious, working a personal upon incomplete or inaccurate information. agenda that undermines the employer’s legitimate business interests. • “Bullying” is never called such—to avoid offending the sensibilities of What Can Urgent Care Operators Do? those who have made the bullying possible—but instead euphemisms While 37% of those in the U.S. workforce intended to trivialize the bullying and its impact are used (including claim to have been victims of workplace bul- incivility, disrespect, difficult people, personality conflict, negative lying and to have reported the incident, conduct, and ill treatment). studies show that 62% of employers ignore • Human Resources tells the target that the harassment isn’t illegal and 5 these complaints. One of the likely reasons that the target and perpetrator will have to “work it out between is that employers do not know how to themselves.” respond. While bullying is “harassment”— • Everyone—co-workers, senior bosses, HR—agree (orally, in person) that unless it’s motivated by a legally protected the bully is a jerk, but there is nothing they will do about it (and later, status such as race, religion, national origin, when the target asks for their support, they deny having agreed with sex, veterans status or physical disability in him/her.) which case it becomes a civil rights issue— • The target’s request to transfer to an open position under another boss there is currently no federal law concerning is mysteriously denied. workplace bullying. Likewise, while 21 states • Employees eventually leave on their own, are forced out of their have proposed anti-bullying bills since 2003, positions through unjust and manipulated performance appraisals, or 6 none have yet to be enacted into law. resort to workplace violence. Targets who tell their stories often face dis- belief from co-workers, bosses, and Human Adapted from How to Bust the Office Bully: Eight Tactics for Explaining Workplace Abuse to Decision- Resources managers, who assume the abuse is Makers; Sarah J. Tracy, Jess K. Aberts, and Kendra Dyanne Rivera; Project for Wellness and Work-Life at Arizona State University, January, 2007. “petty” or that the target is just a “problem employee.” Many targets are actually blamed for their situations, and because being angry, sad or fear- witness to bullying behavior that they have a responsi- ful is simply “not allowed” at work, targets feel impris- bility to express their views and concerns. oned, powerless, heartbroken, and confused (Table 3). Having an anti-bullying policy on the books will not Therefore, it is currently up to employers to recognize the completely prevent a workplace bullying situation but importance of creating a bully-free environment and estab- acknowledging a problem exists will improve overall lishing an anti-bullying policy. communication and circumvent some of the negative An urgent care operation’s anti-bullying policy should consequences of workplace harassment. clearly define what bullying is and give examples of References workplace bullying. One way to determine if particular 1. Workplace Bullying Institute. http://www.workplacebullying.org. Accessed January 30, 2012. behavior would be considered workplace bullying is to 2. Stokowski LA. A Matter of Respect and Dignity: Bullying in the Nursing Profession. Med- use the “reasonable person” test. Would most people scape. http://www.medscape.com/viewarticle/729474. Published September 2010. Accessed January 30, 2012. consider the behavior/actions inappropriate? 3. Vanderstar ES. Symposium on Workplace Bullying: Workplace Bullying in the Health- The policy should list the consequences of instigating care Professions. Journal of Employee Rights and Employer Policy. 2004. Chicago; Kent Col- lege of Law. or contributing to workplace bullying as well as the 4, Pappas S. Your Bullying Boss May be Slowly Killing You., Live Science. January 12, 2012. responsibilities of both management and employees in http://today.msnbc.msn.com/id/45973010/ns/today-money. Accessed January 30, 2012. 5. Tracy SJ, Aberts JK, Rivera KD. How to Bust the Office Bully: Eight Tactics for Explain- taking corrective action. Everyone should sign an ing Workplace Abuse to Decision-Makers. Project for Wellness and Work-Life at Arizona acknowledgement form stating that they have been State University. January, 2007. http://humancommunication.clas.asu.edu/files/Howto- BusttheOfficeBully.pdf Accessed January 30, 2012. made aware of the policy, will abide by its zero-tolerance 6. Healthy Workplace Campaign. http://www.healthyworkplacebill.com. Accessed January standard, and understand that if they are a target of or 30, 2012.

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