Linking Malpractice with Patient Safety Luke Sato, MD Chief Medical Officer & Vice President Loss Prevention and Patient Safety Risk Management Foundation Harvard Medical Institutions, Inc.

Assistant Clinical Professor of Medicine Harvard Medical School Friday, September 12, 2003 Strategies for Protecting Patient Safety

Patient Safety and Risk Management Codes: Case 1

         AD1013 Resuscitation/DNR/End of Life Issues CJ4001 Failure/Delay in Obtaining Consult/Referral CO1001 Communication Among Providers – Failure to Read Medical Record CO1009 Communication Among Providers, Other CS9001 Lack of Availability of Equipment /Supplies / Medications CS9009 Lack of Failure in System for Pt Care, Other DO3006 Insufficient/Lack of Documentation, History DO9005 Content Decisions – Inconsistent Documentation TS4008 Technical Performance – Possible Technical Problem

Issues: Case 2

     Medication look-alikes Preparation of medication Medication administration “Second Victim” Disclosure of error    Among peers/providers Patients and family members Reporting: what, when

2003 CRICO Renewal Survey

I have been named in a medical malpractice lawsuit.

100% 80% 60% 40% 20% 80% 0% No N=3,323 surveys; 3,323 responses to this question 20% Yes

2003 CRICO Renewal Survey

I am concerned about being named in a malpractice claim in the next five years.

100% 80% 54% 60% 40% 25% 21% 20% 12% 6% 6% 0% strongly disagree disagree somewhat disagree neither somewhat agree 20% agree N=3,323 surveys; 3,248 responses to this question 9% strongly agree

2003 CRICO Renewal Survey

My concern over the risk of being named in a malpractice claim has influenced my approach to patient treatment.

100% 61% 80% 60% 40% 31% 20% 13% 14% 6% 7% 0% strongly disagree disagree somewhat disagree neither somewhat agree 22% agree N=3,323 surveys; 3,247 responses to this question 8% strongly agree

As a result of an earlier crisis in the 70s

CRICO and RMF – 25 years of success

 Controlled Risk Insurance Company (CRICO) captive created in 1976 

Ten shareholder institutions

 CareGroup, Children's, Dana Farber, Harvard Pilgrim, Joslin Clinic, Judge Baker, Mass Eye and Ear, MIT, Partners, Harvard   

Operating structure: Insure:

GL CRICO Cayman, CRICO Vermont 8,700+ physicians, 25 hospitals, 100,000 employees, AL, PL,

Premium:

approximately $76 Million for $5 million coverage  Risk Management Foundation of the Harvard Medical Institutions (RMF) a membership organization created in 1979

Patient Safety and Risk Management Data Driven

Proactive Reactive

Learning

Standards of care Vulnerabilities Issues Defensibility Loss Prevention & Patient Safety

Adverse Clinical Event

Risk mitigation

Assertion of claim or lawsuit

Claims management and Defense

Process improvement Education /Research Investigation (RCA)

Medical management (peer review)

RMF:

Claims are the TIP of the iceberg!

public awareness

claims adverse events

hospital operations

“near misses” RMF claims RMF coding

“dirty laundry”

noise/anecdotes Institutional Issues

Mission: “To Assist our Insured Institutions in Making Harvard the Safest Place to Receive and Deliver Healthcare in the World”

Target Areas: Where we are now

91%

% cases (1997-2002) % incurred losses (1997-2002) 1990-1999 levels

39% 26% 37% 23% 24% 22% 19% 20% 16% 6% 5% 13% 12% 14% 8% 7% 67% 77% 55%

RMF Analysis Process & Technologies

RMF Integrated Processes & Technologies

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Patient Safety Initiatives

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C-MAPS U-MAPS Improved Care Improved Safety Loss Prevention Interventions

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CME On-Line

•

Publications/Web Site

•

Research & Guidelines Claims Investigation/Mgt Analysis and Research Service

•Data •Information •Knowledge •Experience •

EIS Aggregated Data

CRICO 1000 900 800 700 600 500 400 300 200 100 0 A D - AD B M R IN - IS BE TR H A A V TI C V IO J E R R - C E LI LA N IC TE A D L C JU O D - G C M O E M C N M S T U - N C IC LI A N TI IC O A N D L O S YS - D TE O C M U S M E N E N - TA EN TI VI O R N O N M EN E Q IL TA - - E L Q IN M U FO C IP - R M M M EN AT AN T IO AG N E N L D I IM C N IT AR O E N D E -IN N R O E LA SU - R N TE E O D R D R M P M N IS IS S - S U U E PE E S N S ID D IN E G N TI C FI LA ED S SI FI S C U AT - IO SU N PE TS R - V IS TE C IO H N N IC A L SK ZZ Z IL L - N O N E /N U LL CRICO

Select a specific insured org

Confidential Confidential

Confidential Confidential Confidential Confidential

Confidential Confidential

Themes from Recently Opened Large-Reserve Claims

Obstetrics   Several non-English speaking patients Interpretation of EFM    Prolonged second-stage labor Prenatal /genetic screening Nurse midwives: four cases  Shoulder dystocia  OB attending called in too late (3)

Themes from Recently Opened Large-Reserve Claims

Medication Error   Anticoagulation management Insulin mistaken for heparin added to TPN resulting in brain damage to infant

Themes from Recently Opened Large-Reserve Claims

Surgery   Several cases: indications for surgery not clear Non-English speaking patients     Informed decision-making not in evidence Delays in assessing post-op complications Poor systems for communicating and acting on abnormal test results Patients’ complaints not heard

Themes from Recently Opened Large-Reserve Claims

Diagnosis   Failure to perform colo-rectal screening Failure to adhere to breast care algorithm     Episodic care patients not getting baseline physical exams Phone consults by specialists when they have only limited history /context Residents deciding whether to admit or d/c without involvement of attending Patients’ concerns about symptoms not being considered

Ongoing Patient Safety Initiatives

 Culture and Leadership  2 Patient Safety Leadership Symposiums  6/25 (Board/Trustee/CEO/CMO/Chiefs)   8/14 (Operations) engaging inst. Board/Trustees  Bi-Monthly Patient Safety Action Group Meetings  Initiatives across the Harvard system are presented, discussed and potentially spread  CRICO Patient Safety Research Grants  10 awarded in May 2003

Ongoing Patient Safety Initiatives (cont)

 Surgery  BWH Surgery Observation Project: Atul Gawande, MD PI for Phase II  OB  Med Teams (Team Training) Dissemination: BIDMC → HVMA → MAH  Incentive Rating Project; favorable response  Diagnosis  Breast Care Algorithm newly revised and released  Colo-rectal Cancer Screening Algorithm

RMF:

Claims can provide a focus public awareness

claims adverse events

IOM report

“near misses” RMF claims RMF coding

patient safety

noise/anecdotes

OB Neonatal Surgery High Risk Investigations Medication Error related investigation

Healthcare Safety Research Institute, Inc.

Institution A

HSRI (501c3)

Institution B

RMF LP

Institution C



RMF Patient Safety Strategy (Quality/Risk/Safety)

fear of litigation…50% at CRICO

Institutions/Practice Groups Patient Safety/Risk

 desire to improve quality of care

Board/Senior Mgmt Clinical Chiefs

 engage/convene/facilitate/ educate/discover

Pt Safety Directors Operations

 26 years of coded claims/suit/ NM/AE data (root cause analysis)

Patients

 share data (for all to react to same data)

Patients

Concluding Remarks

 Is there a link between Malpractice and Patient Safety?

   YES!

issues in processes and systems of the delivery of care addressing Patient Safety will address our litigation crisis  Provide THEIR OWN cases and patterns from these cases to each institution…  medical outcome: function not only of performance of individual care givers but also function of the design and performance of the care delivery system

Concluding Remarks

"Medical malpractice claims and suits are a small, biased sample of clinical activity in a hospital. However, they do offer insight into potential areas where quality and safety improvements can be made. Using information generated from analysis of malpractice claims and suits, questions around risk reduction and safety improvement can be posed to an organization, with a point of reference."