Transcript RMF Operations Committee - American Society of Law

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
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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
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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%
80%
60%
40%
20%
20%
0%
No
N=3,323 surveys; 3,323 responses to this question
Yes
2003 CRICO Renewal Survey
I am concerned about being named in a
malpractice claim in the next five years.
100%
54%
80%
60%
40%
21%
20%
25%
20%
12%
6%
9%
6%
0%
strongly
disagree
disagree
N=3,323 surveys; 3,248 responses to this question
somewhat
disagree
neither
somewhat
agree
agree
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%
22%
20%
14%
13%
8%
7%
6%
0%
strongly
disagree
disagree
N=3,323 surveys; 3,247 responses to this question
somewhat
disagree
neither
somewhat
agree
agree
strongly
agree
As a result of an earlier crisis in the 70s
CRICO and RMF – 25 years of success
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Controlled Risk Insurance Company (CRICO) captive created in 1976
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Ten shareholder institutions  CareGroup, Children's, Dana Farber, Harvard Pilgrim, Joslin Clinic,
Judge Baker, Mass Eye and Ear, MIT, Partners, Harvard
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Operating structure: CRICO Cayman, CRICO Vermont
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Insure: 8,700+ physicians, 25 hospitals, 100,000 employees, AL, PL,
GL
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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
Standards
of care
Learning
Reactive
Vulnerabilities
Loss Prevention &
Patient Safety
Risk mitigation
Adverse
Clinical
Event
Process
improvement
Education
/Research
Medical management
(peer review)
Issues
Defensibility
Assertion of
claim or
lawsuit
Investigation
(RCA)
Claims
management
and Defense
RMF: Claims are the TIP of the iceberg!
public
awareness
claims
RMF claims
adverse events
RMF coding
hospital
operations
“near misses”
“dirty
laundry”
Institutional
Issues
noise/anecdotes
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
100%
91%
% cases (1997-2002)
% incurred losses (1997-2002)
80%
percent of all CRICO
67% 77%
1990-1999 levels
60%
55%
39%
40%
26%
20%
37%
23%
24% 22%
19% 20%
16%
6% 13%
5%
0%
Diagnosis
Surgery
Obstetrics
12% 14%
8%
7%
Medication
Subtotal
RMF Analysis Process & Technologies
RMF Integrated Processes & Technologies
•Patient Safety
Initiatives
Improved Care
Improved Safety
Loss Prevention
Interventions
•CME On-Line
•Publications/Web Site
•Research & Guidelines
•C-MAPS
•U-MAPS
Claims Investigation/Mgt
Analysis
and
Research
Service
•Data
•EIS
•Information
•Knowledge
•Experience
Aggregated Data
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CRICO
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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
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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)
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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
RMF claims
claims
adverse events
RMF coding
IOM
report
“near misses”
patient
safety
noise/anecdotes
OB Neonatal
Surgery High Risk Investigations
Medication Error related investigation
Healthcare Safety Research Institute, Inc.
RMF
Institution A
LP
HSRI (501c3)
Institution B
Institution C
RMF Patient Safety Strategy (Quality/Risk/Safety)
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fear of litigation…50% at
CRICO
desire to improve quality of
care
Institutions/Practice Groups
Patient Safety/Risk
Board/Senior Mgmt
Clinical Chiefs
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engage/convene/facilitate/
educate/discover
26 years of coded claims/suit/
NM/AE data (root cause
analysis)
Pt Safety Directors
Operations
Patients
share data
(for all to react to same data)
Patients
Concluding Remarks
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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."