Linking Malpractice with Patient Safety Luke Sato, MD Chief Medical Officer & Vice President Loss...

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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

Transcript of Linking Malpractice with Patient Safety Luke Sato, MD Chief Medical Officer & Vice President Loss...

Page 1: Linking Malpractice with Patient Safety Luke Sato, MD Chief Medical Officer & Vice President Loss Prevention and Patient Safety Risk Management Foundation.

Linking Malpractice with Patient Safety

Luke Sato, MDChief Medical Officer & Vice President

Loss Prevention and Patient SafetyRisk Management FoundationHarvard Medical Institutions, Inc.

Assistant Clinical Professor of MedicineHarvard Medical School

Friday, September 12, 2003Strategies for Protecting Patient Safety

Page 2: Linking Malpractice with Patient Safety Luke Sato, MD Chief Medical Officer & Vice President Loss Prevention and Patient Safety Risk Management Foundation.
Page 3: Linking Malpractice with Patient Safety Luke Sato, MD Chief Medical Officer & Vice President Loss Prevention and Patient Safety Risk Management Foundation.

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

Page 4: Linking Malpractice with Patient Safety Luke Sato, MD Chief Medical Officer & Vice President Loss Prevention and Patient Safety Risk Management Foundation.

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

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2003 CRICO Renewal Survey

80%

20%

0%

20%

40%

60%

80%

100%

No Yes

N=3,323 surveys; 3,323 responses to this question

I have been named in a medical malpractice lawsuit.

Page 6: Linking Malpractice with Patient Safety Luke Sato, MD Chief Medical Officer & Vice President Loss Prevention and Patient Safety Risk Management Foundation.

2003 CRICO Renewal Survey

6%12%

6%

21%25%

20%

9%

0%

20%

40%

60%

80%

100%

stronglydisagree

disagree somewhatdisagree

neither somewhatagree

agree stronglyagree

54%

N=3,323 surveys; 3,248 responses to this question

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

Page 7: Linking Malpractice with Patient Safety Luke Sato, MD Chief Medical Officer & Vice President Loss Prevention and Patient Safety Risk Management Foundation.

2003 CRICO Renewal Survey

6%13%

7%14%

31%

22%

8%

0%

20%

40%

60%

80%

100%

stronglydisagree

disagree somewhatdisagree

neither somewhatagree

agree stronglyagree

61%

N=3,323 surveys; 3,247 responses to this question

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

Page 8: Linking Malpractice with Patient Safety Luke Sato, MD Chief Medical Officer & Vice President Loss Prevention and Patient Safety Risk Management Foundation.

As a result of an earlier crisis in the 70s

Page 9: Linking Malpractice with Patient Safety Luke Sato, MD Chief Medical Officer & Vice President Loss Prevention and Patient Safety Risk Management Foundation.

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

GL Premium: approximately $76 Million for $5 million coverage

Risk Management Foundation of the Harvard Medical Institutions (RMF) a membership organization created in 1979

Page 10: Linking Malpractice with Patient Safety Luke Sato, MD Chief Medical Officer & Vice President Loss Prevention and Patient Safety Risk Management Foundation.

Patient Safety and Risk Management Data Driven

Claims management and Defense

Investigation(RCA)

ReactiveProactive

Risk mitigationAssertion of

claim or lawsuit

DefensibilityIssues

Loss Prevention &Patient Safety

Process improvement

Education/Research

Medical management (peer review)

LearningStandards

of careVulnerabilities

Adverse Clinical Event

Page 11: Linking Malpractice with Patient Safety Luke Sato, MD Chief Medical Officer & Vice President Loss Prevention and Patient Safety Risk Management Foundation.

“near misses”

noise/anecdotes

RMF: Claims are the TIP of the iceberg!

“dirtylaundry”

hospitaloperations

publicawareness

adverse events

claims RMF claims

RMF coding

InstitutionalIssues

Page 12: Linking Malpractice with Patient Safety Luke Sato, MD Chief Medical Officer & Vice President Loss Prevention and Patient Safety Risk Management Foundation.

Mission:

“To Assist our Insured Institutions in Making Harvard the Safest Place to Receive

and Deliver Healthcare in the World”

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Target Areas: Where we are nowpe

rcen

t of

all

CR

ICO

26% 24%

6%

12%

67%

39%

22%

16% 14%

91%

0%

20%

40%

60%

80%

100%

Diagnosis Surgery Obstetrics Medication Subtotal

23%

5% 8%

37%

20%

13%7%

19%

55%

77%

0%

20%

40%

60%

80%

100%

Diagnosis Surgery Obstetrics Medication Subtotal

% cases (1997-2002)

% incurred losses (1997-2002)

1990-1999 levels

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RMF Analysis Process & Technologies

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Claims Investigation/Mgt

Aggregated Data

Analysis and

Research

Loss PreventionInterventions

Improved CareImproved Safety

RMF Integrated Processes

•Patient Safety Initiatives

Service•Data

•Information•Knowledge•Experience

•EIS

•CME On-Line•Publications/Web Site•Research & Guidelines

•C-MAPS•U-MAPS

& Technologies

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CRICO

0

100

200

300

400

500

600

700

800

900

1000

AD - ADM

INIS

TRATIVE

BR - BEHAVIO

R RELA

TED

CJ - C

LINIC

AL JU

DGMENT

CO -

COMM

UNICATIO

N

CS - CLI

NICAL

SYSTEMS

DO -

DOCUM

ENTATION

EN - ENVIR

ONM

ENTAL

EQ - EQUIP

MENT

IL -

INFO

RMATIO

N LIM

ITED

MC -

MANAGED C

ARE RELA

TED

NI - N

ON-INSURED R

M IS

SUES

NO -

NO R

M ISSUES ID

ENTIFIE

D

PN - PENDIN

G CLA

SSIFIC

ATION

SU - SUPERVIS

ION

TS - TECHNIC

AL SKIL

L

ZZZ - NONE/N

ULL

CRICO

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Select a specific insured org

Page 22: Linking Malpractice with Patient Safety Luke Sato, MD Chief Medical Officer & Vice President Loss Prevention and Patient Safety Risk Management Foundation.

Confidential

Confidential

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ConfidentialConfidential

ConfidentialConfidential

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Confidential

Confidential

Page 25: Linking Malpractice with Patient Safety Luke Sato, MD Chief Medical Officer & Vice President Loss Prevention and Patient Safety Risk Management Foundation.
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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)

Page 27: Linking Malpractice with Patient Safety Luke Sato, MD Chief Medical Officer & Vice President Loss Prevention and Patient Safety Risk Management Foundation.

Themes from Recently Opened Large-Reserve Claims

Medication Error Anticoagulation management Insulin mistaken for heparin added to TPN resulting

in brain damage to infant

Page 28: Linking Malpractice with Patient Safety Luke Sato, MD Chief Medical Officer & Vice President Loss Prevention and Patient Safety Risk Management Foundation.

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

Page 29: Linking Malpractice with Patient Safety Luke Sato, MD Chief Medical Officer & Vice President Loss Prevention and Patient Safety Risk Management Foundation.

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

Page 30: Linking Malpractice with Patient Safety Luke Sato, MD Chief Medical Officer & Vice President Loss Prevention and Patient Safety Risk Management Foundation.

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

Page 31: Linking Malpractice with Patient Safety Luke Sato, MD Chief Medical Officer & Vice President Loss Prevention and Patient Safety Risk Management Foundation.

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

Page 32: Linking Malpractice with Patient Safety Luke Sato, MD Chief Medical Officer & Vice President Loss Prevention and Patient Safety Risk Management Foundation.

“near misses”

noise/anecdotes

RMF: Claims can provide a focus

patientsafety

IOMreport

publicawareness

adverse events

claims

Surgery High Risk InvestigationsMedication Error related investigationOB Neonatal

RMF claims

RMF coding

Page 33: Linking Malpractice with Patient Safety Luke Sato, MD Chief Medical Officer & Vice President Loss Prevention and Patient Safety Risk Management Foundation.

Institution A

Peer Review Protected

Peer Review Protected

Peer Review Protected

Peer Review Protected

Institution C Peer Rev

iew Protec

ted

Peer Rev

iew Protec

ted

Institution B

Peer Review ProtectedPeer Review Protected

RMFRMFRMFRMF

HSRI (501c3)HSRI (501c3)HSRI (501c3)HSRI (501c3)

LPLPLPLP

Healthcare Safety Research Institute, Inc.

Page 34: Linking Malpractice with Patient Safety Luke Sato, MD Chief Medical Officer & Vice President Loss Prevention and Patient Safety Risk Management Foundation.

RMF Patient Safety Strategy (Quality/Risk/Safety)

fear of litigation…50% at CRICO

desire to improve quality of care

engage/convene/facilitate/educate/discover

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

share data(for all to react to same data)

Board/Senior Mgmt

Clinical Chiefs

Pt Safety Directors

Operations

Patient Safety/Risk

Patients

Patients

Institutions/Practice Groups

Page 35: Linking Malpractice with Patient Safety Luke Sato, MD Chief Medical Officer & Vice President Loss Prevention and Patient Safety Risk Management Foundation.

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

Page 36: Linking Malpractice with Patient Safety Luke Sato, MD Chief Medical Officer & Vice President Loss Prevention and Patient Safety Risk Management Foundation.

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."


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