Insurance News http://www.tmgworkcomp.com/blog en Copyright 2021 Texas Medical Group Thu, 30 Dec 2021 21:01:00 GMT Insurance News Live Well, Work Well - January 2022 http://www.tmgworkcomp.com/blog/2021/12/live-well-work-well-january-2022 Thu, 30 Dec 2021 21:01:00 GMT http://www.tmgworkcomp.com/blog/p/63341 Hannah Thomack Live Well Work Well <figure><img src="/images/news/63341/17351/large/Cyber_update_9_.png" data-image="17351" width="750" height="309"></figure><h3>How to Make - and Keep - Your New Year's Resolution</h3> <p>As the new year approaches, you may find yourself reflecting on the past year. This introspection is a significant first step toward selecting a New Year’s resolution to help you grow as a person. However, 80% of New Year’s resolutions fail by mid-February due to a lack of self-discipline, according to U.S. News and World Report. That’s why it’s important to set yourself up for success when you’re choosing a resolution.</p> <figure><img 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K9O6784OckHDh/mDX19RFpv2g55q2hj8LXm5e0d/LtjN/JP8/N8bnJy66ub6vGKph2UaA97NNneAJ85O8Gj9aIiF8NOJnlJUxPvPXiIhJT822M3YozBtSw+cCjNn50+xfNw3nZ0FOHZNh8dG+P9wyPc2tZ22eMuRSEP55ZY8H36U0lub2undYe9da8Eyhjma7UXNZXXxhAZQ8a2GUil6EmlSFoWShuW/BrTnsdS4AMCe7t+M62pCUGuViOb2VvnPeu4a4tLtoIAbCn5x+kpCmHALw8Nc6i5hc+dnWDB97G3kVyvjSE0hqzj8LaBQV7b08M/TE3xjzPTSCG2vLpJiPia7qQln7BHRXTO8/ju/Dz6EhfZTia5Nd3E+0YOriXvri/f1WTb/MtDh/nT06cvKqR/fmaMD4iD3NL64ttQ5HyfPzl9ipnV3NQVwddmZ/nVA0PcfBnb3YmUwpAlv7ZtSzTUmnbX5bU9Pbyss4veZPI866oUhjy9ssz9s3OcLpewt7EE0RgDrst8zedgpnlbY9vpZGx7bcnrVtODBPHz8N2FBSarVX5laJj/eMutfHt+ju8vLLLoxzUppBDnTWk1sXgKoM11eXlHB6/v68dXiv/n+RM8tbKy7eWhCEFSyh1XiWtPiuhyEGCExJgLWzp2MsktqTTvP3iQxEUuStq2+dChQ/zp6VOc5BJCOjLCzS+in0/O9/nwyZPMaYWuW2c6CFi2bf58bJTfP3YjvanUtre7U1n0a3hab8vHFmrNXe3tvHNomK5NXCyrNDsOr+jq5qUdnXx9Zoa/n5pEGbPlJYxCCCYrFUxHx46KAF8uLY6D0CbW0G1+15WS8UqF//bcs9zd2ckb+vp5XW8fo6USzxRWOFupkA8Caiq+d11L0uo47Es3cXNrlsPNLdSU4oG5Wb6zsEA1il7U8mkhBOn6woGdxJ4U0a5kEgcIhNjU2rGTSW5Jp3n/wUNbuiBNts2HDsZCeorNhbQKfHRsjA8Mj2zLclzyff741EnmMFhBwNv6Bwi04oH5eWpRRC2R4Jvzc7x7aHjL29zpzHo1pOtueZVSoDWv7e7h1w4ePG8K6SnFX4+N8arubo6ta3TmSslbBwfpTLh8bHQUxdZqWxqtmfG87VWL2gWkbRvXktSMeVGJ6rYQaOC7Cws8kstxuLmFO9vbeVVXN9kBFwlryfmrbpRyFDFaKvGXY6McLxSoKIUj5ZaLNZ+LEIJ0vcrUTmJvimgiwV0d7TxSrRJWKhv+tjaFP3hwW210M46zNrW/mJB+5MwYH9yikC6tWqAYnDDifYcOc1vdt9qRSPLXk2fRSjFWLmOM2TOW0YxX3fKxhFpze2sbvzoysqkP7my5zLfm51BG055w6XATGwIV93R1Uwwj/mb8zJYCGEZr5r0qgdY7an325ZKwLFKWRe0y2noL6oWbgWcLKzxdiPvSN9s2GduhybYQCKoqohRFlMOQWn0Zp11vHXJZrC75vLytXHH2zl1yDr94YIjDjoOdSmElEliui9OU5tam7QvoKhnH4TcPH+ZIMnnRqP1Hzozy7CWStpd8nz86eZJZDFYQ8r7h4TUBBRjJZEAphJTxw7xHBBRg2vO2FFTSxL68dw4PnSeAlSjik2Nj/MmpkzhS8mAux//2xBP84XPPUjln1dE/6+vj5mwr4Rb2abSmGEV7bh190rJI2fa2V/FtxnpRNEAhDJnyqpwolTheKnK2WmUlCFDEortt3+eF9itlnN60w/J496yIZmyb3zlylF/s6eXGdJrD6Sbe1NbO+w8eelECukpT3Ud6cSHV/NnoaZ65wBLRnO/z4VMnmcdgbyKggdb8w/QUOA5aKe7t7tlxb98Xi681i1uMzEda84rOLvpTGwsna2P4y9FRvjw7TSWKuKGlhZe0tpJ1HAKtz7u+Ugje3N+PJcQl/YFGa3xjWLzO6/mvNBJo2kIRku0iiM+vVY+cr0bttxN13w47bckn7NHp/CqulLyut5fX9fZe0e1mbIcPHTp8UR+pZ9t89MwYv3nwIBLBV3OLvLqtnaGmptgHagxWGPK+kRFuP0dAPz46yhPVKkZr7uvt4+Wde6docCEM4sDfFj7rSLnpsS/UajyxsoyF4LU9Pbx7eASAahRRjqJNp/1Hs1kGUimmPO+SqTmW6zLtedy4zse6F2hxHLiAH3pn2XYX9l9nt7jy6lqyp0X0apJZF2w6zYV9pB9+/nmEEESJBPOlEkkpmQXsMOS9Q8ObCOhpflytIpXi7X19vOmcfve7nQWvhpIyrrR+EbQxdLgJBjdp3xGZOKneEoKxcpmpSoXBpibStn3BBmaOlIxkmpmoVreU3zjtVfeUHxouvH5eEFeW3ylHaoDaJiukjNY7qrfSKg0RvQya14JNFxbSmpRxFf1KhQUpkY6DozXvHRrmjvb2tc8Ga22b4+6kN2UyHG3JoupisVeY8Tzkas7iRdDEhSY2awPRk0xxY0uWHy3nOVkq8Z+feYabW7O8qrubW9vaLygGPRdJjVqP0ZrZ6t6L0Gfd8wXIEEfTf6qra8d00Iy05jvz81SU2nAtjdaN6fxepHld1H4zIT23JqmjDe8bGuaOjo6138d978fW2jYDPF0o8EyxyNHmZt538BDtrntNjudqM1XdWmcAYyBlbx6QcKTkvYcO0TQxzmP5PMUo5KFcjkeXlri3u4dfHRnZNA0mbW/N2tJKsVjzqCpF0w7LSbwcWje5hwTx8tlvzM7uqCm9dY5PVQiBUYqMs/Mka88Glq4lzfWo/aF6FsBmSNvGlZL3DZ8voHHf+9Ja33uEoDuRwGjNmFJ86syZPVNZaMbztrT8UAjw1IUT8ltdlw8dPsL/cfMtvGPffroS8eqlb87P8YPFxU2/422xiIbRmlIUkb9O1favFi2OAxcI6K0Gh3bKz3kIgSslaashonuWjG3zW4cOM+i4G0rqAch6T5j3HhjaMIUP60GkVQtUCIG0be4bGOQPbrmVdw8No4OAE8UC5T1QLLgcReQDf0uReYGgEAR4lzjufU1NvGP/fn776NE16/N0ubzpZ+e3GnE3BmPbzNe8rX1+l5Cx1i39PIfIxAVcdsrPeS87IUha1o5xOaxn541oFzPjeZTOaYwn6hf/1w8McedmU/jKCwIqbJu39vTytnrX0cPNzWitydjOnugyuhwEFMOQrZQdkUKQDwKmq1UOt7Rs+Jsyhu8vLHCgqYme+vr5vO9jTOzj69hkNhBqzVi5vGX/srQsZqoetF/6s7uFJtvGMgbDC9H4VZ/o3e1dl5X6dyUJteZHy/m1RH1Yt1ppB/qpGyJ6BXkkn6OScDHrLBjLdbm9pYWXniugZ8b40bopvLRt3tbby1sHYgFd8n0+MT5O2nH41aHhHbde+MUw61URjgNbqGYviINtjyzlzhPRJd/nE2OjAHQmElhCsOj7eEoxkErxU93d523vZLHI1BYj8xAXI5nyqhi2tlx0N9DkODhSxtXq6+4hQSykZ70qtpBc/2QnsVapa8NvhaDJtnfckk9oiOgV5Q29/aycPcuPpVyzRrXWLPo+ul4EI1oV0NJGAX1rzwsCmvd9Pnz6FLko4kMHhvZMvuKM521rxYwtBA8t5nhdb9+GAiy2ENzd0cmpcomVMCTQmqzj8PKODt46MEjnOS1htDF8bWZ6W4VIjNbMV721VKq9QKI+HfaU2uAb1cYwucWA37Xi3MASUu64Enir7MxR7VJcS1KOQsR6EQ1DTmnNR06d4s6ODn64tMQTlXLcSG+TKXze9/nj0dOsKMVvDw9ztGVvCCjAVNXb1pI9KQSlKORT42f4nRuOrRW2aE8k+NCRI3gq4qnlZf6v48d554Eh3tTfv+l2vjU3t1Z6basYrVkKfEpRtGdqurpCkLZs8pv4HLf6crleCCDruvH9s8PG2hDRK0S+Xg90MgjOy4E0SvF4ucTjpSIQ97lftUB/9hwB/fCpk8wYQ1ppni0UOdCU2TG+qsshLsTsobdZAMORkh8vL/PJsTF+5ZwiJCnL5oZslld2dnG0efP6n4/kFvnM2Ylti4RZLdDs+3tGRKUQcZGQ6PxzkbFs5A7RJgNUIoVZL/VCxL3SdpiAQkNErwjLQcCfnDrFZBQSXSAtZkNXSyEQlnW+BXr6FDPGID2P27u6+fr8HBnb4vV9m1tYu4liGMbLPV9ENXtHSr45P0dFRbzzwBDt66brWcflfzl27LzvRFpz/+wsX5icJDJ6+5aWMQjXZdarciiT2faYdypZ192w9NMAjhDc3dFB2rZ3gEcUQqP5p4UFKlG0JpoGdlxvpVUaInqZxAJ6kskwuKCAnovlOPyzzs41AV0OAv741CmmjUYGAe8/dJg72ts5VSriyt1vhQIs+j41Y150vqsjJQ/ncoyWSvxMby8v6+jctDhzJYp4bmWF++dmOVEsYkn5oqeqQgimq3tr+WfGsjccy2qy/f3zc9dvUJsghdgwTqMUWWdnLjhpiOhlsFIX0LPhhS3QC9FXD5QshwEfPvk8MyYuyvy+4RHuaG/nz0+f5tZsKz/d03M1hn7NmalWEbZ9wQIYW8GRknwQ8LcTE3x1ZoaBVIreZL3HkjHkAp/papVF38cYs/UGaBdgLxZozl6gZ/uO9onWVys1LNE9xkrdejwbbN0CXUVHEZ+bOMt0tcqJQoFZwAqjtfX0Hx09TagVv3Dg0NUZ/HVgxvOuiDUnhcAVgkoUcaJU5Llice1v68uyXQnhiws0ewRakdgjM4IW297UpRJdxizhSiMAa10NUsELpfx2Ig0RfREsX4YFCvHDWQG+tbyM0ZqkEPzGcCygHxs9zWOVCs1ac7JY5Mg5OZK7lelq5UX5Qy9E3BxNXNUkTqM1RWNYCUN6EjvzAd4uLa5z3nWwhODu9g7StnXdfaIAShseXc7jrRYgEYKEEDtytRI0RHTb+ErxZ6sCehmFe43WRLUa0nHodByOtDTz8dFRHqnnj644Dn86NsoHRw5ywy4XUk9FcYvky2hNcT0wWhPaNnOeR09iaxWgdjotjhuXIRQvdP3UxjBereAIed1FVBBX8ArPWa2UsOxNK3rtBHbmqHYwx4tFxoJgy03WLoUOQ86GIf/hyScpab0mNDoM8RIJfpBb3PUiOlmpsqJe6GS6m5C2zfFCgVuzrXsiuJSyLGwhCDFrKbuGuGXLTmLDAgchaHJ25molaBQg2TaXLAQiBPIiBW6FlIhz21e4LhUpN1hq0rKwfJ/XdO/+wNKj+SXkDuyNsxV0FPH40hL+LnwBbEbGtus9uzY++te7atPFqjgJKWmyLHaqQ6UhotukL5VCB+GmgQshBEJKXtbWFlcKP+fNKW2bJstiXzKJtONUE+k4vKa9nYNuYq1nk7QspJS8c/9+hnZ5jmI+CHh0aQm1Sxu/6ShiGXh0ael6D+WK4Np2fG/uIqtaCLEjizGv0hDRbTLc1MRLWrM469ZyA2uC+LN9fbxraDiOLq67UaVtk5QWHzp0mLcNDCKEwEokeGNXN+8aGuY3jxxhyE3gNjeTtm1+bf9+Xtl1fiGN3caXJiepWdau84eux2jNl6enKezSF8F6nHohj12VtiXiVsk7dSbT8IluEykEvzI8wkdHTzOaSoKO1/IarXljZxdvH9wHwD2dnXynWCQKgrjtsTG8f3h4rZjI70iBrzUvbY+rO7U4Dr956BAP5fPc2tKyaW+h3caPlpZ4aDmP2sUCCrE1umLbfG5igvcePLirrLhzEcStv8Uuq0/bmtg8v3Un0BDRF0Gb6/K7R2/g4VyO4/X18LdnWzd0pnzHvv2kZmb40coyrmVxX18/t7S2rv39lta287bb6rq8+Qp3Jr1eLPkBf3t2Io727lALYjtEvs/DUcSxXI6f6uq63sO5LOJmbzsrkHRRjKFlBzaoW6Uhoi+ShJTc293NvZvUroR4dc3PDQ7ylv7+eOq+Q9+iV4NIa/5mfIySEJdsSLdrMHEp48+dnWCkuZm+LTa924m0XmDV0o5ECPQOXq0EDZ/oVceW8idKQAFOlnVM3zMAACAASURBVEo8Xam8qIUIOxkdKTzH4YHZ2R2zuufF0GzbiJ1SsmkL6CiieYfmiELDEm1wFWipt4UWyeQFG6PtSuoJ6t3JxO6x5DYh67pIaWGfU7x6JyKkJPQ8mjdp97xTEGY3v1Ib7FjGKxWmPA+lNde/5cSVQQhJs2Vxa1vbrp5dVKOIHy8v11tw7OxrI6QkLSR3tLfv2CIpDRFt0KBBg8ug4RNt0KBBg8ugIaINGjRocBk0RLRBgwYNLoOGiDZo0KDBZdAQ0QYNGjS4DBoi2qBBgwaXwXVJtlfGXDQ7zRICXf+MgF2dkxdqHTdOw9DuJnBlXD1cssObg+0wDPF9s8q1PH9Rfb8WXDLJ/rxxCnFZlkqk9VrFpd3+LFwpcvXOsRkp48Z713k811xEA2P4oxPHWY4UWm1cVy2EQArB7x69gW/Pz/O07zMg4IOHDl/rYV4RTpVKfOrsBFOVCgjB4UyGZttm1hhucF3eNTR8vYe4a3hsaYkvzs2iwxArkeBn2tt5Tc/VL9YyUanwkdHTALxnZIRDmeaLfj4fBPy/J44TGYN0XV6RzfLm/oEXte+qUvz3E8epaI2wLG5pauJf7D+wq1dLXQ6eUvzVmTGeKhapRRFNjsO/OXKUA01N13Vc11xEjTHMeh4lKdeKUwgp47etUugoQmnNShiyhCHhB0DcHO7rc7NIy2YkmeSlHR3XeujbIjKGvzkzxiygAcu2ydVq1ByHJcdhOQiu9xB3FZ5SLBlDFEXYtn3pDgNXiFBrckqBgGALS1iVMXFnU9vGsiyKYbhp33plDP84PU0gBK1S8vq+vk23Net5+JaFBJbDzYuB/6TwzdlZflyrEUYRQgiqUcQPl3L8IL+EEIJ72trZfx0E9ZqLqCME7zwwxEdHT8fTWtvmJZkMt7e181cz0xitqSrF63p6eJnWJIlvpidXlvlOqYS0LAqex02trThCxK1e6xN/RwgsKRmvVLAF7EtvPKFztRrFMCQhJf2p1IaeLfkgYMn3MUDasmhz3bh4LXFLkPmahzLgSkG7m6DZcS46jcj5Pgu+j6p3KnzX4D4662uVfQwtloU2Jm47YeKapEnLIlCKSc+jxbbprlcKUsZQCkMKYYhfb+DVnnDpcOPtRSZu7BVvB1KWTSEMWPB9etwELa67Ni5tDLO1GhWlSElJTzKJu+48LAcBOd9HCOhNpsisK/yw+rfVc9SeSJA6p/j06j7KUcRyEKwdX3sisXb8yphYkOrHnbIsylHEbM2jy03Qum68855HMYo42tLCSwoFHg8CdBSdd+4NcRNBg4n/s+58auJpsC0E/mpt03plrdVjL4YhC7UaBuhKvDCGdtflN4eGQcBAKq7xWlOKKc+j1XHoTCTwlFo7lmbb5pVdXTy4soKOIhwpCYxhslKhybLoS6UwwES5zFdmprGbm2kLQl7R3Y27bjzUz/Fre3r42uIiOopit0B9P4FWzNd8PK3JWBZ9qSRi3VnJBz5LfrDp/VyKIhZqNZQxJKSkPZEgs0m1e20MlSiiEIZUVQQmXnffU78vI60JjdlwHWc9D08pDjQ1YdXP95zv4ytFi23Te04x83OpKcVcrUagNVnHWduXMoZT5RIqDBFScm9HJy9pa+Wbc3Oc1BpjDH1ugq5kkoSUSCEItGbO86gZQ3P93EP8YnxhyWs87pzvsxwGDCRT2+4qes1FVArB/qYmRN3hKSyLrkSCl3V0MO1VEcB3F+Y5Xq2CUqSE5C0D/Xx6fJwAwBgeE5IT1Qpv6u7mkaUllsIQKSWH02mUNjxeKGBZkjd0dfPz+/ax5Pt8cmKc50uleBtaM9SU4d379zOcyfC5sxN8fylPRUVI20YHAR2Oy+/fdBNPLi/z5fk58rUaluuiwpAmKfmdI0c51Hzhqd3fT54lqm8rkpKHFhdoc11OezUwmjbb5m0Dg3zs9Cm0kEhL8tJsK6PlMhN+jZRl8e7Bfby8s5P/eWaMJ4tFyr6PqPcNb7JsXtrayruHh3k0l+OL83NEQYAFvKKrmx/kFlkxhg7b5l8ePMiBpgxnymU+PXmW8UoFJQRSa3pSae7r7+O2tnY+PT7ODwvLlMMIA3QkktzX18fdnZ383eQk388vUY7WnyOH//XGm2g/p5DF306M88NCgXKtBvXxpiyL21qy/NrICE+vrPCp6SlUGCKF4BUdnfwwv8SS1mQtiw+OHORwczPfmp/ji7OzeEqxz3VJWRZG6/ParkBsqf7hc89SVAq0wRbwr44e5VNnxlnC0Cct3jo4wJ+ePIkRAst1OZZK8Z6Rg/zj9BTfXVpixfcRUtLiOLypu4c72tv5w+eeBSGxEi6vzLZyT2cnHz75PJO+Txp4RWcXj+eXCI3BSiR4W1cXfak0shQ/8OPlCv/12WeY8n0SlsUvDAzyis7O2IiQEr9QYFEI/tPx53hJJsO7DwytiZklBL3JFEKItRiCEIJnCit8YWaGqXIZIyW2MQw3NfHuoWEGUik+OzHOQ/k8FaXWrlWX6/L7N97Ej/J5vrawQN6vYTkOKgxII/i9m25i+Byj4/7ZGb6ey1HyPEy9L5grJIczTbz/4CGeyOf50uICyvexheBlHZ18a2GeSGv+2223c7ZS4e9mppmtVjDSwgXubG3jXQcObNq585Fcjn+cm2OuWgEr/vyR5mZ+fWiYM+UyJ2s1VBCAMTyxnCcf+DxbLK41QPycV+NL01P8+2PHWAxCPjt5lulqFSMlDvCSbJZfHx7h/tlZ/qmwggoCUlJyZ3s7311cpAoMuC7/6vCRtRf+VrhugaVVdBQxXqnww5VlXt7RwYGmDJ+eGKdQn7oldGytrTr3MYYAjVIKX2sKQUDRGAhDHvU8pG1jjEYpw/2zM7yqq4tPjp/h+TCMrTUdW2uTYcDfjJ/hrQODfH1hAYAE0CElOpUijBTTnsdnz04QWBY20C0lJpGgrNQL47kAXhStFSTWxJauEIK8ijBao7Um1JrlMETYNqiIBxbm45s+iqhJyVdnZrirs5OpSgXfccD3oT6lqxDxYKnIbYUCCkNRa6K6RfSVuVmklKgwZNlx+ObcHL80NMxHTp8iL0R8/rVGCcGigBPFIou+z/fKJaIwWivzthwGfHL8DBUV8bW52bhC/7pzVIuiTc/DjOfhuy7a87Dq58Ezhh95VW7O53GlpKh1veK94atzs0jbQoURJdvmG7Mz9KUO8veTk9SEwEQRU0JgfD+2yDZ5AI0xrAQBlXqXAVtrFmo1JiplIsehphSLvh+3+LBt7Pos4Ae5HF9Z1wPKaE0xCvnM5FlsIShFEYEQ2JbE14oH5maZAVQYUrFt7l9ciPu4C4GtNZ5SaPPCvX28UkbUmxAGUvCVqUluamkhqltPq89DUSmqm7goVN3KwxgkgnwQ8NFTp/AsCw2gFKEQjAUBHz99ijf1D/DNpSV0fRbXLiUqmURrw6Tn8dmJcZTjYBtDtxCYRJJiEBDp86/jou9TSyRQnoelFArwheb5MORb83O02A4lYwjr993X5mYRlkUCGCuX+MvRUXzLis9HFOFLyQ+9Kh1zs9xX7wCxyplymU+MnyESAlN37flCcML3+auxMe7s7EDVnyeAQhiyHATodfefZzRBEDFZ9fjrM2coyzhATRQRSMkTtRpfm5lB158XFUUUjOGr83MgJDoMmXUcHlxc5OcGBzd9rjfD+oM/+IM/2PKnrxDlKOI78/NoAUYpCkHA87UaYRjykrY2OpMJHpmfJzAGC8N9g/tYCULmVYS0LO7MtvKBkRGONLcgheBEpQLGcCCd5oMHD/J8sYhnDEZrWl2X7y8uEilFUgh+94ajeFHEXBBQ8X0yrsNYpQwIel2XV/f2cXdHB2/q70cZw7cW5kEIWiyLV/f0cHdXF2/o6WVfU9NFo8OtCZeHFxfBsmi1bX77hhs4lGnm4YV5tBAkgLfv20c+CJiLQoQQ3N3Wzn39/fx4eRllDEopfqqzi45kgpdnW3ltTw93dnSwEgQsqdgv1CYtXtXdzRO5HGWlEELwC4OD3NzcwnPlEhhDqj7VenBlBaMUPY7Dbx0+wnipRNWy6BKCZwsFCnX/3bv3H+BIczPHy2UipSiHEcth3Oakx3V5dW8vd3d08qb+fjoTyQ1TawOkbIu7mlv4mZ5eXtreQU0r5usilRGCe3t6eC6fp6AUQkh+trePu9s7eKq4gjEGF+hMJngonwdjyFgWv3P4CMu1Gkt1S/RoUxNH1rWStqXElpJnikWEZXFnaysDqTSPFgqoMERLyT3tHUTGsKgUThjyq8MjfG12hqUwRABv6enlFV1dPLVSQLoufY7D/qYmzvg+RmsOJFOcLpVY8n2kZfGWnh7u6ejk6UIhvkeAXz4wxHilwslqFSEltzQ18csHDvBEfpkQCKKI1/T04ErJqZoHIr7vfvfoDdzW1nreVPJspcJTpRIAQ6kUlSjk6VoNrRQjySQfOHSY48vLVKOIQhC84JMVgr5Eklf39nJPZydv7Osn0JrvLS1hgFbb5tU9PdzT1cWb+wcYTKfPc5HYUnJzKs3renu5q6ODhJScrdUwWiO14W2DAzy+uEhFKYSU3NrSwvuGR3h1Ty+P5/OMhiFozQ2ZZt4zcpAn80uEgBcEvKqre4P74KvT04xHIRjDbS1Z3rX/AE/klwiiiHmvyut6+5grl1kxBgG8a2iIN/T182Q+j088o/35gUF+8cABni8WeLbmYbTmYDrNBw8d5rmVFWrGUA587hsY5EcL8/jGIIzhvSMjdDou44GPqUf9X9rRseWo/3WvJ2onk9zd0sK7hobXUkHa3ETcHlUIjDGk6l0yhYi9Pi22zb56D6K1Kt2WRW8yyZHmFtoch7zWoBQ534/f+kKghOBLk5Ms1KdtAbA/nabTdliWklmt+fTMNDoMOZrJ8BsjBzmUyTChNaUo4u/m59FhyEAqzftGRtbGsBntjhu/NaXEFoKBVJpiECDWvTlTtk2L46zdTMOZJm5qbSUhBJEQaKMRQjDclOHrc3OcLpdYqFaJjEEbg7QsAmNosm2ceqdRHYYca8kC8Uskbs8sWPR9qH+mI5HgaEsLv3n0KGWlUFrxP06exCiF0ZrvLy4Q1oMhVjLJvqY0nopYkpI5rfn0zMzaOXr/wUMbfJgCGG7KcP/8HM8Xi8x7XjxepZCWJNCGlGWRlHLNQjva0kJnwgWtEdICISiGIdSn7a2uyw0tLTyxnOb5CxR6lsBtbW18YfIsWkq8KGKyUom3YQxYFlPVKkH9nPRaFgOpFCtBEM8MlOLHK8tYhdgSsmybyGjaEkmklGilCOr+eurpd8eyrXQkEnHN1Po1aHacNQtTSMm+pgzHWrI02zaeVvVbQtK2Ol0UgoTtsD+VuuRDa4itQ60UUkr602mONDfT6rqs+D5GCLqTKbqqVZalZFpF/O3MNCYMOdbSwq8MDXMglWLSGApRxBfm51FhyL5UmvcdHGEwtfF+Hspk+Ob8PN+YnWW+5hHUz5PluoTGkLEdnPpxaqV4fV8/I/XutJX6jEYrxaxX5YuTk1SVQiYS1Op+6vVOmaX6iyo+Z2luam0l4zjUoghsm1Br0lbcITc+zuQLcY36TKAnmWQwnebb83Px+VKKxVqNL5ydoBiGiGSSWr1Kvg3xs2kMNza34EjJN5dy9RS17fUEuy4iap/j00pISXLd7wTrqhwag1z/f2D9pGf9jbdZ6kfKtuPPCIEjJT/d00PWdtDEfrSbs1mOtWT59uICp4slpr0qJWMYVYpHl3L83rEb+c78PMdLRaarVfJaM4/mazMzfODQoQse4/qxrOaFivrxrI7b2hAK2Ph3AEtIylHEh59/nmXbQlWr/PLQECcKRX5U7+1kr8shPGcAG7absuOX0GrgDqC37rRfjXQLIUAIXtLWzkgmgxSCmtEMJFPct28/316Y53SxxFS1Qrl+jh7MLfKWdSk8lSji/z5xnEUpCSoV3nXgAFNVjweX84BY6x1+/njX/dsYEtJa+3eoYp/XetfBZrmX7a5LbzLJjFLMeTW8+ktB1LuNPlcoUAgDsCwOtbTgWhayvmNpWRxtbuEl7W1I4uPuclyeKhTWtm8LgSVWT28cuFDrIvar4rlZLuf6+3c1D3r1oNe7t87Fqk/l439T7xkf/y6s73v1+9Ky2JdO84a+Pr69uMDJYpHpSnytToYhP87n+Tc3HOO7uUWO1/+2bAxzGL4xM8tvjIys3bca+MipkzwfRagw5E3d3Ugh+PLs7Ibzv/p5oxQp64XO8I4VBxyFZdGdSPLG/n4cKQhjb9rafbv2eSnXboHV67x2busBsPVncfXT633Fq99zRDw6ISXtbrxvV1pxEAxIWNYGfTnvnK8p0NZs0Ws+nY+M4Qtnz3K25sUJ9cZQCUMmaj4t9Yjvw0s5flwqEUURWBZZyyYyhvFaDRWGLNVqnK3VCCLF4/k8s34NoxR+FCER/Gg5H0dqhcAR4GlNKARR3Y+6HASMliscLxa4JdvKo0s5sq7L/nQaTykW6n7HftelEARYlmR/Ko0lBGdrcYOvNsti1qvy4PIyva57Xg+Y++dmOeV56PpbtxgGTFbjaZ7WGg1oo3lyeZliFNXFQlEKQ54tl9BaY4A5z+NMpRwHYYiFdbRcin2uxlCLImwh+OHyMkEUxUEXYzhbqTLhxVOaEBhMpRgtFonqfuSxSpmnVpb53vLympWV0zoW2SjCUxETlTKPLy/Tn0xyslikxXXicxQpFutR0n2uy03ZFxrwTVUrfHV2Fh0ESOKHY7RUpqIUxmh8pXCl5JGlHLW6+8EYzaxXY7RaxdR9tR2uy5lSCWUMXhRxplLm2UIBv36ufKW4va0Nd92DK4XgbLXCWd+n7NdYjiKk0fQmEpSiiOUgzkoAeF13N4PpNGcqZWa1Roch1SjC14qJaoUnCgVSlsVj+SXyvh/7kLXGCCgphTGG6UqZZworsTtACDJSckd7B/8wPcVy3cINVYQCniwVCCOFsCzSQtKecHmssIKq73fS91msVje4KDyl+PupeOZktMaPIkYyGY4XCmitWfF9TpVKjJbLsWWnFD/T08OTK8u0Og4H0k2UlSJXv58HHId8GOJYFgdSKRCCyfrUv922eFln55psrPg+n588SxBF6CgiISUTlQqFKKoflyIwmqcLBYK6dZ5Xiqxt05VMUokiniqX0WGIp6I4XatW49lSiWoYcks2u8HQKIUhz9U8It9n0fM4XihwtloFy6JZCG7ItvBgPo8XxlP+fBjRn0pyvFCgoDWmbvGOlyu0JRKcKBYwWq/te67m8Vy5TCUMCJXmsVIpTpWyLGwhOFEqMlt3VdSAG5pbyG6xr9M1t0QjY3h8OY+VTiPqfrJl2+ZJDEdrNQ41N3O6VIR0Got4uj9aLnNvTzf3Ly5guQ41BE9pTXOlzKlSCSvpYqI4j/CZlRVqjoNlWUjXJef7vLmvn8/PziASCU5GEUJrhCUx5QqB1nxpagrZ2ooOQ0wUIR0HGYbc2d7BX42NsZxpQtX9UJbjoJXiro52vjIzw3IiwT1BQP85U/sThQJ2Og21GtpxeDi3SGciiUynIQgwtsVj+TwzQYBVd0mcLpVQBmQ6hRWECNcl7/tkbAfPtkFrnqhWSBuDnUxgDEx6Hs8VCgSJBJaUSMfhuUIBicBOp9FhiJ9Ok5AWr+nq5oHlfDy+MEQohZ1MciAIuG9wH2Mnn6eWSDBrDPO1WuxOIU76/ofpKUw2u/EcBSG3t7VvOO42N0GTtPDd+Dw96Xk0aY1Vn/IvKsWJYpGq62IphXQcThSLNNk2dlNTnM2QTmMwHGtp4XgYoqOIp0slmoTArlvPo+UyvtZkzrm/bsxmeahaBSGQlsT2avx0dzdfWFzEYBBCElWq7GuKv/mzA4Ocev4EK8kkS8bwSK0Wb0gIFms1xsplrGQS6gL9xr4+pubnkZbFvJSYSmXNRSPqboiJWhz5RggmKhWyKytEiQSWkFiJBM8WC7yyu5u01njJJFprjhtDtVjkzQMv2D+R1jxfLGKlUxilyUnJgaYML8228rhXpWYMz0URJpFAas0bOuPMgD987jhuWyu6LoCW4yCDgDs6Ovn46GkKmczG+zmKeNk5PsC049CRSLAgJSoIeD4MSQUB0rIQlkUVeHQpR1C/jgjBmG0x5XncmM1yV2cXD+dynBRxa/Af+bXYPeS6JAL/vHzXe7q6eHRpiTPJJGVjOBFFyGQSE0XcN7gPX2m8VAqrfq4npCDv+9za1s50YQXl+ywIwWLN4/e6unhpNcvjnkekNY/7fn3fDo7vM4bA1PVFum78IvR97GQSHUVUkwlyvs/+LbYtv+aV7ZUxfGd+Hs/EVs8q0rK5raWFgXSaZwsFxmteHIm1bPpclzva23k4l+OHK8vUwpDuVJp72tuZqlapao0xcf7kQCrNlFeND05aNEvJvT09PL2yzGMrKyzWakgDfekUt2RbuaGlhe8tLDDuVcl5saO/O5XiFe0dHGlp4ZFcjpPVCvOVCkYIWt0Ed7a2cnt7O58/O8HX5+f534/dyHBm4+P86FKOxTBCqwghJGlLkrZscmGI0bEF1u64rIQBqh6AdYWkzXWZD2LLQ1o2g4kEthR8N7dETUW8vK2dzkSC09UKWum6vzXFWc+Lz4GUtFixC6NQzwSQts3NmWYONDXxyNISTxVWWAkCXCHY15Th5e3tDKTTTFYqPJxfYqJu2XQlkxzOZLitrZ1Hl3KMVzeeo3va2jmazZ53jU8Ui3w3l6McBtzZ1s5gKsWJcjkeC7AvnWaiWqlfI0lGWrhSko8ijFZI2+FYUxMdiQRfmp4mF/j8VEcHGdth3PMwWmELwb3dPRumkBC7Jr67MI8mFrVmy+LW1jYeXFzAIBBSkJaSe7t71qbdi7UaD+XzjBYLKOKW2IeaMhzLZnk8n69HyOMp7Cu7unlsOc/ThSJdrsNAKs2nzk6ghKDHtvm3NxzjoaVcHJEWcV50dzLFdD3QIS2LTsfh5R2dnC6V+E5ukeUgoNV1uaMly53rFpH4SvHdxQUCbdZcBa/s6iJj2/xgaYlniwXKYUR7wuW2bJY764Gz7y4sMF6tsOTVQEBPKsU99fv54aUcz5fLLFTiF01bMsGd2Sy3t5+/eGXK8/jG/BxLNZ9jzRluaW3j6cJKvfGpoS3hshyErE6qpW1zU1OGofqz4GvNg7lFjheKVOt5yUPNGe5sbVvL2VxPNYp4aCnHiWIJT0V0JZLc0Zrl1rb4OX+yWFxb5Sik5K62dtpcl2/MzvB8qYRAMJBM8pbBQRJSbjhHSSnY35ThrrY2ilHEqFeN841lfD2qKqKqYh2R0uKutra1PO1L0WgPchl8YfIsTy8v8x9uvuU8P2+DvUnO9/nY6GmSto0NTFarLAYBdiLBTakUv33k6HVfy93g2nLdo/O7mYSUvGP/gYaA/gShgNPVKv9/e2capNlVHubn3PVbe9+30eyrBAiQQCA5wtgmYBtbJiGG2OWQcmLHSUj5F3bishNXfiSuhCqXkz9ObIOXBENwKIJjg8yONiQkDZp9prunZ7qnl2/f7n5Ofpzb33QPkjA1M2EY3efXTHX3d+93l/fec877Pq9dKulVfcPAcl1yUvKu6ZksgL4Gyd5EMzK+B0IpebpSYdX3qPoBApguFHggnRLJeO2RBdGMjIyMm+A1NZxX0M+tA50Sc2O+2q0kUtcXBAy+Mz82485CoVfEt98qTCFuub8z6n/+9TzEbemIVOqGXvDituzDjcRpyt2N2912+m7vqyXEbXW4JkqRkN4rt/k730peU0G0F8f8zulT9JTCsCzuKxZvm9MzlAn/6cwZGmlJ3KF8gQ/t339btpVxa6iGAR89c0bLRByHtw4M8pPfQw31d0MCv3vuLJtRhIy1Xs+0LB6bmeWB0VEudtr8wfIySaRXoE3X4bGpaR64zdrHz62t8lSrRezrajDLdXjHyChrnseZXpckjDAsk1+45560Gu728MdLi5wLQz44PcOJl8n6uFO5a4OoTuq/TGSYjJomf3dmBtCrq4FlYUipSwtvAfUg5LNrVzEsm/35PG8dG+tvq51WYjRu0bZ+0Lja6/HlagUQvK5c5t6hoe/6N98vFFq9JxwHU0o6aUHDrZQgV4OAOiClTvoXwCdWVjiSSknqMiFJ03hMab2slORW04oiGkCUxFqkkspQWnHU3x/TtrTW8DaRKMWpRoNekrCw/wdrbvmuDKJKKS6223x+YwOnXGI8Snh4YgJTCN45Nc3ntjZR265HKVnqdHBNk3tuELq2ooh13yeSkvGcy4T7nXljUileaNR5otvFsCxansd9w0PYwuDHpmf45LU1lJJYIkesFEudDoYQ7CuVEOhEdqkUQqRloEKw1O0yYtv9PLUN36cS+FiGyWw+R8naXUmhfx5gGwaz+XzfG7mTWEoCJftVbkXLohVFrHoeY47DRC5HJCUrvR4Sxd5Ccdf0g5ckrHo9QqkYsC1mcvldQ7t136cW6jeZkmUz6jg4hsEz1Qrf6HQQQmBLyd5SiVxaJbJNJCVhOvUh0n1b8zxaUcSeYnFXLmg9DFn3vL73czw9Rl4cIwGVHsecabDY7sCOY91NjVJCaPesUoqY6+WaA6mU4yupC3T7+4VS9q1BcVqGPJnLMZwWEHjpOVRsl4YKFrtdypbFzI58SAF8cO9efu/8ed0iR0qIY9q5HH++ssLP7d3Lw4NDfKWmCyJeVyhw/8hIek3Dmu/RTH24c/k8rmniJwkJalvpiSOMVCCtPZ9508SX181SAu0X3flgeOfUNGcunGdTCGSSkAQBRwcHKVoW3+71EJbFCTfHwdTq344jrnkesVSMuW7/OpVK0UsS6mFIO62SKpgmM/kcjmHq6rO0YkwIQc4wqIcBlTCkYJjEwFvGximn1283jrmWukUtYNh1GHHcO65Fyl0ZRDtJwu9fvACGQdBssSYEv3H6FG8fGma2qXNReQAAGe9JREFUWIT0YrnmefyH06dYCQIEgndNaP+oAv5qbY3HtzZphiHCNMkJwcMjo/zMwsKuk3jF6/Fny0skQuiKIiG4cMrj78/M9G8glSRUA5/fOX2aS14PIQSPjo7x/j17+M9nz+iyPAT35FyEEJyVkjc7Dh/Yu48/WVri+WaDEK1pG7Ft3jc3zwOjo3TimD9ZWuJkq0mU1sWPOi7vn5vr33zbvNCo86erqyRBiCEEbx0b49lalQbgJgk/OjXFtxsNFj0PwzQ5XizyywcO4pomT1UqfGZtlU3fx7AsRJJwoFTm5++5h7Fcjo8tXuK5RoPIEBimRRKGLLgu75ya5i/X15FpRcsXWy2eqFX5xX37dw3XHl9f5wu1KkkQ4BgGrx8e5olqldAwmLFt/sXBQww7Dp9audz3ZCIEeSF449AQP3vPXv774iUupWV7E5bNeC7HU/WatmMNDfPT8/P8x9On8NOh+qPDI0Qy4evNJnF6/j9y7BjjuTyG0eoHdAl89OwZVjwPP02WV0lCyXZ4dHyMn5yZ5b+eP8fVMEQpxazrUrIsTkYRh02TDx8+0k97EsBsoXg9DSoV6sRBwNNJnQfbY8zkCxhmE6UUg6mgZjMI+OOlJc532si0I8R8ocg/2ruXr29t8my7TRKEWK7DT09NUfEDvtZsIIOAXzl0mE9fucK1tIDDBf7Nfa9jYMeDdjqf5z3T03zs6lXdbcKyWO52uZy2tbGThJ+Zn6eYago/v7lJPa1ecgW8bWSU9y/s4VSzycdWVmj6HlhafEOSMF0o8KE99yAMwUfPntXynDRZ/vl6jbZp8otzc/z2fa8jlwb452s1/nztKpuej+U4yEQXWHxgbo6HxyduXbC4BdyVQVRtT9CnbxhSKXpSEkjZ9w/KOGY5LfFTUtuSvrB+jXdOTbHYafPp9WuotJZcJgk90+Txep2FYoG3jI33tyWV2iWQiNNtbZuW9LYSVlUAQtdTK+BLG+s8ND5OkCR0lULGESd9D8O2dfmm6/K/r6zwbK9LlCSoNHDUDYOPLy2yv1Tis6tXeSHw9c9Tk00tjvijxUvcUyzukiVHUtKVkkRpp+rnNzYQhn6YeELw2a0tvQ2lSKKI070eFztthhyHP9p+SABJqJV4l6KQjy8t8paxcZ7udJBSUsJg2BIkuRxCqV3OTJQiUgoppW6+toPtfYtT89aXtrb0cYsiNiyLL29sMJZz+WKzSZLWbiugZxg82e0ysHqVcPv7RSHtMGTR97TLVUqeatQ5UC4TSEkXMFPnQILS21UKlCTZcc52strrEZkmRloyLIFOHPHZq6u8fmhYbzs9bmd8X59D00Dkv3NY2r9WhMBBB9YwvWY/sbzM0cEBXUljmtqCpBR/eOkii0mij08cgyFYS2I+vrjIsOv0z6uZJHSjmAvtlpbKmCbLnQ6+TOim5yJM6/5v5C1j43x1c5NFpZBRxF9fWyNIEoTj8PbRMWbyeV5s1PnU2po+RlL7YD3T5MuNBvtLZd2yw7ZIehIrTgUiQrCRJPzFlSv8+Nws3SRBCgFRxBc3NsAQGEmCIUS/i0KQJHxi5TI1QEjJpBCYtk1PiO+4du4E7srl4mI6LDNME9OymC8U+c0jR3nPzAyx1OWhpm2zv1Dg148cZTStcw6lpBL4PFmpIAytjXvH5CT/8vCRVM0HJxuNXduazRd448gIpm1jOg5vHBnht44c5Y0jo31rjGFbzLouv37kKDO5nJaEpC0x3j09owOgkriWxYcW9vBbR4/xyMQkT1UqxIGPUIp/evAg75nW87o+8HS1wslGg9jzMIBfOXSIH52aAiHwDIOlbnfXfr5+eJg9loVhGKl7cZZfWNiDIfQUQlFKPnL4CCcGBjEtC4Rg3fN5tlpDpcfnvoFBfu34cUqmSRIEXOp0eLFeR6ZDt3HX5eHJKd4/v8CHjxzlgbExDhRL+ti4Lj88OcW/O36CIzskGwBvGx+nnOgHmRCCX9y3j/dMTWPaNnEQcKrV5Evr61qcLATvm5/nF/buQwBJEPBsrcZbx8aRYYhAMGhZ/NrhIxwplzEtC8OyqIYBj0xMYqT6vQTFu2dmGUmH56QP0p0odAbHz+3bx6/uP8CvHT/BLx861B9hCMdm3ff58dk5ZGpct02Tn52b47eOHOP9C3te1hIEumxxyHH4ibl5rdqLY64FPl/f3OwLok0hWPM8LnQ6JL5PXgg+cvwEbxgcQknJlV6X+4dHKKUKubKUHBkYYMPToh6UYt3r8ejEpN6mELx3fmFXy5dtTCF479wcIg22jTjGF4J8kvTXE55I/bjCMPih8XE+fPgIdnqcvlWrMV/I86HJSf71iXv51SNHeN+ePZhp7f1V32O2UOQNg4P6GjQM5gp5PnL4CP/2+AkOla9fE1EqwZFxjC0E9w0N8e7ZOf753n08kn6XO4m78k3UFIJB29GTRELgGiYzN9TBCsNgwnXZVyoxaNvUldImKKkN6TLRZpiT9boWg0iJZRj4NzwJHcOgaFn9G7Bk2Uy/zLZGHId9pRIjtsN6aiIC+i5Ow7JZcF0eGtdvuRt+qnIDkJK/WlvDi6/38tnyfW2qSvfnc6ur+u1DKUQ6D7aTvGnhpMcDKdlX1vuClAjbpmRZHCiXmS3kOZOaqgIpqQY+Mr1Jp/N5DpYHKJkWXRWRKMVcWgffMk0uJwmXUx/r8XKZXzp4iLyp1W1CCIYc5zuOjT5muoQSoVuWHB4Y1HLizQ2UlFRvGDEcKJUpOw4q0VakXpxon6pSYFkMWjb7y2Vm8wUupP5RP0n0nPaOQDlg29jbx+QVEMCQ7fDFzU2Wux0aQaDfWKXENE0SKRnK5bSy0bIYt2zeMTn1t6pcCpOEH5qYYLHd5kWvR+L7hDv2xRCCevrmnyQJsRD8+eXLbAU+GAaJEEzl88zlcpwNAsI4Zs33aCepy1NK1nyfYdfFsEzwA+4bGnrFOcVjg0O8fmCQ5zttkjDEsC3eOTnVn/utBwEqSZBJov0WXS3wsYXAS2LGHJdTjSaPb2yw4Xn4SUKcnqNEKWwhKJoWIg2ibx0b4+AND1SAom1z/8gIT3Y6JFLyhUYDWakwYJp8YH6BN94wVfX95q4MosCuYVmidueGvhqOob2j26Lng+UB3jYxjil0AM2/TK7nzneNaEfw+m4T4Ob2jZ/i7vhss7+vKr3gxnUnQ6XoyQRLGDxVqfbn1d4+McFMOnz0ZML8ywwlb9wb9XL/3rE/liFwjOuLENs5ttveRmGaHCyX+TuTk3x5a5PFdpvLnS5dpTgbhjxXq+063tErDMV2ZkZu5/IG6fQFQuCmTf22HyCRlESJ7HeJNYU+Vgr0NEK6f36y41zc8O37Ls4d+3RjHqRjGqx5Hh89d5bEdclFEf/kwAH+6to1Lnn6QWMKgbF93tJ9fTV25T8K3Zju/ffcw4VTL9E1TT1/vH0s1PUcUiH0dfnOqSmGHAeJohfHTOfz7CuVOBsEBFLyXK1GrFRfeL3ueZhCoBRM5HKMf5feQUcHBnixp3twyTjZ1SLaTo+3YZrsL5d5+/gElmEQSEneNPj0lRW+2G6jpOT+cpl7h4f5+OIisRD9POm+f1QpcsbLHysB/PzefRyt13ih3mC112U1imgbBp+5eoXXDQ/fUXmk35f2IP8/WPc9XkybhXXjmMVej7Vel5caTW0HT/2MhjB4tl4jTJ+YplJM5nIshiEyiminvselTocXOm0KhmD/Db3Hz7daLAcBSRhSCwKWPD1P+a1albUgQMUJQZJgC4NnazX8NJXEj7Qn81r6hA+UYsPrcWxQt4l4sV6nLUAmklYUUgsDznfaPFer8cDoGMvdDi1AJgmtMKIaBpxvt3mmUuENwyMM7PAhnm+3+FKthp/2epKJZN33WfS0wzMGLKGHZa10kSSIIvaXy5xut5FRRCXwOdVqcqWnjfEF4JHJSZ6uVhhyHGZyeepRSCM1rx8rFunEMWtRRBKGrHs9Fj2PgmnuMuTE22avdCh5sd3ipUaDdhRh2jZHSiWm8nmuJbql9kq3q01UUYTpOBwoFLhveJivbm5oP20cc77d4myrRZh+xkPDwxQsi+dbLZIwpOL7nGo2uZz6XQXQTWLONVv6jUtKgiTGixMuBD6J7yMAL0641GnrflaAH8dc6XW5mrpbQylZ83ocLpd3uU5BL1J98vJlbSiTUjeqi2LePDpKThic6nX7QdSwLPbkczwwOspX19e1DzdNu9rwPc6123y7Xuft41qW/OTWFonUfaUQ2mbUiyJ8KakGAcI0OVYq8aaRkVdM2Vr1PD599SqNMOhPb9SDgONDQ+TSjpgXw5Ak1PPOvThhudPh+VYTW8GpZpN6EJCknUlXPY+tMAQpkULgxzHfbjToRBEqSWikXRX2lW4UGsI3Kls044TZXI6yY3OpozMtcgIenZy6o1bo78o5UYCD5QFySYKdz6Nsm/Opa/RSp43pOJiOw1Ycc67V0k5Ex8EqFDjTbPLo5BQzhoGVy9ExTZ4PQ16IQtbSp+6N3Ju6SE3HIbAszqBY6XW52G5j5XKYjkNbCM6323RMQ28/l+NceqNv/47vujxZqRArhSkEj80v4CowXZdrwPNhyOkkYTMdGj02P48LmLkcq6jrP9+xgLbNhu/jp9ux8rpX0PlOC6tYxHQcZD7P6WaTK71e//hc6HS4d2iIe4tFrFwOz7K4kCSIXA5DCN47N8+AbfO5zU0+1ajziWqFy3GM6Tjk4pj7hoY5keaFGrZN17I4rSS1MHzF8yak5GqvR9U0MB3dauOh0TF+cnaOQaX9shtCsKZ0d82iUvzU7Jx+q0/fXC0hOJOeVyufJ58k3Dc8zIFyGSeOMV2XwHW53O1iGwZ2Po9VKHCyUWfZu/79lztdBh0HogjTdUkchxfqNWzDwCoU9DFqtzidumNNxyFyXZ6sVnmlb/hivYaRz2uHbKHAS40GCvihqSkO53K4AwNY+TxWPk8gJUXL4r3z89qP67osJgnPhyHn0qF6AtxTKpMT4JRKGLkcdqGg55kdB7tYxMjlsFyXfcXSq+a81oOATcvU10guh5XPc6bTwUtzVd8xNc0s2unatSxeiNL7Im2aN18oYuZzGJbJuhA6FU1K7WPN5Xi+VmMrbS9iOg5brsP5dpuXmzV+vlbj/3o9/qxa4QuNBsJxMCyLt4yN6ymYO4i7unb+YrvN16oVWlHEoGVz7+AAnTjGl3oAaQKTuTxrvgcqdVuaBg+NjdOJY56oVLjQbhEpKFt6CPOGwSF9Y93At2pVvtlo4EUxE/kcbxkZ4Zrn6VXRdHuz+QKr6TAQIcgZAhT46VBVCIEjBG+fmOgPV670ujxdq3G120UpxVShwKGSTlp3DIPlTodn6jVWu12EEEzm8hxOk9rtHdMDa57HS+22nkc0BCXDxDYM6ulqtzAEE6nEejsN3AQeHh/XbzqVCmfaLbxEMuY6vGFwiONDQ4RS8tXNTa56Ho200ddMocjbxsaYKxSQSvFEZYuTrRZBFDFTKPLoxMSuN9EgSfjNkyepyAQrSfiVQ4d5sVGnHsfcPzjIQ+MTCHTxwlO1KkvtNlIpFoolHhwdYSZfYLHT4d+fegnDtpm3Hd63sMBXK1uYwuAd4+PsT9tbn242+UqlQk4IfmRqiqtej1acpMNLPVWwPaAWSi96nW42+Wa9jikEj4yNESvFtdRc76TD7N72qrcQWMDDExO7esiDnqr4xtam9t9KhTANhgxtlAfYCnyebzRTB6zJrOtyLK0QOtNq8ly9TsUPMICZQp7jg4McTps1PlXZopVmk6AUbx4Z5Xy7TaufuQEPjIz25zdfjmoY8mytpvdUJ9RiAW8dG+s30OvEMU9Wq1xotwil6t8X9w8NYwCf39zgSq/HTC7H28bGOdtssl1mMmCZdKIYmXbfMCyTacfhxOB3FmCcb7c52WpxrdMmEYKiZXG8PMCDY2N31Fso3OVBNOMHg69vbvI/1lbxUwP5sYEBfvnAwZftTf5K/OHiJb5Rq6GkpGA7PDI6wt9b2HMb9zojQ3PXDuczfnBY933I5zFdFzOX46VGo98L6W/LSreLnQ6pk7zLSzsazGVk3E7u2tX5jB8cHhgdZToo6mT/1BZU/h7eQgEem19Ih64JwjAZ+C6r5BkZt4psOJ+RkZFxE2Rvohl3LKGU/TJJAeRu8u0yTLMWzHQxKCPjVpAF0Yw7lv928QJLac7muG3zq0eO3lTw+4NLl1iSCYdsmw/t3XdLFXcZr12yIJpxx9KKon7ajv09+Fi/srHBUhigooifmptj2NFVOr04pim1cOXVSj0zMr4XsiCa8aootLFIKl166ApBICXLvS6z+TyjjotUilXPoxaGOIbBQqGwy2m6Gfhs+D5SaZflqOsyZNv9Estrnsdm4GMimM7nGU1LE981PcPvXbygK8lSYcv235gCXMOkt8NPqfct4UubG2yYJpHn8cDYGJYwMIXgJ+bmCID8jvgpleKq16MeRjiGwUwux6DjkCilXQTpZxdMEy+OWe71GLJt5nc0pWtHEVe9HqFSWAjGXJdR172jShMzbh9ZEM14VdpRyG+/9BJeKiE5VipR8QPWXYcfKxZ5eHyCP1i8xLl2G2wbmSSMOw4fmF/gxNAQn1xZ4WvVCj5g2hYyinGShN84cS9ly+JjS4ucbLWIDUNLhIXg4dExHpuf18LlVHZsottHXPC04m7acXj3zCy/v3gJpMTK5XjX6CjVMGQtSYhTi9V/uXCBCcdh3HW54HkIpSgIwa8fP4GXJHxsafH6vscxg7bNuycmOTAwwO+cPoVKa+PfNDzMhXabTSmxlOJnZ+d4eGKCZ6pVPrW2Si0IMF1XFzNIxQfn5nhk4s7yXmbcHrIgmvGqKHRFkQ+oKNIVLYaBmyTIQoE/W17mfKSNTsL3kUDVMPjT5SX+wZ49/PW1NYRlkZOSGdtBOY62nivFX1y5wotBoH2o6XC9a5o8Xq8xnc/tkl+Abvy3Xd21bZMPUtOVlYpHpFK7fJmxUlpYkvpGVbq4FMtEi47Tfcf3UULQBP7nlRXeMz2jF7YMA+KYr25tAtqGrxyHL6xf4/XDw/yvlRUaAkSSMIvumeRli1avKbIgmvGqlG2bH5ma5rObGyRSMmDb/OP9+5nM5dnyff5ybY1E6HYbHz56jKcqFZ5oNakEAedaLa0iUoqSbfP60RGmc3n2FIs4hsE3a9V+u41fOnSYtV6Pz2xoE/6TlQp7iqVdFvgfnZrm3PlzqFRBd3xoiEfGxvlas9EPjj88OcUTW1tI04Qk4Z8dOMBCQYtQzp86RWgILMNg1fM502wgDQNXCP7V8eN8Y2uLJxoNhGlSCQMeHBvnqVYTlOLhoWHePDbK7549S5QktNKWIXrFX+vgjgwOslAsMpvLM5P1oH/NkAXRjFfFQFBOpczbRqXtWudaGJKgtWaJUnzi8mVacaTN80KwUCyxr1RiRUpqSvGZrS1kHDFru/zU3FxfRyekZF+53BdLKKmbCIY3yF5KlnVd1ScErmFQ2uFy3f6dfjuOVBQ94jikzSr0dxKCVhTpAC60YX5/qcxSu4NhtrXtP0kYdhz9N0IwWyxwoFTGNQwiIUikpGxZvHFkhK+1myRS8TeNBqpapSAEH1xY4M0jt7dLZ8adQRZEM74rO5dHdurdbKH7Oom08dyPTU8zkcshlaIrtYvyDcPDfKNS4Vy7xXKnQzVOWDNivra50XdRqtQRGqb6NYV2V96YzrRt4ZdoobGCfveA7Z/vWnVPP/fG76GU0r189P+QCmIlrwdtIXCEoWuihdByGHb7V1EKwxD8w717OVav82KjwUq3w4rn0XNdPnv1Km8aGf1byZkzfrC5a32iGbeGbhzziZXL1MMQmSS006Z79w4NkTdNnqlW8FPXZTXwWfN8TrdbPFetacfn1qa2S7kugZRsBAHCsjiQz2MJgzoKmSRcaLU42WjQjSIs1+X+cpk1z2PR85BJQiQEY7bDcrdDICV+HHO62eJUs0GYzqd2wogTQ0M8U60SpsF1sdvlYqvFcrfLotdDJgnSNJl0HGphiIcgjGPOtlqcajbxoghhGuwvFDjdbOn5Wynx0m6fZ3pd3QPJccgj2AwCNsKQCdsmb1osdTpgGAyYJq0o4vF6jaJgl7Uq4+4imwHPeFUimbDc7Wo5iOPQdV1eqNX6b3M/s7AHWwhM12VNwEtxxEWl2PR9lFJ8aX2d/9Pp8MlajVNBgOE4mHHMwxOTPDY/TwHtCL0mBHXTxMq5jAPvmpnlQrutfaeuiyzkCWXCscFBLRrJ57nQbpE3TazUz3nV93AMg+Pp7xi2zaZh8K1ajUudDiKVnBjFIs0w5H0Le3AQWPk8K0rRsy0s1+VorsDrhoapCrT7MnWPnm+3rn9GocDVXo/TzSaP+x6fqtf4cqeN4boI0+RtY2Nc7na4ZFls+sH3+zRm3Eay2vmMVyWUkqerFaK0j7kwDUqGucuQvtTp8Gy9xqbvIxRMFfIcGxjkQLnMt2pVlj2PrZ4HAsZyed40NNT3e655Pb5Zq3Gl28UyDPaXyzw4MsKA7fCtWo1m2ulUmCYHi0WGHIfPra3RiCMeGhmlaJlc9n1UIjGF4MHRUSTwN+vrrHg9bCE4XC4zaDvUIz1fKyyTOTfHwXKZpU6H5xp1NnyfnGFwqFzmwdExQil5plpJj4LAMQQDlk01jlCJ/oxp28E1TU62W1zrdPreyxMDA9w/PMLpZpOqlBzK5ZjOFpruWrIgmpGRkXETZMP5jIyMjJsgC6IZGRkZN0EWRDMyMjJugiyIZmRkZNwEWRDNyMjIuAmyIJqRkZFxE2RBNCMjI+MmyIJoRkZGxk2QBdGMjIyMmyALohkZGRk3QRZEMzIyMm6C/wdVsmyqPy2mnQAAAABJRU5ErkJggg==" width="415" height="165" style="cursor: pointer; max-width: 100%; height: 165px; width: 415px;"></figure> <p>Regardless of what you choose as your resolution, make sure it’s a “SMART” goal&mdash;one that is specific, measurable, attainable, realistic and timely&mdash;to increase the odds that you will stick to it. Here’s what that means:</p> <ul><li><strong>Specific</strong>&mdash;A specific goal is simple and strategic. It’s something you can easily conceptualize. For example, instead of saying you’ll eat healthier, be specific about how you can actually do that (e.g., eat a vegetable at every meal, eat breakfast every day or eat fish twice a week).</li><li><strong>Measurable</strong>&mdash;A measurable goal is quantified. You’ll be able to see if you’re making progress as you go. For example, if you want to save $500 for your emergency fund or save for a down payment on a home, you’ll be able to track your savings and prove you’re making progress along the way.</li><li><strong>Achievable</strong>&mdash;An achievable goal is realistic and attainable. If you’ve never worked out before, a daily workout goal won’t likely be feasible or sustainable in the long run. Alternatively, if you’re already taking walks, start with increasing the duration or frequency of them.</li><li><strong>Relevant</strong>&mdash;A relevant goal needs to make sense or be appropriate to you. You want your goal to matter, so reflect on the past year about what’s working in your life and what’s not. Timing is equally important, so ensure this is the right time for you to tackle the resolution.</li><li><strong>Timely</strong>&mdash;A timely goal is accomplished within a specific time frame. You can adjust this period as needed and make new goals or deadlines after achieving the first one.</li></ul> <p>Remember that New Year’s resolutions don’t have to be health-related, so find what matters to you to help you live a better life in 2022.&nbsp;</p><p><br></p> <h3>Don't Let Winter Derail Your Workout</h3> <p>If you find it harder to keep up with your workouts as the temperatures drop, you’re not alone. Many Americans find it increasingly difficult to remain committed as the holiday blues, shorter days and less-than-ideal weather create obstacles. Whether you’re a gym-goer or outdoor exerciser, there are simple ways to overcome winter obstacles and keep your fitness on track:</p> <ul><li><strong>Remember to warm up.</strong>&nbsp;If you’re an outdoor exerciser and the weather is colder, try doing your warmup inside. Not only will you raise your internal body temperature before going outside, but you’ll also increase the temperature of your muscles, which can reduce your risk for injury.</li><li><strong>Prep the night before.</strong>&nbsp;If you’re an early morning exerciser, set out everything you need for the next day the night before. Then, all you need to do when your alarm goes off is get up, get dressed and go to the gym.&nbsp;</li><li><strong>Have a backup plan.</strong>&nbsp;Even the most dedicated exercisers can lose their motivation. That’s why it’s essential to have a backup workout plan that you can do at home. It doesn’t have to be lengthy, as doing something is better than doing nothing at all.</li></ul> <p>Staying on top of your fitness during winter can be challenging, but keep pushing and think about&nbsp;<em>why</em>&nbsp;you work out in the first place. Focus on your reason.</p><p><br></p> <h3>The Health Benefits of Being Organized</h3> <p>The new year can signal a fresh start for many. As such, January is dubbed Get Organized Month as many people are eager to tackle their homes’ organization. Decluttering can do more for your health than you may realize. Consider the following health benefits of being organized:</p> <ul><li><strong>Boost your energy and productivity.</strong>&nbsp;A messy area may make you feel confused or scattered. When your space is clutter-free, you can focus more on meaningful activities.</li><li><strong>Reduce your stress and anxiety.</strong>&nbsp;By eliminating clutter, you’ll feel more in control and able to handle challenges that come your way.</li><li><strong>Sleep better.</strong>&nbsp;When you keep up with the organization, you can rest easy at night knowing that everything is cleaned up and in its place.</li><li><strong>Eat healthier.</strong>&nbsp;Not only does snack and food organization reduce clutter, but it can also he­­lp you easily grab healthy options and control portions.</li></ul> <p>This month is a great time to get organized and set yourself up for a clutter-free year to feel more balanced.</p><p><br></p><hr><p><br></p> <p><span style="color: rgb(153, 153, 153);">This article is intended for informational purposes only and is not intended to be exhaustive, nor should any discussion or opinions be construed as professional advice. Readers should contact a health professional for appropriate advice. &copy; 2021 Zywave, Inc. All rights reserved.</span></p> <p><br></p> <p> <a href="http://www.tmgworkcomp.com/blog/2021/12/live-well-work-well-january-2022">Read the full article at www.tmgworkcomp.com</a> </p> Legal Update: EEOC Issues New Guidance on COVID-19 and ADA Disability http://www.tmgworkcomp.com/blog/2021/12/legal-update-eeoc-issues-new-guidance-on-covid-19-and-ada-disability Thu, 23 Dec 2021 15:35:00 GMT http://www.tmgworkcomp.com/blog/p/63279 EEOC COVID19 <figure><img src="/images/news/63279/17296/large/Cyber_update_8_.png" data-image="17296" width="750" height="309"></figure> <p><br></p> <p>On Dec. 14, 2021, the Equal Employment Opportunity Commission (EEOC) issued 14 new answers to frequently asked questions (<a href="https://www.eeoc.gov/wysk/what-you-should-know-about-covid-19-and-ada-rehabilitation-act-and-other-eeo-laws#M">FAQs</a>) about what employers may or may not do to comply with federal fair employment laws during the COVID-19 pandemic. The new FAQs specifically address the definition of “disability” and how to determine whether an individual with COVID-19 meets it under the Americans with Disabilities Act (ADA).&nbsp;&nbsp; </p> <p><br></p> <h3>ADA and COVID-19 Background</h3> <p>Under the ADA, employers with 15 or more employees may face liability if they take certain adverse employment actions against individuals who have been diagnosed with or are believed to have COVID-19. The ADA also requires these employers to provide reasonable accommodations for individuals with disabilities, including any related to COVID-19. Smaller employers may be subject to similar rules under applicable state or local law.&nbsp;</p> <p><br></p> <h3>Three-Part Definition</h3> <p>The EEOC’s new FAQs clarify that COVID-19 may qualify an individual for ADA protection based on “actual” disability, a “record of” disability or being “regarded as” having a disability. Employers must perform an individualized assessment to determine whether a specific employee’s COVID-19 meets any of these definitions.</p> <p><br></p> <h3>Disability Types</h3> <p>COVID-19 is an actual disability if it is a physical or mental impairment that “substantially limits one or more major life activities.” The FAQs provide examples of situations in which an individual with COVID-19 would (and would not) meet this definition.&nbsp;</p> <p>The FAQs also explain and provide examples illustrating how certain adverse employment actions may violate the ADA even if an individual only had COVID-19 in the past (“record of” disability) or is mistakenly believed to have COVID-19 (“regarded as” having a disability).</p> <p><br></p> <h3><strong>Highlights</strong></h3> <p><strong>COVID-19 as a Disability</strong></p> <p>Determining whether COVID-19 is a disability is determined on a case-by-case basis and always requires an individualized assessment.</p> <p><strong>Actual Disability</strong> </p> <p>COVID-19 is an actual disability if it substantially limits one or more major life activities.&nbsp;&nbsp;</p> <p><strong>Major Life Activities</strong> </p> <p>Major life activities include major bodily functions, such as respiratory, lung or heart function, and most daily activities, such as walking or concentrating.&nbsp;</p><p><br></p><p><br></p><p><br></p><p><span style="color: rgb(153, 153, 153);">This Legal Update is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers should contact legal counsel for legal advice. &copy;2021 Zywave, Inc. All rights reserved.</span> </p><p><br></p> <p> <a href="http://www.tmgworkcomp.com/blog/2021/12/legal-update-eeoc-issues-new-guidance-on-covid-19-and-ada-disability">Read the full article at www.tmgworkcomp.com</a> </p> Risk Tips: Managing Pandemic Related Clinician Burnout http://www.tmgworkcomp.com/blog/2021/12/risk-tips-managing-pandemic-related-clinician-burnout Mon, 20 Dec 2021 19:42:00 GMT http://www.tmgworkcomp.com/blog/p/63261 Physicians COVID19 <h2><strong>Managing Pandemic Related Clinician Burnout</strong></h2> <p></p> <p>Clinician burnout was prevalent before the COVID-19 pandemic, and it continues as even more workplace hardships and moral dilemmas have arisen. Clinicians have experienced concerns about contracting the COVID-19 virus and taking it home to their families as well as longer hours and increased workloads, staffing shortages, technology issues, regulatory compliance difficulties, and so much more.<br></p> <p>Sixty-one percent of physicians now report experiencing feelings of burnout, which shows a significant increase since 2018. To combat this burnout, healthcare organizations should prioritize their clinicians’ health and well-being. Leaders should identify and modify processes and systems in their healthcare organizations that fuel clinician burnout. Positive work and learning environments should be in place for clinicians. It also may benefit healthcare organizations to create a leadership role and function that is responsible for the professional well-being of all clinicians.<br></p> <p><br></p> <p>The following risk tips include more specific details on mitigating clinician burnout and fostering professional well-being.</p> <ul><li>Monitor the number of hours that clinicians are required to work, try to distribute workweeks effectively, and adjust staffing procedures and schedules where possible. Make sure clinicians receive adequate breaks.</li><li>Pay attention to clinicians’ time constraints. Assess total workload and the complexity of clinicians’ duties, including continuing professional medical education, maintenance of certification, required institutional learning modules, and work performed outside of scheduled hours.&nbsp;</li><li>Provide adequate resources including sufficient and effective personal protective equipment.</li><li>Provide ongoing assessment of clinicians’ health and well-being to respond to their needs and identify risks or emerging issues. This monitoring can be done using data and validated measurement tools to guide system-oriented efforts to minimize burden, protect privacy, and address any stigma or pressure that clinicians may perceive related to measurement or reporting.</li><li>Reduce the stigma and eliminate the barriers associated with obtaining the support and services needed to manage burnout. Identify mental health professionals and counseling options available to support clinicians, and eliminate obstacles that discourage access to professional and personal support programs for individual clinicians.</li><li>Provide appropriate measures for clinicians’ personal safety, and acknowledge and address concerns about their safety as well as their families’ safety.</li><li>Provide access to resources such as coaching and adequate time for professional and personal development. If possible, obtain clinicians to coach other clinicians.&nbsp;</li><li>Promote a work culture in which clinicians feel supported and able to speak up without repercussions. Give them a psychologically safe environment to openly talk about barriers to their well-being, including stress and burnout. Incorporate items about stress into general care practices.</li><li>Identify any part of the organization’s environment, culture, and infrastructure that can contribute to clinician burnout. Closely monitor implemented technology for negative consequences and create a mitigation plan to address any issues.</li><li>Encourage clinicians to report safety incidents, such as encounters with violent people or exposure to blood or bodily fluids; adopt policies and procedures for immediate follow-up.</li><li>Do not require clinicians to return to work during critical situations that may pose a continuing or serious danger to their lives until action has been taken to ameliorate it. If clinicians contract COVID-19 following exposure in their workplaces, be certain to provide them compensation, rehabilitation, and curative services as necessary and provide any other resources needed.</li><li>Facilitate peer support programs, and create opportunities for professional connection. Allow time for reflection and processing. Encourage clinicians to check in with their teammates and regularly connect with meaning. Encourage them to maintain professional connections and prioritize where to focus energies.</li><li>Keep clinicians educated, informed, and up-to-date on information and technical updates regarding COVID-19 via a central access point if possible. Make sure they’re familiar with technical updates.</li><li>Give clinicians access to the appropriate tools for them to assess, triage, test, and treat patients as well as educate them on infection prevention and control.</li><li>Evaluate how business and management decisions may affect work demands and resources, patient care quality and safety, and levels of burnout, and adjust decision-making as necessary.</li><li>Create mechanisms for cooperation and collaboration between clinicians, management, and clinical teams.</li><li>Support the implementation of new ideas, approaches, and technologies that may enhance clinicians’ well-being and improve quality of care. Implement evidence-based approaches to reduce the risk of burnout while ensuring the appropriate development of competencies, skills, professionalism, and ethical standards.</li><li>Consider designating funding for research on clinician professional well-being.</li></ul> <p><br></p> <p><strong></strong></p> <hr> <p><br></p> <h3><strong>Resources</strong></h3> <p></p> <p><a href="https://www.ahrq.gov/prevention/clinician/ahrq-works/burnout/index.html">Agency for Healthcare Research and Quality: Physician Burnout</a></p> <p><a href="https://www.acponline.org/practice-resources/physician-well-being-and-professional-fulfillment/individual-physician-wellness-and-burnout-tools">American College of Physicians: Individual Physician Wellness and Burnout Tools</a></p> <p><a href="https://www.ama-assn.org/system/files/2021-02/webinar-intentional-professional-connection-slides.pdf">American Medical Association: No One Should Care Alone: Creating Processes for Intentional Professional Connection in a time of "Social Distancing"... and Beyond...</a></p> <p><a href="https://www.ama-assn.org/practice-management/physician-health">American Medical Association: Physician Health</a></p> <p><a href="https://www.psychiatry.org/psychiatrists/practice/well-being-and-burnout/well-being-resources">American Psychiatric Association: Well-Being Resources</a></p> <p><a href="http://www.ihi.org/Topics/Joy-In-Work/Pages/default.aspx">Institute for Healthcare Improvement: Joy in Work</a></p> <p><a href="https://www.medpro.com/culture-of-wellbeing-resiliency">MedPro Group: Five Ways Healthcare Organizations Can Confront Burnout and Build Cultures of Well-Being and Resiliency</a></p> <p><a href="https://www.medpro.com/documents/10502/2824311/Risk+Resources_Physician-Provider+Burnout.pdf">MedPro Group: Risk Resources: Burnout in Healthcare</a></p> <p><a href="https://physiciansfoundation.org/wp-content/uploads/2021/08/2021-Survey-Of-Americas-Physicians-Covid-19-Impact-Edition-A-Year-Later.pdf">The Physician's Foundation: 2021 Survey of America's Physicians COVID-19 Impact Edition: A Year Later</a></p> <p><br></p> <hr> <p><br></p> <h3><strong>Endnotes</strong></h3> <p></p> <p>The Physician’s Foundation. (2021). 2021 survey of America’s physicians COVID-19 impact edition: A year later.</p> <p>Retrieved from <a href="https://physiciansfoundation.org/wp-content/uploads/2021/08/2021-Survey-Of-Americas-Physicians-Covid�19-Impact-Edition-A-Year-Later.pdf">https://physiciansfoundation.o...</a><br><br></p> <p>American Medical Association. (2021, March 29). Managing mental health during COVID-19. Retrieved from www.ama�assn.org/delivering-care/public-health/managing-mental-health-during-covid-19; National Academies of Sciences, Engineering, and Medicine. (2019). Taking action against clinician burnout: A systems approach to professional well-being. Washington, DC: The National Academies Press. https://doi.org/10.17226/25521; Berg, S. (2020, March 12). 6 big things that must change to beat physician burnout. American Medical Association. Retrieved from www.ama�assn.org/practice-management/physician-health/6-big-things-must-change-beat-physician-burnout; National Academies of Sciences, Engineering, and Medicine. (n.d.). Checklist for health care leadership to take action against clinician burnout. Retrieved from <a href="https://nam.edu/systems-approaches-to-improve-patient-care-by-supporting-clinician-well-being/checklist�for-health-care-leadership-to-take-action-against-clinician-burnout/">https://nam.edu/systems-approa...</a></p> <p><br></p> <hr> <p>This document does not constitute legal or medical advice and should not be construed as rules or establishing a standard of care. Because the facts applicable to your situation may vary, or the laws applicable in your jurisdiction may differ, please contact your attorney or other professional advisors if you have any questions related to your legal or medical obligations or rights, state or federal laws, contract interpretation, or other legal questions.</p> <p>MedPro Group is the marketing name used to refer to the insurance operations of The Medical Protective Company, Princeton Insurance Company, PLICO, Inc. and MedPro RRG Risk Retention Group. All insurance products are underwritten and administered by these and other Berkshire Hathaway affiliates, including National Fire & Marine Insurance Company. Product availability is based upon business and/or regulatory approval and may differ among companies.&nbsp;</p> <p>&copy; 2021 MedPro Group Inc. All rights reserved<br></p> <p><br></p> <p><br></p> <figure><img src="/images/news/63261/17284/large/Cyber_update_7_.png" data-image="17284" width="799" height="329" style="width: 799px; height: 329px;"></figure> <p> <a href="http://www.tmgworkcomp.com/blog/2021/12/risk-tips-managing-pandemic-related-clinician-burnout">Read the full article at www.tmgworkcomp.com</a> </p> Legal Update: Court Reinstates OSHA Vaccination Mandate for Private Employers http://www.tmgworkcomp.com/blog/2021/12/legal-update-court-reinstates-osha-vaccination-mandate-for-private-employers Mon, 20 Dec 2021 16:29:00 GMT http://www.tmgworkcomp.com/blog/p/63253 COVID19 <figure><img src="/images/news/63253/17282/large/Cyber_update_6_.png" data-image="17282" width="750" height="309"></figure> <p><br></p> <p>On Friday, Dec. 17, 2021, the 6th Circuit Federal Court of Appeals&nbsp;<a href="https://www.opn.ca6.uscourts.gov/opinions.pdf/21a0287p-06.pdf" target="_blank" rel="noopener" aria-label="reinstated (opens in a new tab)" style="background-color: rgb(255, 255, 255);">reinstated</a>&nbsp;the Occupational Safety and Health Administration’s (OSHA)&nbsp;<a href="https://www.federalregister.gov/public-inspection/2021-23643/covid-19-vaccination-and-testing-emergency-temporary-standard" target="_blank" rel="noopener" aria-label="federal emergency temporary standard (opens in a new tab)" style="background-color: rgb(255, 255, 255);">federal emergency temporary standard</a>&nbsp;(ETS) for COVID-19. The 6th Circuit decision reverses the&nbsp;<a href="https://www.ca5.uscourts.gov/opinions/pub/21/21-60845-CV0.pdf" target="_blank">stay ordered</a>&nbsp;in November by the 5th Circuit and allows OSHA to resume ETS implementation and enforcement nationwide.<br></p> <p>The ETS establishes a mandatory vaccination policy requirement for private employers with 100 or more employees. ETS opponents have already filed an appeal with the U.S. Supreme Court challenging the 6th Circuit’s decision.&nbsp;</p> <p><span class=" img-responsive" src="https://www.sanfordtatum.com/images/news/63246/17275/large/Cyber_update_6_.png" data-image="17275" width="629" height="259"></span></p> <p><br></p> <h3>OSHA Response and Guidance</h3> <p>OSHA has <a href="https://www.osha.gov/coronavirus/ets2">published</a> the following guidance regarding the reinstatement:</p> <p>To account for any uncertainty created by the stay, OSHA is exercising enforcement discretion with respect to the compliance dates of the ETS. To provide employers with sufficient time to come into compliance, OSHA will not issue citations for noncompliance with any requirements of the ETS before January 10 and will not issue citations for noncompliance with the standard’s testing requirements before February 9, so long as an employer is exercising reasonable, good faith efforts to come into compliance with the standard. OSHA will work closely with the regulated community to provide compliance assistance.<br></p> <p><br></p> <h3>Impact on Employers</h3> <p>&nbsp;The 6th Circuit’s decision suggests the ETS may survive its legal challenges. Employers subject to the ETS should monitor legal developments closely. They should also consider what measuresthey would need to adopt to be considered to have made reasonable, good faith efforts to comply if the Supreme Court upholds the ETS.</p> <p><a href="https://www.osha.gov/coronavirus/ets2" target="_blank" rel="noopener" aria-label="published (opens in a new tab)"><br></a></p> <p> <a href="http://www.tmgworkcomp.com/blog/2021/12/legal-update-court-reinstates-osha-vaccination-mandate-for-private-employers">Read the full article at www.tmgworkcomp.com</a> </p> Auto Insights: Prepare Your Vehicle for Winter http://www.tmgworkcomp.com/blog/2021/12/auto-insights-prepare-your-vehicle-for-winter Tue, 14 Dec 2021 15:36:00 GMT http://www.tmgworkcomp.com/blog/p/63172 Winter Weather Auto Safety <p>Winter weather can create various driving challenges. Cold temperatures make it difficult for engines to work properly, while snow limits tire traction and salt causes rust on exterior paint. That’s why it is important to protect your car during the winter months by “winterizing” your vehicle before the beginning of the season. Consider these car winterizing tips before the temperature drops.</p> <ul><li><strong>Check your tire pressure on a regular basis</strong>&mdash;Cold temperatures cause tire air pressure to drop.</li><li><strong>Check your car battery</strong>&mdash;Extreme temperatures can cause your vehicle’s battery to operate at less than 50%. If your battery is over three years old, have it tested.</li><li><strong>Check the antifreeze mixture</strong>&mdash;The ideal mixture of antifreeze and water in your radiator is 50:50.</li><li><strong>Change the oil in your engine and check the viscosity grade</strong>&mdash;To reduce the risk of problems with your engine oil, place thinner oil in your engine before the cold weather season.</li><li><strong>Conduct inspections</strong>&mdash; Be sure to have your belts and hoses inspected. In addition, make sure you inspect your wipers and refill the wiper fluid.</li><li><strong>Install snow tires on your vehicle</strong>&mdash;Snow tires will increase traction and reduce your chances of slipping on slick surfaces.</li></ul> <p><strong>Protecting Your Vehicle Against the Cold</strong></p> <p>The winter may be hard on you, resulting in dry skin, brittle hair and an increased risk of the flu. But, it’s also hard on your vehicle. Take the necessary steps to protect your car against the cold to ensure that it will last the entire season long.</p> <p>For additional vehicle maintenance tips and auto insurance solutions, contact us today.</p> <p><br></p> <figure><img src="/images/news/63172/17256/large/Cyber_update_4_.png" data-image="17256" width="750" height="309"></figure> <p> <a href="http://www.tmgworkcomp.com/blog/2021/12/auto-insights-prepare-your-vehicle-for-winter">Read the full article at www.tmgworkcomp.com</a> </p> Safety Matters: Avoid Winter Slip-ups http://www.tmgworkcomp.com/blog/2021/12/safety-matters-avoid-winter-slip-ups Mon, 13 Dec 2021 21:03:00 GMT http://www.tmgworkcomp.com/blog/p/63185 Trips and Slips <figure><img src="/images/news/63185/17254/large/Cyber_update_5_.png" data-image="17254" width="750" height="309"></figure><p>Winter months present additional hazards that are typically not factors for employees during warmer weather – specifically, slip and fall concerns. With snow and ice-covered conditions, you run the risk of taking major falls, which can lead to serious injuries.&nbsp;</p> <p><strong>Prevention</strong></p> <p>Education is essential in preventing winter weather-related injuries. Consider the following recommendations to prevent slip and fall injuries during the winter months:</p> <ul><li>Wear the proper footwear that provides traction on snow and ice. Footwear should be made of anti-slip material; avoid plastic and leather-soled shoes or boots.</li><li>Exercise caution when entering and exiting vehicles, and use the vehicle for balance and support.</li><li>Try to walk only in designated areas that are safe for foot traffic. If you notice that a walkway is covered in ice, walk on the grass next to the sidewalk, which will have more traction.</li><li>Avoid inclines that are typically difficult to walk up or down as they may be more treacherous in winter conditions.</li><li>Take small steps to maintain your center of balance, walk slowly and never run. When possible, walk with your hands free to maintain your balance. And despite the cold temperatures, avoid putting your hands in your pockets. This will help you better maintain your balance and allow you to break a fall should you slip.</li><li>Use handrails, walls or anything stationary to assist in steadying your feet.</li><li>Look ahead to the path in front of you to avoid hazards.</li><li>Test a potentially slippery area before stepping on it by tapping your foot on the surface first.</li><li>Remove debris, water and ice from all working walkways.</li><li>Steer clear of roof edges, floor openings and other drop-offs to avoid slipping hazards.</li><li>Sand or salt surfaces covered by ice or snow to provide traction.</li><li>Dry your shoes or boots on floor mats when entering a building.</li><li>Report trip and fall hazards immediately to your supervisor.</li><li>Seek shelter immediately in the event of severe weather conditions.&nbsp;</li></ul> <p><strong>If You Begin to Slip...</strong></p> <ul><li>Twist your body and roll backward to avoid falling forward and injuring your face.</li><li>Try to relax your body when you start to feel your legs give way.</li></ul> <p>If you are carrying a load, throw it off to the side so it does not land on you when you fall. This will also free your arms to help break your fall.</p> <p>This safety matters flyer is for general informational purposes only, and is not intended as medical or legal advice. &copy; 2015, 2019, 2020 Zywave, Inc. All rights reserved.</p> <p> <a href="http://www.tmgworkcomp.com/blog/2021/12/safety-matters-avoid-winter-slip-ups">Read the full article at www.tmgworkcomp.com</a> </p> Prescribing as a Key Area for Safety Improvement http://www.tmgworkcomp.com/blog/2021/12/prescribing-as-a-key-area-for-safety-improvement Wed, 08 Dec 2021 16:28:00 GMT http://www.tmgworkcomp.com/blog/p/63147 <h2 class="text-center">Medication Prescribing as a Key Area for Safety Improvement in Ambulatory Care</h2> <h3 class="text-center">Laura M. Cascella, MA</h3> <p></p> <p>Medications are a cornerstone of patient care and treatment, and the medication process involves various steps from initial patient assessment to ongoing monitoring. One of the first steps in the medication process is prescribing (or ordering), which &mdash; by itself &mdash; is complex, particularly as the number of prescription drugs on the market has increased.</p> <p>Although measuring prescribing errors in ambulatory care is somewhat tricky because of certain variables, research has suggested that these errors are not uncommon and can lead to adverse outcomes. (1) Additionally, a CRICO Strategies analysis of more than 28,500 malpractice cases showed that prescribing errors occurred in about one-third of medication-related claims in the ambulatory setting. (2)</p> <p>Technologies such as electronic health records (EHRs) and computerized provider order entry (CPOE) have shown promise in reducing some prescribing errors, like those linked to illegibility and harmful drug interactions. However, technology does not eliminate all errors, and lapses can still occur &mdash; for example, in relation to clinical judgment and decision-making. A study that examined 3,850 computer-generated prescriptions found that about 1 in 10 included at least one error, of which more than a third had potential for harm. (3)</p> <p>CRICO’s aforementioned malpractice analysis also points to the possibility of technology eroding interpersonal communication and teamwork:<br>Medication safety requires a balance of efficiency in routine processes and teamwork to support each other’s decisions and actions. The tools (e.g., CPOE) employed to reduce ordering errors are effective, but they incorporate features (e.g., forcing functions, alerts) which instill confidence at the cost of peer engagement. (4)</p> <p>With prescribing identified as a key area for safety improvement, this article aims to provide an overview of several aspects of the prescribing process &mdash; including reconciling patient medications, prescribing new medications and refills, and managing patients on high-alert medications &mdash; and offer helpful risk management tips and strategies.&nbsp;</p> <p><br></p> <h3>Medication Reconciliation</h3> <p>In ambulatory care settings &mdash; just as in inpatient care settings &mdash; careful evaluation of patients’ medical histories and health status is an essential element of high-quality care and an important initial step for safe prescribing. Gathering and maintaining detailed and accurate information “is the first priority in medication safety, as it guides physicians to choose the appropriate medication, dose, route, and frequency.” (5)</p> <p>A vital factor in patient evaluation is medication reconciliation. Given that an estimated 8 out of 10 Americans take at least one medication and almost a third take five or more medications, it is reasonable to assume that patients are receiving prescriptions from more than one provider &mdash; such as family physicians, specialists, and dentists &mdash; and taking any number of over-the-counter (OTC) drugs, supplements, or herbal remedies. (6) Further, patients who have been hospitalized might have had additions or adjustments to their medication regimens.</p> <p>Comprehensively reviewing and reconciling all medications and products that patients use, as opposed to only the medications prescribed at a single practice, and keeping up-to-date health records can help practitioners make informed treatment decisions and reduce the risk of dangerous or undesirable medication interactions and suboptimal treatment outcomes.</p> <p><br></p> <p>The following risk management tips offer strategies for managing and improving the medication reconciliation process.&nbsp;</p> <p><br></p> <p><strong>Risk Management Tips for Medication Reconciliation</strong></p> <p>• At each office visit, review all medications that the patient is taking, including prescription drugs, OTC medications, herbal products, dietary supplements, vitamins, and alternative therapies.</p> <p>• To assist with reconciliation, ask the patient to bring his/her medications, a written list of medications, or digital pictures of his/her medication bottles to the appointment. Patients who take multiple medications might have difficulty remembering drug names, dosages, etc., from memory.</p> <p>• Document all information related to drug, material, or food allergies in a prominent and consistent location in the patient’s health record. List the name of the allergen, the date the allergy was identified, and the patient’s reaction.</p> <p>• Consider recommending medication management tools to help patients keep track of their medications. Examples of these tools include apps, wallet cards, or forms, which can ultimately assist with the reconciliation process. Various organizations offer these types of resources, including the Agency for Healthcare Research and Quality (AHRQ) and the Institute for Safe Medication Practices (ISMP).</p> <p>• Do not rely solely on health information technology to facilitate medication reconciliation. AHRQ explains that research has found that “electronic tools often lacked the functionality to accurately reconcile medications, perhaps explaining why medication discrepancies persist even in organizations with fully integrated electronic medical records.” (7)</p> <p>• Use a medication flow sheet to document all medication orders, including refills, in the patient’s health record. Ensure this information is located in a prominent place. Flow sheets should include ample information, such as drug name, dose, administration route, frequency, and purpose.</p> <p>• When transferring or “handing off” patient care to another provider outside of the practice, send a thorough and detailed list of the patient’s medications to the new provider.&nbsp;</p> <p><br></p> <h3>New Prescriptions, Refills, and Samples</h3> <p>Writing prescriptions, handling requests for medication refills, and providing sample medications are routine aspects of patient care in healthcare practices. Yet, even routine activities can be vulnerable to errors and oversights in busy clinical settings. Implementing standardized protocols and thorough prescribing guidelines can help address these vulnerabilities, improve patient safety, and potentially minimize liability risks.&nbsp;</p> <p>Prescribing guidelines should clearly establish which staff members in the practice are authorized to prescribe medications, order refills, and dispense samples. Prescribing privileges vary by state and might also vary by drug classification (e.g., controlled substances), so knowing whether your state limits or restricts prescribing by certain professions is important.</p> <p>Prescribing guidelines also should establish policies for handling requests for new prescriptions, managing medication refills, standardizing prescription writing through accepted and agreed-upon terminology and abbreviations, and educating staff about potential errors and adverse drug events (ADEs) that can occur during the prescription process, such as problems with “look-alike/sound-alike” drug names and variations in dose designations.&nbsp;</p> <p><br></p> <p>The following risk management tips offer strategies for developing effective prescribing guidelines and managing processes associated with new prescriptions, refills, and samples.</p> <p><br></p> <p><strong>Risk Management Tips for New Prescriptions, Refills, and Samples</strong></p> <p>• Stay within your scope/expertise and follow evidence-based guidelines and accepted treatment principles when prescribing medications.</p> <p>• Ensure that accountability for writing prescriptions, handling refill requests, dispensing sample medications, and administering medications is designated to healthcare professionals who are (a) legally permitted by state law to perform these activities and (b) are properly trained and credentialed.</p> <p>• Consider a patient’s lifestyle, frequency of use, and cost when prescribing new medications. These factors might affect patient adherence to treatment plans.</p> <p>• Maintain adequate and current drug references and resources, and ensure staff members have easy access to these resources.</p> <p>• Consider how health technology, such as clinical decision support, can assist in the prescribing process. Also, be aware of the limitations of such technology when devising guidelines and protocols.</p> <p>• Make sure prescribing guidelines clearly establish when patients must have medical evaluations, testing, or follow-up before healthcare providers will prescribe new medications or refill existing prescriptions.</p> <p>• Set clear parameters for when prescribing in the absence of a medical evaluation is appropriate and define limitations and restrictions, such as only providing a limited quantity of medication until the patient can come in for evaluation.</p> <p>• Establish a list of potentially problematic abbreviations, symbols, and dose designations for your practice. Consider using ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations.</p> <p>• Ask staff to reference the list of error-prone abbreviations, symbols, and dose designations when communicating medical information to patients, pharmacists, and other providers.</p> <p>• Establish policies that target potential problems with drug names and dosages. For example, require staff to always include the indication for use on prescriptions, use leading zeros as the standard format for writing out dosages, and use commas for dosing units at or higher than 1,000. Consider how technology in your practice can support these safety processes.</p> <p>• Ensure processes are in place to guide storage, labeling, dispensing, and documentation related to sample medications. For example, expiration dates on medication samples should be routinely audited, and a careful review of patient allergies should take place prior to providing sample medications.</p> <p><br></p> <h3>High-Alert Medications</h3> <p></p> <p>High-alert medications pose special risks and challenges for healthcare practices striving to implement medication safety measures. “High-alert” refers to medications that “have a propensity to cause serious harm when used in error” and that “require extra precautions when administered, prescribed, dispensed, or refilled.” (8)</p> <p>Although medication errors are not necessarily more common with high-alert drugs, they are more likely to lead to severe outcomes. ISMP has compiled a list of high-alert medications used in community/ambulatory settings that includes classes of medications (e.g., opioids) and specific medications (e.g., warfarin).&nbsp;</p> <p>To minimize the risks associated with high-alert medications, healthcare practices can incorporate specific safeguards into their prescribing processes. An initial step in establishing safeguards involves determining which high-alert medications are prescribed, stored, and/or administered in the practice. Once a list has been generated, specific strategies can be developed and implemented to ensure patient safety.&nbsp;</p> <p><br></p> <p>The following risk management tips offer strategies for developing effective policies and protocols to manage patients on high-alert medications.</p> <p><br></p> <p><strong>Risk Management Tips for High-Alert Medications</strong></p> <p>• Identify which high-alert medications are prescribed, stored, and/or administered in your organization, and share the list with staff members.</p> <p>• Ensure your organization has a standard written procedure and reliable system for tracking test/lab results. The procedure should include guidance for timely review of test/lab results and patient follow-up.</p> <p>• Develop standard protocols for monitoring patients receiving high-alert medications. At a minimum, standard protocols should include frequency of assessment and blood monitoring, guidance for adjusting medications, and standards for patient/family education. Consider using a medication monitoring service or implementing one of your own (e.g., a warfarin clinic).</p> <p>• Define and communicate each healthcare team member’s role relative to medication management, especially when high-alert medications are involved. Provide staff with medication management education.</p> <p>• If you have an EHR system, enable pertinent medication alerts and track pending test results, patient notifications, and other elements of your standard medication safety protocols.</p> <p>• For patients who take high-alert medications, thoroughly document in their health records complete information about prescriptions and refills, any necessary medical follow-up, lab work and results, informed consent conversations, special instructions, and the provision of patient education.</p> <p>• Use data obtained from prescription drug monitoring programs when prescribing narcotics, or refer patients to pain specialists as appropriate.</p> <p>• Consider using medication contracts for patients who take high-alert medications. Contracts should indicate appropriate medication use and expectations. Have the patient sign the contract and keep a copy in the patient’s record.</p> <p>• Establish a policy that requires patients to have a medical evaluation before refills of high-alert drugs are authorized.</p> <p>• Include full and detailed instructions on prescriptions for high-alert medications, as well as the indication for use. Avoid using “as directed” in place of specific instructions.</p> <p>• Allow ample time to discuss high-alert medications with patients and answer questions. Explain how and when the patient should take the medication, and discuss any monitoring or follow-up.</p> <p>• Consider patients’ health literacy when providing educational materials. Ask patients to “repeat back” the purpose of their medications and how they should take each drug to ensure they have a firm understanding of appropriate use.</p> <p>• Design a process for tracking ADEs. Debrief “near misses” and actual events with your team to learn from each occurrence and to prevent future ADEs from happening.</p> <p><br></p> <h3>Conclusion</h3> <p></p> <p>Although errors can occur at various stages in the medication process, the complex nature of prescribing opens the door to a number of potential safety issues. The risk of errors and oversights can increase in the absence of clearly defined processes and protocols for safe prescribing.&nbsp;</p> <p>To avoid possibly harmful ADEs that result from prescribing errors, ambulatory care organizations should develop strategies and implement safeguards that target key areas of the prescribing process for safety improvement. When staff members who are authorized to write prescriptions are aware of these safeguards and in compliance with organizational policies, the risk of serious, but preventable errors is minimized.</p> <p><a href="/news/63147/17233/Prescribing_as_a_Key_Area_for_Safety_Improvement.pdf" data-file="17233">Prescribing_as_a_Key_Area_for_Safety_Improvement.pdf</a></p> <p><br></p> <h3>Endnotes</h3> <hr> <p></p> <p>1 Gandhi, T. K., Weingart, S. N., Seger, A. C., Borus, J., Burdick, E., Poon, E. G., Leape, L. L., &hellip; Bates, D. W. (2005). Outpatient prescribing errors and the impact of computerized prescribing. Journal of General Internal Medicine, 20(9), 837-41; Abramson, E. L., Barron, Y., Quaresimo, J., & Kaushal, R. (2011). Electronic prescribing within an electronic health record reduces ambulatory prescribing errors. Joint Commission Journal on Quality and Patient Safety, 37(10), 470–478.<br>2 CRICO Strategies. (2017). Medication-related malpractice risks: CRICO 2016 CBS benchmarking report. Retrieved from <a href="http://www.rmf.harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Medication">www.rmf.harvard.edu/Malpractic...</a><br>3 Nanji, K. C., Rothschild, J. M., Salzberg, C., Keohane, C. A., Zigmont, K., Devita, J., . . . Poon, E. G. (2011). Errors associated with outpatient computerized prescribing systems. Journal of the American Medical Informatics Association, 18, 767–773. doi:10.1136/amiajnl-2011-000205<br>4 CRICO Strategies, Medication-related malpractice risks: CRICO 2016 CBS benchmarking report, p.9.<br>5 Jenkins, R. H., & Vaida, A. J. (2007). Simple strategies to avoid medication errors. American Academy of Family Physicians. Retrieved from <a href="http://www.aafp.org/fpm/2007/0200/p41.html">http://www.aafp.org/fpm/2007/0...</a><br>6 The Centers for Disease Control and Prevention. (2018, June 29). Medication safety basics. Retrieved from&nbsp;<a href="http://www.cdc.gov/medicationsafety/basics.html">www.cdc.gov/medicationsafety/b...</a><br>7 Agency for Healthcare Research and Quality. (2018, August). Patient safety primer: Medication reconciliation. AHRQ PSNet. Retrieved from <a href="https://psnet.ahrq.gov/primers/primer/1/Medication-Reconciliation">https://psnet.ahrq.gov/primers...</a><br>8 Jenkins, et al., Simple strategies.</p> <p></p> <hr> <p>&nbsp;This document should not be construed as medical or legal advice. Because the facts applicable to your situation may vary, or the laws applicable in your jurisdiction may differ, please contact your attorney or other professional advisors if you have any questions related to your legal or medical obligations or rights, state or federal laws, contract interpretation, or other legal questions.</p><p>MedPro Group is the marketing name used to refer to the insurance operations of The Medical Protective Company, Princeton Insurance Company, PLICO, Inc. and MedPro RRG Risk Retention Group. All insurance products are underwritten and administered by these and other Berkshire Hathaway affiliates, including National Fire & Marine Insurance Company. Product availability is based upon business and regulatory approval and may differ among companies.<br></p> <p><br>&copy; 2019 MedPro Group Inc. All rights reserved.</p> <p></p> <figure><img src="/images/news/63147/17234/large/Cyber_update_3_.png" data-image="17234" width="930" height="383" style="width: 930px; height: 383px;"></figure> <p> <a href="http://www.tmgworkcomp.com/blog/2021/12/prescribing-as-a-key-area-for-safety-improvement">Read the full article at www.tmgworkcomp.com</a> </p> Risk Management Review: Medical Malpractice http://www.tmgworkcomp.com/blog/2021/11/risk-management-review Mon, 29 Nov 2021 19:03:00 GMT http://www.tmgworkcomp.com/blog/p/62749 Medical Malpractice <h2 class="text-center"><span style="color: rgb(0, 0, 0);"><strong></strong></span><strong>Patient Disregards Physician's Recommendations for Immediate Treatment; Complications Result, Leading to Malpractice Lawsuit</strong></h2> <h3 class="text-center"><span style="color: rgb(0, 0, 0);">Theodore Passineau, JD, HRM, RPLU, CPHRM, FASHRM</span></h3> <p><br></p> <h3><span style="color: rgb(0, 0, 0);">Introduction</span></h3> <p>Doctors have dealt with patient nonadherence to care and treatment for many decades. All too often, when patients disregard their doctor’s advice and it doesn’t go well, they try to blame the doctor. This challenge is frequently complicated when the doctor is part of a large, often multispecialty network rather than a solo or small group practice (where he/she might more easily develop personal relationships with patients). This case from the Northwest illustrates how easily a case can “go sideways.”&nbsp;<br></p> <p><br></p> <h3><span style="color: rgb(0, 0, 0);">Facts</span></h3> <p>The patient was a 52-year-old male who had seen Dr. T, a MedPro-insured internist, on an as-needed basis through the large multispecialty clinic with which Dr. T was associated. Dr. T had treated him 8 years earlier following a motor vehicle accident resulting in injury to his cervical spine. The patient had fully recovered from that injury.<br></p> <p>On November 2, the patient became sick at home. He was vomiting and had a headache, general body aches, and nausea. He had no prodromal illness and believed he had the flu.</p> <p>On November 3, he presented to Dr. R (another MedPro-insured internist) at the clinic’s urgent care facility complaining of fever, nausea, vomiting, headache, and abdominal pain. His temperature was 103.3 degrees. Appropriate lab tests were ordered, but the results were not available that day. A chest X-ray also showed possible pneumonia. The doctor prescribed levofloxacin and instructed the patient to contact the clinic if his symptoms worsened. Two days later, the lab results were available and indicated elevated liver enzymes; the patient was called and asked to return to the office, which he did that day. Dr. R saw the patient again and informed the patient that elevated liver enzymes and bilirubin appeared on his test results. A CT of the abdomen and pelvis was performed, which showed a cyst on the kidney and possibly the liver. An ultrasound of the right upper abdominal quadrant also was performed; it was positive for gallstones. Repeat liver enzymes showed some improvement and lipase was within normal limits.</p> <p>Dr. R explained to the patient that he had gallstones and would need to be monitored to see if his liver enzymes continued to normalize. Dr. R also explained to the patient that he would need surgery because a serious complication could result from this condition in the absence of surgical treatment.<br></p> <p>On November 7, the patient and his wife saw Dr. R for follow-up care. His bilirubin, alkaline phosphatase, and lipase were all within normal limits; the alanine aminotransferase and aspartate aminotransferase were elevated but were lowering. The patient explained that he was aware that Dr. R preferred for him to see a surgeon regarding his gallbladder, but that he was feeling fine, so he and his wife were going on a long-planned vacation the following day. Dr. R was hesitant to approve the patient’s plans, but he ultimately acquiesced. He explained that he would have the surgery department contact the patient to arrange an appointment for after their return. Dr. R’s documentation of this conversation was as follows: “Discussed surgery if desired and if symptoms return again.”</p> <p>Unfortunately, there was no indication in the health record that Dr. R requested follow-up by the surgery department, and the patient contended that no call took place. Because he felt good, the patient did not re-contact the practice.</p> <p>On December 16, the patient presented to the emergency department (ED) with a sudden onset of crampy abdominal pain “after eating cereal.” He was nauseated and had vomited three times. Lab tests showed elevated liver and pancreatic enzymes. The patient was admitted to the hospital with a diagnosis of pancreatitis. Dr. T and a member of the clinic’s surgery department saw the patient every day during this hospitalization. The plan at that time was watchful waiting to allow the pancreas to improve/heal and then proceed to surgery if needed.&nbsp;</p> <p>On December 20, the patient had continued pain in the abdomen with the introduction of clear liquids. The surgeon noted that a CT showed that the pancreatic head remained inflamed. The plan of care included continued rest of the abdomen.&nbsp;</p> <p>On December 21, because of continued pain and the inability to tolerate liquids, a nasogastric (NG) tube was placed for decompression. The patient removed the tube himself, complaining that it made him feel worse and made him gag. The tube was then reinserted and the patient obtained relief from his discomfort.<br></p> <p>On December 24, the NG tube was clamped and the patient appeared to be improving. He ate ice chips without difficulty. His pain was controlled, and the plan was to discharge him the following day. On December 25, the patient pulled out his NG tube on his own. He was up and laughing with his family. The surgeon approved discharge home on clear liquids. However, the patient interpreted “clear liquids” to include pudding, broth, sports drinks, other liquids, and crackers.<br></p> <p>On December 28, the patient returned to the ED, and he was diagnosed with abdominal pain and ileus. He was treated with ondansetron and hydromorphone. His amylase was 76, lipase was 427, and his white blood cell count was 14 K/uL, with 83 percent neutrophils. The on-call physician approved discharge, recommending that the patient see Dr. T in 3 days and return to the ED if he developed chills, nausea, vomiting, or fever. The patient misunderstood the instructions to see Dr. T in 3 days; he contended that he was told “to call” Dr. T in 3 days.</p> <p>On January 4, the patient followed up with Dr. T for a repeat CT of the abdomen that showed persistent changes in the pancreas and gallbladder. Pancreatic necrosis could not be excluded. Dr. T recalls deliberating as to whether outpatient management was possible or if admission that day was necessary. He decided to schedule the patient to see the surgeon and permit him to convalesce at home.</p> <p>On January 6, the patient had a sudden onset of projectile vomiting and was admitted to the hospital with acute and chronic pancreatitis. A CT showed worsening of the pancreatitis, with possible abscess/necrotizing infection. Dr. T admitted the patient to the intensive care unit and consulted the surgery, infectious disease, and critical care departments.</p> <p>On January 8, surgery was performed for a pancreatic abscess with necrosis. The gallbladder was removed, and a jejunotomy tube was placed. The wound was left open, requiring packing and drain attention. The patient and his wife contend that when the surgeon saw them that morning she stated, “If the pancreas is necrotic today, it was on Friday and surgery was needed.”</p> <p>From January 8 to February 28, the patient convalesced in the hospital, being treated for a duodenal obstruction resulting from postoperative narrowing. In addition, on February 11, the patient was diagnosed with a thrombus of the left femoral vein and posterior tibial veins. On February 28, he was transferred to a transitional care hospital. He ultimately required additional treatment at a tertiary care center for a ductal fistula that had formed between the pancreas and biliary duct remnant. He had fully recovered by August of that year and had no residual permanent injury.&nbsp;<br></p> <p>Later that year, a medical malpractice lawsuit was initiated against the group practice, Dr. R, and Dr. T. After extensive discovery, the case was taken to trial, resulting in a verdict in favor of both doctors and the group practice. Defense costs were in the very high range.</p> <p><br></p> <h3><span style="color: rgb(0, 0, 0);">Discussion</span></h3> <p>An examination of this case shows that basically all of the providers’ failures were related to communication in one form or another. Unfortunately, such failures are not uncommon in daily practice, and they can have significant effects on patient care and the defensibility of malpractice cases.<br></p> <p>It is easy to see how Dr. R’s documentation of the conversation about surgery on November 7 could be misinterpreted. The documentation of “Discussed surgery if desired and if symptoms return again” becomes problematic in more than one way. A note this short and obtuse would not be very helpful to Dr. R if he were subsequently trying to recall what he was thinking when he wrote it. Additionally, another provider would have difficulty understanding exactly what Dr. R meant.<br></p> <p>A purpose of documentation that is less commonly recognized is its use to re-create the treatment circumstances at a later time, either as part of a peer review process, board of medicine inquiry, or in a subsequent legal process. Unclear and incomplete documentation is of little value when trying to reconstruct the case later (sometimes much later).</p> <p>It is clear that Dr. R’s intended referral to the surgery department did not happen. This can occur for many reasons, such as Dr. R being interrupted just as he was preparing to enter the referral (it was an electronic order entering system), incorrectly entering the information (such as the wrong date), or simply forgetting to do it.</p> <p>A simple solution (which works equally well with tracking test results) is to enlist the patient as a “fail-safe” technique. When a doctor indicates that he/she is going to order a test, consult, etc., he/she should tell the patient: “You should hear from surgery in the next 7 days. If you don’t, please let me know so that I can follow up.” This statement does two things. First, the typical patient is less likely to forget about it when he/she is expecting a call within a certain timeframe. Second, it puts some responsibility on the patient, which can be beneficial in circumstances such as this one in which disputed communication occurred.</p> <p>On December 28, when the patient was discharged from the ED, it was anticipated that he would come in to the practice in 3 days, an instruction he misunderstood. Although the discharge summary was not available for review, if it did not specifically say that he was to come to the practice on December 31, it should not be surprising that he might misunderstand, especially when he had previously misunderstood the meaning of “clear liquids.”</p> <p>Discharge instructions are very valuable to facilitate patient adherence as well as document what the patient was told; however, they must be clear, concise, and easy to understand to ensure patient comprehension. It is noteworthy that the patient did not call the clinic either.</p> <p>Finally, there is the issue of the surgeon’s alleged remark stating, “If the pancreas is necrotic today, it was on Friday and needed surgery.” Although it was disputed that the surgeon actually said this, if she did, it was obviously inappropriate and should not have been said. These kinds of remarks can rarely be used as evidence of malpractice, but they can serve as an impetus for less-than-completely-happy patients to contact an attorney.<br></p> <p><br></p> <h3><span style="color: rgb(0, 0, 0);">Summary Suggestions</span></h3> <p>The following suggestions may be valuable to physicians treating patients who are demonstrating less than full adherence to treatment recommendations:</p> <ul><li>&nbsp;Ensure that your verbal communication with the patient is clear and understandable. Include the diagnosis and the treatment plan, and explain the consequences of not following the treatment plan. Using a technique such as “<a href="https://www.ahrq.gov/patient-safety/reports/engage/interventions/teachback.html">teach-back</a>” can help facilitate patient comprehension and identify potential issues or areas of misunderstanding.</li><li>Similarly, ensure that documentation of clinically significant conversations with patients are clear and understandable. Should patients call back to verify information, it will be necessary to accurately determine what the patients were originally told.</li><li>Implement a reliable and consistent process to track and monitor the status of diagnostic tests, referrals, and those patients requiring follow-up. Enlist the patient as a “double-check” on expected activity, such as referral calls or test results.</li><li>Provide a visit summary and discharge instructions. Ensure that discharge instructions are clear, understandable to the patient, and in the patient’s primary language. Summaries and instructions are of no value if the patient cannot easily understand them.</li><li>Be cautious whenever commenting on another provider’s care. You may not have a complete understanding of what was said or the exact circumstances, which can result in commentary that is inaccurate and potentially damaging.</li></ul> <p><br></p> <h3><span style="color: rgb(0, 0, 0);">Conclusion</span></h3> <p>Unfortunately, there will always be patients who don’t adhere to recommendations and treatment plans for many reasons, including miscommunication, fear, stubbornness, or just “not getting it.”</p> <p></p> <p>Every clinically significant conversation should be conducted with this fact in mind. You cannot change your patient; you can only arm your patient with accurate information in a way that maximizes his/her chances of understanding. Be sure to always thoroughly document your conversations with patients.</p> <p></p> <p><br></p> <figure><img src="/images/news/62749/17178/large/Cyber_update.png" data-image="17178" width="725" height="299" style="width: 725px; height: 299px;"></figure> <hr> <p></p> <p><span style="color: rgb(102, 102, 102);">This document does not constitute legal or medical advice and should not be construed as rules or establishing a standard of care. Because the facts applicable to your situation may vary, or the laws applicable in your jurisdiction may differ, please contact your attorney or other professional advisors if you have any questions related to your legal or medical obligations or rights, state or federal laws, contract interpretation, or other legal questions.</span></p> <p><span style="color: rgb(102, 102, 102);">MedPro Group is the marketing name used to refer to the insurance operations of The Medical Protective Company, Princeton Insurance Company, PLICO, Inc. and MedPro RRG Risk Retention Group. All insurance products are under�written and administered by these and other Berkshire Hathaway affiliates, including National Fire & Marine Insurance Company. Product availability is based upon business and/or regulatory approval and may differ among companies. &copy; 2021 MedPro Group Inc. All rights reserved.</span></p> <p></p> <p> <a href="http://www.tmgworkcomp.com/blog/2021/11/risk-management-review">Read the full article at www.tmgworkcomp.com</a> </p> Health Care Risk Insights: Footwear in Health Care Settings http://www.tmgworkcomp.com/blog/2021/11/health-care-risk-insights-footwear-in-health-care-settings Tue, 09 Nov 2021 21:43:00 GMT http://www.tmgworkcomp.com/blog/p/62551 OSHA Health Care Risk Insights <h3><img src="/images/news/62551/17009/large/Cyber_update_23_.png" data-image="17009" width="750" height="309"></h3> <p><br></p> <p>Footwear is an important issue for health care professionals, many of whom spend long stretches of time standing or walking throughout the day. Good footwear is essential to worker comfort, but comfort concerns must be balanced with safety.</p> <p><br></p> <h3>Employer Obligations</h3> <p><span class="bodyChar">It might be tempting to assume that footwear concerns only apply to construction, manufacturing or other professions where heavy machinery, dangerous tools or heights pose an especially large danger. However, health care settings pose a number of hazards, ranging from falling objects, objects piercing footwear, slip, trips and falls, the contraction of blood borne illness and other potentially infectious materials (OPIMs). </span></p> <p><span class="bodyChar">OSHA hasn’t released any footwear guidance specifically tailored to the health care sector, but health care employees engage in work that might bring their feet into contact with several overlapping hazards. In particular, employers in health care settings need to be mindful of the standards regarding protective footwear and the standard regarding contact with blood borne pathogens.</span></p> <p></p> <p><br></p> <h3>Protective Footwear Standards</h3> <p><span class="bodyChar">OSHA has regulations regarding personal protective equipment (PPE), and protective footwear in particular (29 CFR 1910.132 and 1910.136). These standards don’t specify footwear types, but they do mandate that employees must use protective footwear if there is a danger of foot injuries due to falling or rolling objects, objects piercing the sole, or exposure to an electrical hazard. The standards also reference the American National Standards Institute (ANSI) and the American Society for Testing and Materials (ASTM) standards that footwear must meet to be in compliance with OSHA regulations. In health care settings, employees may come into contact with sharp medical instruments, needles, heavy rolling objects (like gurneys or hospital beds), and other heavy medical equipment. Under OSHA standards, foot protection must be used whenever work processes or environments could cause foot injuries. More importantly, from OSHA’s point of view, it is the employer’s responsibility to determine if and when employees are exposed to any hazards.</span></p> <p><span class="bodyChar">If employees are exposed, however infrequently, to any hazards during the course of business activities, then during that period of exposure, they would be required to wear protective footwear. If an employee is not exposed to any foot hazards, then the use of protective footwear would not be required.</span></p> <p><span class="sectionheaderChar">&nbsp;</span></p> <h3>Blood borne Pathogens Standard</h3> <p><span class="bodyChar">In addition to protecting their employees from foot injuries, employers have an obligation to protect their employees from contracting illnesses on the job. Specifically, the OSHA blood borne pathogens standard (29 CFR 1910.1030) requires that employers provide appropriate PPE when there is a risk of occupational exposure to blood or OPIMs. Under this standard, employers must provide adequate PPE at no cost to affected employees.</span></p> <p><span class="bodyChar">Blood borne pathogen PPE is considered “appropriate” only if it does not permit blood or OPIMs to pass through to or reach the employee's work clothes, street clothes, undergarments, skin, eyes, mouth or other mucous membranes. This requirement is evaluated under normal conditions of use and for the duration of time in which the PPE will be used. </span></p> <p><span class="bodyChar">However, when considering what PPE to provide, employers should note that under the blood borne pathogens standard, PPE <strong>excludes</strong> general work clothes (including shoes) an individual would normally wear outside of the facility. </span></p> <p>For these reasons, health care employers should consider providing PPE for employees to change into (and out of, when leaving the workplace) or PPE that protects workers’ “street shoes” when there is a reasonable expectation that employees’ feet may be exposed to blood. <span class="bodyChar"></span></p> <p><br></p> <h3>Drafting a Footwear Policy</h3> <p><span class="bodyChar">OSHA guidelines may not offer the specificity that many employers or employees would like, especially when it comes to questions about certain brands or styles of footwear. The benefit, though, to both employers and employees is that the guidelines allow all parties to find footwear solutions that balance competing workplace needs.</span></p> <p><span class="bodyChar">Remember these needs when drafting a dress code or footwear policy. Doctors, nurses and other health care employees need footwear that keeps their feet safe from hazards but that is also comfortable enough to wear during shifts filled with long periods of walking or standing. </span></p> <p><span class="bodyChar">Consider the specific hazards that your employees face&mdash;both frequently and infrequently&mdash;to make sure your policies match the circumstances your employees will actually have to deal with. After all, employees in a clinic might be exposed to radically different hazards than the ones present in an emergency or operating room or laboratory.</span></p> <p><span class="bodyChar">Please contact us at info@tmgworkcomp.com if you have further questions regarding workplace safety or OSHA compliance.</span></p> <p><br></p> <p><a href="/news/62551/17010/Footwear_in_Health_Care_Settings.pdf" data-file="17010">Footwear_in_Health_Care_Settings.pdf</a></p> <p><br></p> <p></p> <p><span style="color: rgb(153, 153, 153);">This Risk Insights is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers should contact legal counsel or an insurance professional for appropriate advice. Source: OSHA. Design &copy; 2016 Zywave, Inc. All rights reserved</span>. </p> <p> <a href="http://www.tmgworkcomp.com/blog/2021/11/health-care-risk-insights-footwear-in-health-care-settings">Read the full article at www.tmgworkcomp.com</a> </p> Preventing Trips and Slips: Health Care http://www.tmgworkcomp.com/blog/2021/11/playing-it-safe-health-care Tue, 09 Nov 2021 21:31:00 GMT http://www.tmgworkcomp.com/blog/p/62549 Trips and Slips <h3></h3> <figure><img src="/images/news/62549/17004/large/Cyber_update_22_.png" data-image="17004" width="750" height="309"></figure> <h2></h2> <h2>Preventing Trips and Slips</h2> <p><em>Helpful tips for health care workers</em></p> <p></p> <p>Wet floors, spills and excess clutter can mean disaster for employees working in a health care setting. Injuries caused by slips, trips and falls range from sprained or strained muscles and joints, to broken bones and head injury. There are several precautions you should take to ensure your safety and the safety of others in our facility. </p> <p><br></p> <h3>Floors </h3> <ul><li>Keep floors clean and dry at all times. Wet floors present a slip hazard and can promote the growth of infection-causing microbes like mold, fungi and bacteria. </li><li>Remove all objects and clutter from aisles, exits and passageways. </li><li>In the event that grease or oil spills on the kitchen floor, clean the mess immediately and alert your co-workers of the problem before they accidentally fall. </li><li>Use floor or ceiling electrical plugs for power to avoid running a cord down a long hallway. </li><li>Display warning signs to alert others of a wet floor. </li><li>Use floor mats while surfaces are drying after cleaning to provide traction. </li><li>Clean up spills immediately. </li><li>In areas prone to slipping (toilet and shower areas), use a no-skid wax product to clean. </li><li>While washing the floor, wear protective footgear to prevent falling. </li><li>Keep an eye out for uneven floors, and fix them or notify someone who can immediately.</li></ul> <p><br></p> <h3>Other Recommendations</h3> <ul><li>Use strong ladders to reach as opposed to standing on small stools or boxes. </li><li>Stretch out bulging carpets to prevent trips and falls. </li><li>Use the handrails while walking down stairs to prevent slipping walking too fast. Repair broken light fixtures and replace bulbs for adequate visibility.</li></ul> <p><br></p> <h3>Always Stay Alert</h3> <p>I<strong></strong>f you notice any situation that you think could present a slipping, tripping or falling hazard in the facility, act immediately to remedy it or notify your supervisor. You could be saving an unsuspecting victim serious pain.&nbsp; &nbsp; &nbsp;&nbsp;</p> <p><br></p> <p><span style="color: rgb(153, 153, 153);"><a href="/news/62549/17003/Health_Care-Preventing_Trips_and_Slips.pdf" data-file="17003">Health_Care-Preventing_Trips_and_Slips.pdf</a><br></span></p> <p><span style="color: rgb(153, 153, 153);"><br></span></p> <p><span style="color: rgb(153, 153, 153);"><br></span></p> <p><span style="color: rgb(153, 153, 153);"><br></span></p> <p><span style="color: rgb(153, 153, 153);">This flyer is for informational purposes only and is not intended as medical or legal advice.</span></p> <p><span style="color: rgb(153, 153, 153);">&copy; 2007-2010, 2018 Zywave, Inc. All rights reserved</span> </p> <p><br></p> <p> <a href="http://www.tmgworkcomp.com/blog/2021/11/playing-it-safe-health-care">Read the full article at www.tmgworkcomp.com</a> </p>