Southeast Texas Medical Associates, LLP James L. Holly, M.D. Southeast Texas Medical Associates, LLP

Governance Board - Harassment, Neglect, Abuse, Exploitation – Role of HCAHPS & CAHPS
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R3.01.06.03 the patient has the right to be free from neglect,
  exploitation and verbal, mental, physical and sexual abuse


Sexual, Mental, Physical Abuse

SETMA has a zero-tolerance of inappropriate physical contact between providers and/or employees and patients.  All contact between patients and providers of opposite sex requires a chaperone to be present when disrobing is required or where examinations of an intimate are required.   Where possible or at the patient’s request such examinations will be completed with a provider of the same sex.


SETMA investigates all patient complaints and allegations.  The process involves all complaints being reported to SETMA’s Director of Care Coordination who performs and investigation.  The report is then sent to the CEO and COO who determine a plan of action which is carried out. 

When the com0laint is about quality of care, a report is made to the patient and provider about the outcome of the investigation.  If the complaint is substantiated and it rises to the level of patient endangerment, it is referred to the appropriate licensing agency for their investigation.  All complaints which are substantiated are also reviewed by SETMA’s Risk Management Committee.

When the compliant is about sexual harassment or physical abuse, the complaint is sent directly to the CElO, who immediately, with a witness, investigates and prepares a plan of action.  If the allegations are substantiated as they were once, summary dismissal tales place as we have a zero tolerance for such behavior 

SETMA’s Employee Handbook explicitly deals with harassment, complaints, abuse and neglect.


Neglect is avoided in SETMA by our daily auditing of provider conduct as to reviewing test results, answer telephone calls and answering patient inquiries.  Patient safety and quality are assured by the timely review of the evaluation of patients via consultations, laboratory results.

 If a complaint of neglect is made, SETMA’s Chief Medical Officer reviews the patient care to determine if neglect took place.  The result of the investigation is communicated to the CEO and to the patient.  In that such an accusation has resulted from the breakdown of the relationship between the patient and the provider, every attempt is made to reconcile that relationship and when and if that is not possible, the patient is offered the opportunity to see another provider within SETMA.  If that is not desire, SETMA offers to help the patient find another provider outside of SETMA and facilitates the transfer of records and healthcare information with a summary of the patient’s current care and on-going healthcare needs.


SETMA does not allow solicitation of patients by providers or staff for commercial reasons outside the scope of their healthcare needs.  SETMA providers and staff do not offer items for sale and no unprofessional commercialization of the provider/patient relation is allowed.  SETMA complies with all Stark regulations and other Texas Medical Board, State and Federal statues which regulate patient-provider relationships.

As part of the ethical training of SETMA’s staff, we regularly discuss the tension between professionalism and entrepreneurism.   The following two publications highlight some of those discussions:

  1. Entrepreneurship vs Professionalism Part I: Drivers of Healthcare Cost
  2. Entrepreneurism versus Professionalism Part II: Republicans and Democrats Both Have it Wrong

Other safe guards against abuse and/or misuse of the patient-provider relationship are in place at SETMA by:

  1. Our Care Coordination Department’s completion of the Hospital Consumer Assessment of Healthcare Providers and Services (HCAHPS) on every patient who leaves the hospital.  An explanation of this program is made on SEMTA’s website for review by our patients and community at Hospital Consumer Assessment Of Healthcare Providers and Systems (HCAHPS)
  2. SETMA’s employment of an independent, NCQA-endorsed agency for the quarterly completion of the Consumer Assessment of Healthcare Providers and Systems (CAHPS).    An explanation of this program is made on SETMA’s website for review by our patients and community at Consumer Assessment of Health Care Provider and Systems.