Can Managers Override Policy and Drs Orders?!?

Can Managers Override Policy and Drs Orders?!?

Because cauti are high, our manager said that now we can't get orders from the provider. It has to go through him and he has to approve a foley. Does a manager trump Drs orders and policies?!?!? He said we have to straight cath patients q4-6 and there's no harm doing this daily. 

36 Answers

Specializes in Travel, Home Health, Med-Surg.

No, A manager cannot overide a providers order or the facility policy. If there is a discrepancy between one of those it needs to be clarified. If a manager wants you to straight cath instead of placing an indwelling cath you still need an MD order. I once had a manager want me to start chemo on a pt that had not yet signed a chemo consent, which was policy, and I told him I would do it but chart that he told me too (I was bluffing bc I never would have) and he backed down. Always keep your ducks in a row!

Specializes in Nurse Leader specializing in Labor & Delivery.

Um, is the manager an MD? If not, then no. LOL

Specializes in Travel, Home Health, Med-Surg.
1 hour ago, Aloe_sky said:

That’s what I thought! he’s not an MD, not a PA or even an NP. The nerves LOL. 

Even if he was that was still probably not policy as he was not the patients provider. Not sure why the manager wanted you to straight cath but if it was that important he should have spoken to the provider himself for an order/exception (there could have been a valid reason for the pt, IDK). 

Specializes in ER.

If my manager wants me to do something and I have doubts, I get them to put it in writing. Then it’s their head. Or if I want to go over their head, it’s in writing and taken seriously.

Specializes in Occupational Health.

Sounds like practicing medicine without a license to me.

I wonder if there's something missing here?

Maybe the manager just wants to know of any patient who is being considered for a Foley so they can speak to the MD to change the order to a straight cath instead?

It may not be a matter of overriding MD orders or policy but being involved to reduce the number of Foleys. He says it has to go "through"  him not "to"  him. If the provider agrees that a straight cath would be appropriate then the patient is saved a Foley. If they do not agree then the patient gets a Foley per order.

If on the other hand he is changing orders from Foley to straight cath, then big no. 

mtmkjr said:

Maybe the manager just wants to know of any patient who is being considered for a Foley so they can speak to the MD to change the order to a straight cath instead?

They should have a protocol that staff nurses can utilize instead. Protocols go through proper channels that include approval from the medical staff line. Joe Blow saying that medical decision-making must go through him is not the same.

mtmkjr said:

He says it has to go "through"  him not "to"  him.

As a general concept that is also a no from me. More common are instructions to refer certain things to the charge nurse for approval/decision-making. I won't do that, either. Or a house supervisor. My obligation to the patient is to communicate with provider team about my assessments and their needs. I don't think "But I told my charge nurse/manager..."  is going to get me very far if I need to defend my actions with regard to patients' medical needs.

On 9/10/2022 at 10:41 AM, JKL33 said:

They should have a protocol that staff nurses can utilize instead. Protocols go through proper channels that include approval from the medical staff line. Joe Blow saying that medical decision-making must go through him is not the same.

As a general concept that is also a no from me. More common are instructions to refer certain things to the charge nurse for approval/decision-making. I won't do that, either. Or a house supervisor. My obligation to the patient is to communicate with provider team about my assessments and their needs. I don't think "But I told my charge nurse/manager..."  is going to get me very far if I need to defend my actions with regard to patients' medical needs.

It doesn't change your obligation to the patient. The manager is observing a unacceptable rate of CAUTIs and wants to reduce the number of Foleys. Assuming the best about this manager, which I usually try to do, I can imagine a situation where providers need a little more pressure to change practice. Again assuming the best, this is aimed at improving outcomes for the benefit of the patient

And yes protocols should be updated to reflect this best practice but in the meantime reminders might be needed if there is room to order differently. Obviously I wouldn't support going against current policies and protocols. 

The nurse is ultimately following the provider order not the managers - the provider would have to agree that straight cath is OK, and may choose a Foley in spite of manager suggesting otherwise.  The nurse is still the patient advocate and following appropriate orders, and would reflect standard practice under scrutiny. 

Specializes in Tele, ICU, Staff Development.

"You want me to straight cath my patient without an order?"

46 minutes ago, mtmkjr said:

The nurse is still the patient advocate and following appropriate orders, and would reflect standard practice under scrutiny. 

I suspect the OP has simplified (or perhaps their manager did in conveying the message to staff) but what they wrote here for us to comment on is that they were told they can't get orders from the provider and that [if their patient is having an issue...for which a foley might be considered] they are to go to him. If that is true, that is a no. As a general concept.

And let's not overlook the elephant in the room, which is that any UTIs associated with multiple straight caths by (often inexperienced) extremely harried staff members is not something that is being measured and it doesn't have an acronym-turned-word for people to crow about. It's good that we have been able to decrease inappropriate use of indwelling catheters and infections associated with them, but for now we have replaced that with an intervention/outcomes we aren't vigorously measuring. If that straight cath patient develops a UTI, at least it won't be a CAUTI!! Whew! ?

You could also decrease CAUTI rate by telling nurses that they must report to the nurse manager if they think their patient needs a urine culture. ?

Specializes in NICU, PICU, Transport, L&D, Hospice.
On 9/8/2022 at 3:35 PM, Aloe_sky said:

Because cauti are high, our manager said that now we can’t get orders from the provider. It has to go through him and he has to approve a foley. Does a manager trump Drs orders and policies?!?!? He said we have to straight cath patients q4-6 and there’s no harm doing this daily. 

Does your manager want to put his directive in writing? He should.  Will he object to you documenting that he was the professional who provided that guidance? 

It's really up to you as to whether you will follow the doctor's orders or the manager's orders. But if you choose to follow the manager's orders you need to document the specific actions that you took and document why you chose to do something different from what the provider ordered.  That won't necessarily save you should there be repercussions but it will at least make the patient record clear as to who was dictating the care. 

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