Breaking the Rules

If you think about it, rule-breaking plays an enormous role in the life and work of a patient advocate.

Rule breaking – is one reason (even if it’s not the only reasons) we exist – a problem we fight. One reason we are hired.

Rule breaking – might be a success tactic – a way to win the fight.

Rule breaking – is one of the major factors that separates private, individual professional advocates from our hospital and insurance counterparts – the distinction that often makes the difference to patient-clients’ outcomes.

Identifying the Rule Breakers

System-employed rule-breakers are those individuals or institutions who violate common sense, expectations, and certainly the health of our clients – broken physical, mental or financial rules, and often the rules of fairness. Whether they have done so intentionally, or by mistake, doesn’t matter. We are called upon to help out when our clients don’t get the medical treatment they need or want, or when their bank accounts and financial security are threatened, perceived or real, by the healthcare system.

If we accept a general definition of rule-breaking to include the rules of fairness and ethics, then it’s easy to see how our very profession of health advocacy is created to stand up to those rule breakers, to help our clients overcome their victimhood. (Sadly – that’s what too many of them are – victims.)

So, then, our working definition: healthcare system employer rule-breakers are those who may violate common sense, expectations, fairness, and ethics to create victims of their customers – their patients.

Fighting the Rule Breakers

Since our jobs as independent, private patient advocates are to successfully fix what the rule breakers have broken, then it follows logically that we must sometimes break the rules ourselves to be successful. Sometimes our best defense of our clients is a good offense with the perpetrators. And that, in a nutshell, is what separates us from those who work directly for the rule-breakers to begin with.

Here I cite the Allegiance Factor: the requirement on the part of any advocate to march to the tune of whoever is paying for his or her services. A hospital advocate works for – the hospital – whose job it is to make a profit, and to cover its own backside (or its doctors, surgeons or other personnel backsides.) The insurance advocate works for – the insurer – whose job it is to make a profit by denying as much care as it can possibly get away with. The private, independent care professional works directly for patient-clients – who come to the independent advocate precisely because the rule breakers are threatening their health and security by violating the rules, or because they fear that possibility.

Need some horror stories to prove the point? Just take a look at some of the hundreds of requests we get each year for help.

The Independent Patient Advocate as Rule Breaker

From medical errors, including misdiagnosis (or failure to diagnose), to imposing expensive treatment options that a patient would never, on her own, choose if she had all the facts, to overtesting and overtreatment, to hospital-acquired infections, to “admitting” patients to the hospital under observation status, to insurance payment denials, outrageous, often erroneous hospital bills – a major reason patients seek out a patient advocate is to help them get past the problems the rule breakers have caused.

So, to the point, sometimes we independent advocates need to circumvent the rules in order to get our patient-clients what they need.

Not only is it OK for us to do that if it gets our clients what they need, I would go so far as to say that in some cases, it’s imperative we break the rules. And if you can’t, then you need to step aside and let someone else take the reins.

A few observations about being the advocate who breaks the rules:

  • Rule-breaking on behalf of a client can look very different, depending on who it is we are advocating for. We all know that we wouldn’t think twice about breaking any rule necessary for one of our children, for example. As professional advocates, we owe it to our clients to take care of their needs by going to the same extreme we would go to for our own children.
  • Being a successful rule-breaker doesn’t require, nor does it call for, bad behavior. The most successful advocate rule-breakers are those who are just as respectful as they skirt the status quo, as they are when they are following the rules. Bad behavior, including yelling, calling names, blaming, or other forms of disrespect, is not only not good for your own practice, but it puts a black eye on our entire profession. Further, it should go without saying, no one is asking you to break the rules by breaking the law.
  • nurse-rulebreakerBased on conversations with hundreds of advocates (and advocate wannabes) sometimes the advocates who have the most difficulty with breaking the rules are those who have worked inside the healthcare system for a long period of time – most notably nurses. Now, I’m sure this statement will dismay some of you nurses – and that is not the intent – because I’m one of your biggest fans. But the typical nurse (not you, perhaps, but you know this nurse) is someone who has learned and executed specific processes, protocols, and sometimes suffered shabby treatment at the hands of other professional co-workers. While inside the system, under those circumstances, it’s often difficult to see the big picture “what needs to be done” forest for the “but I’ve never done it that way before” trees.
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    (I challenge those of you who might not want to admit that predisposition of yours to try to solve problems within the confines you were always expected to solve them before, then to think outside those boxes – to break a few rules to get a client what he/she needs. It will make you feel incredibly powerful!)
  • Rule-breaking doesn’t need to appear to be rule-breaking when it comes to fixing our clients’ difficult situations. Sometimes it requires an end-run (calling a second insurance company representative to get a different answer), or calling in some chips (finding an acquaintance who you’ve helped before who can help you with your client now.) But to the system that is used to patient-lemmings just going along with everything they say, it appears to be rule breaking. They might not like it – but if your client gets what he needs, you shouldn’t care if they like it or not. (Just don’t burn bridges.)
  • Rule-breaking is a great reason to collaborate with other professionals. When you run into a situation with your client that seems unsolvable within the system, you can reach out to other advocates to brainstorm ideas and come up with solutions. You can do this by phone, or by Forum, or by connecting with another advocate through the AdvoConnection Directory. Another advocate will be able to see ideas or ask questions you may not have thought of. Together you can noodle ways to solve your client’s situation – whether or not it breaks the rules.
  • Finally – know that breaking the rules can and will make you a hero, and not just to the client who has hired you. Sometimes providers will be happy you righted the ship, no matter how you did it, because it will untie his/her hands for doing what they know is right for their patients. Of course, your clients will consider your efforts to be heroic when they – finally – get what they need, improving the quality, or length, of their lives.

rulebreaking

What rules have you “broken” for a client? Or what rules have you struggled to break?


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4 thoughts on “Breaking the Rules”

  1. Spot on again! To address your portion of the article that discusses how to interact with “the system” to get results for your client. One of my clients termed my conversations with the staff this way. I explained to the family during my consult, that I identify the issue, approach the staff (typically in a SNF) and let them know I’ve identified an issue and would like to work with them to create a solution. After the first few visits to see my client, a family member approached me and said “I like your ‘ever so pleasant voice’ that you use with the staff.” It is definitely a bit of a dance that needs to happen with the staff to have them work WITH you. Of course every situation is different and produces different results. That said, I have noticed the E.S.P.V. works most of the time. We do break the rules as your article explains. It is being tactful and professional when we break them that gets us results for our client.

  2. I think being a rule breaker has more to do with personality type that the profession we choose. Some people feel more safe with tight boundaries, some like the 50,000 view. Most nurses I know are as unhappy with modern healthcare as I was, but feel stuck in the hospital. I always felt that if I was doing what I was made to do, I would succeed. As an ICU nurse, I almost got fired once for strongly advocating for a patient and that turned out to be a very good thing. It showed me something about modern healthcare that I needed to see and made me mad enough to spend the money and have the courage to go out on my own. It was the best decision I ever made. Sometimes courage comes through the fires of affliction, and we get where we need to be…!

  3. When I was in nursing school in 1973, one of the instructors, Sister Catherine, told us in our first clinical rotation that ‘we had to learn the rules before we begain breaking them’. I agree we ‘break rules’ in cutting through the red tape of the healthcare system, but we need to know what the rules are and why they are in place.

    I agree wtih Sandy’s comment we need to do it with respect. If we go in and cause disruption right off, we are viewed negatively. But if we go in and learn what is happpening and then work to reset expectations we have a better chance of improving things.

  4. Having lived in Europe and worked in European hospitals before coming to USA, I find this post particularly interesting. I have a lot of European clients who live in the USA and are lost in the US healthcare system.
    An added difficulty for them comes from the cultural differences:
    1) in most European cultures (typically in Southern Europe and some Latin American countries but not only), the rules are usually more flexible than in the US (which can also create some chaotic situations sometimes in Europe). It would not be considered a big issue to change the rules or to ask for a change (you could even appear as very rigid for not doing so).
    In some cultures, if you do not tell your management when they do a mistake, it could be seen as being a bad employee (in Switzerland or even more in the Netherlands and Scandinavia). It is usually not the case in US hospitals as stated in the comment by Teri above.
    Also, in some countries, if you don’t get angry when facing a “stubborn” employee, you often dont’ get anywhere (in France for instance).
    It is therefore our everyday job to address this cultural shocks where both parties have to admit that a little flexibility towards the other culture is needed (a usual human reaction being to think that your own culture is doing the things the way it should be).

    USA becomes always more international (it is already the 2nd biggest Spanish speaking country in the world after Mexico and before Spain). These cultural shocks are probably going to be more frequent and patient advocates (especially in international cities and Southern States like Ca, AZ, NM, TX and FL) will probably soon face more and more the kinds of misunderstanding we face everyday.

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