Center for Patient and Professional Advocacy at Vanderbilt Patient Advocacy Reporting System (PARS...
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Transcript of Center for Patient and Professional Advocacy at Vanderbilt Patient Advocacy Reporting System (PARS...
Center for Patient andProfessional Advocacyat Vanderbilt
Patient Advocacy Reporting System (PARS®)Project:
Experiences of peer messengers who deliver uncomfortable news to physician colleagues
James W. Pichert, Ph.D. [email protected]
Center for Patient & Professional Advocacy, Vanderbilt University School of Medicine
www.mc.vanderbilt.edu/cppa1
Center for Patient andProfessional Advocacyat Vanderbilt
It Takes a Team – Thanks To:
• Jeff Jay• Peggy Westlake• Dr. Janis Karrass• Robert Wohlfarth• Nik Zakrzewski• Dr. Tom Catron• Dr. Jerry Hickson• Dr. Ilene Moore• Marbie Sebes
• Kelly Blumenberg• Sue Garey• Heather Pottkotter• Stephanie Marks• Heather Gillespie• Brittney Jenkins• Cindy Butts, Ann Loffi• Debbie Toundas• Carol Farina
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Center for Patient andProfessional Advocacyat Vanderbilt
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The PARS® Project
• Fair, systematic process involves surveillance for all professionals; IDs & intervenes with outliers:• Promotes professionalism, fair/just culture• Addresses and reduces malpractice risk/cost and
unprofessional behavior• Helps satisfy regulatory requirements
• Can help improve interactions among pts and care providers, leading to better outcomes
• Helps competitive advantage by IDing and helping address threats to reputation and patient safety
Center for Patient andProfessional Advocacyat Vanderbilt
The PARS® Project Overview
• PARS® identifies and supports interventions on high-malpractice-risk physicians (and healthcare facilities) using nationally-benchmarked scores derived from unsolicited patient complaints
• Results of >1,800 initial and follow-up interventions in practices ranging from rural hospitals to metropolitan medical centers show substantial:• Reduction in malpractice claims• Return on Investment
(Patient Advocacy Reporting System)
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PARS® SitesDevelopment SitesProspective SitesMajor Educ. Sites
Center for Patient andProfessional Advocacyat Vanderbilt
• 1-6%+ hospital patients injured due to negligence• ~2% of all patients injured by negligence sue• ~2-7x more patients sue without valid claims• Non-$$ factors motivate patients to sue• Some MDs/units attract more suits• High risk today = high risk tomorrow• Unsolicited comment/concerns predict claims• PARS® risk profiles make effective intervention tools
Medical Malpractice Research Background Summary
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Academic vs Community Medical Center
30 35 40 45 50 55 60 65 70 75 80 85 90 95 1000
25
50
75
100
Academic Med CtrCommunity Med Ctr
% of Physicians
% o
f Con
cern
s
35-50% are associated with NO concerns
Hickson et al., SMJ. 2007; Hickson et al., JAMA. 2002 Jun 12;287(22):2951-29577
50% of concerns associated with 9-14% of Physicians
Center for Patient andProfessional Advocacyat Vanderbilt
Critical Questions:
• If you were at high risk and there was a reliable method to identify and make you aware, would you want to know?
• If a member of your group was at high risk and you had a reliable system to identify and provide opportunity for improvement (and risk reduction), would you want her or him to know?
Center for Patient andProfessional Advocacyat Vanderbilt
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Who would you want to deliver the message to you?
And “when”?
Apparent pattern
Single “unprofessional" incidents (merit?)
Promoting Professionalism Pyramid
"Informal" Peer (or ?) Cup of Coffee
Intervention
Level 1 "Awareness" Intervention by Peer
Level 2 “Guided" Intervention by Authority
Level 3 "Disciplinary" Intervention by HR/legal
Pattern persists
No ∆
Vast majority of professionals - no issues - provide feedback on progress
Adapted from Hickson GB, Pichert JW, Webb LE, Gabbe SG, Acad Med, Nov, 2007
Mandated Reviews
Center for Patient andProfessional Advocacyat Vanderbilt
A Committee of “Messenger” Physician Peers is formed to deliver the data
Committee Members: • Are committed to confidentiality, fairness, respect• Are respected by colleagues• Are willing to serve (8 hours of training)• Most have risk scores below the intervention
threshold (but at several sites physicians intervened upon are messengers)
• Agree to review, then take data to outliers at request of messenger committee chair
(Under Existing QA/Peer Review)
Center for Patient andProfessional Advocacyat Vanderbilt
Intervention on Dr. __
• Letter with standings, assurances prior to & at meeting• “You are here” graph with
4-yr Risk Scores• Complaint Type Summary
“Concerns bullet list”– Redacted narrative reports
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Complaint Type SummaryDr. _____________Audit Period: Date 1 – Date 2
Complaint Type Categories
Number of Complaints Distribution of Complaints
Your Complaints
Average for Surgery
Your Complaints
Average for Surgery
Care & Treatment 19 4.5 30.2% 39.8%
Communication 15 2.9 23.8% 25.7%
Humanistic Concern 14 1.3 22.2% 11.5%
Access/Availability 9 1.9 14.3% 16.8%
Safety of Environment 0 0.0 0.0% 0.0%
Money/Payment Issues 6 0.7 9.5% 6.2%
Total # of Complaints 63 11.3
Total Number of Reports Note: each report may contain multiple complaints
Past 48 months 26 5.9
Past 12 months 6 1.7
Center for Patient andProfessional Advocacyat Vanderbilt
Representative Concerns by Category
Concern for Patient/Family• I never felt like he cared whether [my spouse] lived or died. He
does NOT live up to your motto• He may be famous worldwide for his surgery, but I have to tell
you that he’s also famous among the patients in his waiting room—and they come from all over—for being the rudest, crudest, most arrogant jerk doctor in this state
Communication• He did not keep us informed about my daughter’s condition…
and didn’t answer our questions• Pt upset with lack of info from Dr. __...no one is able to tell him
what his x-rays showCare and Treatment• Dr.___ delay in care made my mother’s medical status worse
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Center for Patient andProfessional Advocacyat Vanderbilt
What are these interventions all about?
First, some philosophy, process.Then we’ll see a PARS® intervention.
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Center for Patient andProfessional Advocacyat Vanderbilt
PARS® Level 1 “Awareness” Intervention
• “Messengers” agree to share data profiles• Make high risk providers aware of data via letter;
messenger makes visit to share scores, benchmarks, de-ID’d complaint reports
• No diagnoses or prescriptions, rather encourage creative thinking, problem solving
• Info is confidential beyond those designated to know; confidentiality is a high priority
• Annual follow-ups promote accountability• If no change, “Level 2” involves authorities, supports
those authorities with dataMoore, Pichert, Hickson, Federspiel, Blackford. Vanderbilt Law Review. 2006.
Center for Patient andProfessional Advocacyat Vanderbilt16
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Messenger Committee Co-chairs assign folders
Messengers meet with physicians, share data, complete debriefing report, report to Co-
chairs PRN; Co-chairs track intervention completion
Messenger physicians well trained to deliver interventions
Well trained messengers; CPPA provides 6 hrs well
tested intervention training
Debriefing report tracking & follow-up with messengers;
CPPA tracks meeting completion and outcomes, provides info to Co-chairs
Carefully considered assignments; CPPA provides
guidelines/experience for matching
The PARS® Process What is Required?
Center for Patient andProfessional Advocacyat Vanderbilt
Importance of Messenger Debriefing Reports
• Used for tracking the overall institutional progress of PARS® • Informs CPPA if meeting occurred and physician reaction• Helps CPPA determine if additional materials need to be
provided as follow-up• Send the form back to CPPA regardless of what happens at your
meeting If the meeting occurs, tell us how it went If it doesn’t occur, tell us how far you got in the process (i.e.
sent letter, contacted multiple times with no response, delivered materials but meeting did not occur, etc.)
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Center for Patient andProfessional Advocacyat Vanderbilt
PARS® Messenger Experiences
• Will Messengers agree to serve, be trained, serve over time?
• To what do high risk docs attribute their status?• Does “matching” of Messenger with High Risk
physician matter? (Physician specialty, other demographics)
• Does high flyer “outcome” correspond to their response at time of the intervention?
• What does this add to understanding of Physician change?
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Center for Patient andProfessional Advocacyat Vanderbilt
PARS® Messenger Experiences
• Date range 1/1/2005 – 12/31/2009: 5 years• Interventions Possible = 1151
• No meeting (refused, left, no report found) = 89 (7.9%)• Letter only: “done well…interventions suspended,” so
no regular debriefing= 143 (12.4%)• No L2s included as these are done by authorities
• Interventions with data = 919• # indiv human beings to be intervened upon = 554• # messengers = 233, most did 1-6 interventions
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Center for Patient andProfessional Advocacyat Vanderbilt
Length of Interventions
First interventions: Range (min) 5-90
Mean Length(minutes) 33
Median 30
Followup interventions: Range (min) 2-120
Mean Length(minutes) 30
Median 30
Center for Patient andProfessional Advocacyat Vanderbilt
Why might your practice stand out?
Center for Patient andProfessional Advocacyat Vanderbilt
Does Messenger Agree with “Issues”
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Agree (%) Disagree (%) Uncertain (%)
First Meeting
59 10 6
Follow Up All
58 12 9
Center for Patient andProfessional Advocacyat Vanderbilt
Does Messenger Agree with “Issues”
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Agree (%) Disagree (%) Uncertain (%)
First Meeting
59 10 6
Follow Up All
58 12 9
F-U Good 67 9 9
F-U Bad 51 23 8
F-U Mixed/ Neutral
58 9 9
Center for Patient andProfessional Advocacyat Vanderbilt
High Risk Physician “Receptivity”
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Positive Negative NeutralFirst-Time 81.8% 2.3% 16%Follow-Up 75.6% 1.9% 23%
Center for Patient andProfessional Advocacyat Vanderbilt
High Risk Physician “Receptivity”
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Positive Negative NeutralFirst-Time 81.8% 2.3% 16%Follow-Up 75.6% 1.9% 23% "Bad news" 17.0% 0.4% 6% "Good news" 27.0% 0.4% 5% "Mixed" "Neutral" "Recidivist"
Center for Patient andProfessional Advocacyat Vanderbilt
High Risk Physician “Receptivity”
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Positive Negative NeutralFirst-Time 81.8% 2.3% 16%Follow-Up 75.6% 1.9% 23% "Bad news" 17.0% 0.4% 6% "Good news" 27.0% 0.4% 5% "Mixed" 14.0% 0.0% 4% "Neutral" 15.7% 0.8% 7% "Recidivist"
Center for Patient andProfessional Advocacyat Vanderbilt
High Risk Physician “Receptivity”
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Positive Negative NeutralFirst-Time 81.8% 2.3% 16%Follow-Up 75.6% 1.9% 23% "Bad news" 17.0% 0.4% 6% "Good news" 27.0% 0.4% 5% "Mixed" 14.0% 0.0% 4% "Neutral" 15.7% 0.8% 7% "Recidivist” (n=15) 60.0% 6.7% 33%
# Follow-Up Interventions Needed to Reach "Visits
Suspended”
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Follow-up: feedback to high risk physicians--do scores improve
or, if not, initiate the process to move intervention to next level
Construct & deliver follow-up data/materials; CPPA provides yearly data and
recommendations (based on 10+ years exp)
The PARS® Process
Keep key leaders informed about risk score stats over
time, promote process
Periodic Risk Mgmt experience reviews
Prepare & deliver present’ns to key leaders; defend fairness
of process as needed; CPPA provides presentation
templates and data; special requests within reason
CPPA supports several risk mgmt and quality initiatives
----------------------------------------------------------------------------------------------------------
What is Required?
Center for Patient andProfessional Advocacyat Vanderbilt
Composite Physician Intervention Results on Complaints:
34 Hospitals/Med Groups
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Center for Patient andProfessional Advocacyat Vanderbilt
Total # of high complaint physicians 706Departed after initial intervention 48First follow-up later in 2011 –2012 134 Total with follow-up results 524
Results for those with follow-up data: Good – Intervention visits suspended 249 48% Good – Anticipate suspension in 2011-2012 94 18% Some improvement – Still need tracking 32 6%
Subtotal for those doing better 375 72% Unimproved/worse 107 20%
Departed Unimproved 42 8% Total follow-up results 524
PARS® Progress Report
35 This material is confidential and privileged information under the provisions set forth in T.C.A. §§ 63-1-150 and 68-11-272 and shall not be disclosed to unauthorized persons
Center for Patient andProfessional Advocacyat Vanderbilt
Total # high complaint physicians 97Departed after initial intervention 6First follow-up in 2012 7 Total with follow-up results 84
Results for those with follow-up data: Good – Intervention Visits suspended 46 (56%) Good – Anticipate suspension in 2012 7 (8%) Some Improvement—still needs tracking 7 (8%)
Subtotal 60 (72%) Unimproved/worse 12 (14%) Departed Unimproved 12 (14%) Total follow-up results 84
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VUMC PARS® Progress Report
This material is confidential and privileged information under the provisions set forth in T.C.A. §§ 63-1-150 and 68-11-272 and shall not be disclosed to unauthorized persons
Center for Patient andProfessional Advocacyat Vanderbilt
What about those who don’t improve?
• Departed: 34%• Continuing to receive feedback: 60%• Currently at “Level 2 Authority”: 6%
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Center for Patient andProfessional Advocacyat Vanderbilt
Level 2 Historical Outcomes
• N = 68• N = 22 (32%) first L2 this year, no follow-up
data• Improved: 28 (41%)• Remain unimproved: 18 (27%)
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Center for Patient andProfessional Advocacyat Vanderbilt
But does the PARS® Program produce a Return
on Investment (ROI)?We began with a pilot RCT…
39 Confidential and privileged pursuant to the provisions of Peer Review Statutes.
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Intervention Study Claims and Exposure Years Among High Risk Surgeons
0.38
0.47
0.40
0.24
0.0
0.1
0.2
0.3
0.4
0.5
Control Group Intervention Group
Ris
k M
anag
emen
t F
ile O
peni
ngs
with
E
xpen
ditu
res
Pre-InterventionPost-Intervention (p = 0.15)
RMF
Ope
ning
s w
ith E
xpen
ditu
res
per
Phys
icia
n-Ex
posu
re Y
ear
Malpractice Claims (per 100 MDs) FY1992 – 2009
* Data used with permission, State Volunteer Mutual Insurance Company, a mutual insurer of 10,500 TN non-VUMC physicians of all specialties, 29% to 33% who practiced in Middle TN during the target date.
This material is confidential and privileged information under the provisions set forth in T.C.A. §§ 63-1-150 and 68-11-272 and shall not be disclosed to unauthorized persons.
0
10
20
30
40
50
60
70
FY 99 FY 00 FY 01 FY 02 FY 03 FY 04 FY 05 FY 06 FY 07
Suits
per
MM
RVU
s
Academic Medical Center
Vanderbilt
Number of Suits per MM RVUs**trends continue, data pending expiration of statutes of limitations in two states represented
Center for Patient andProfessional Advocacyat Vanderbilt
Summary, limitations and discussion
• Messengers can be recruited and trained; they will serve over time
• Training needs to prepare for a range of reactions, assertions and questions (“push-backs”)
• High risk physicians “blame” external forces twice as often as internal issues—(and may be correct)
• Need more drill down re “matching”• Limitations: self reported data, what else?• What does this add to our understanding of just
culture and Phys/HCP change?
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Center for Patient andProfessional Advocacyat Vanderbilt
It Takes a Team – Thanks To:
• Jeff Jay• Peggy Westlake• Dr. Janis Karrass• Robert Wohlfarth• Nik Zakrzewski• Dr. Tom Catron• Dr. Jerry Hickson• Dr. Ilene Moore
• Marbie Sebes• Kelly Blumenberg• Sue Garey• Heather Pottkotter• Stephanie Marks• Heather Gillespie• Brittney Jenkins• All the messengers
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