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					 Annual NPSF
 Patient Safety
   Congress         ISSUES IN AMBULATORY
                    PATIENT SAFETY
                    SOME PRACTICAL
May 14 - 16, 2008
Gaylord Opryland
                    IMPLEMENTATIONS
 Nashville, TN
                    ALAN LEMBITZ MD, COPIC
      PATIENT SAFETY BARRIERS

    • We understand the problem
    • We have enough reports and data to move
      forward
    • “We have the met the enemy, and he is
      us” (POGO)




2008 NPSF Patient Safety Congress   Connect, Communicate, Commit
        PATIENT SAFETY BARRIERS

    •   Unexplained Clinical Variation
    •   Process
    •   Culture
    •   Training and Experience
    •   Human Factors
    •   Complexity and Accelerating Technology



2008 NPSF Patient Safety Congress   Connect, Communicate, Commit
                             One Perspective

    • COPIC
    • 6000 Physicians in CO, 1000 in NE, about
      50 hospitals, and nearly 100 ambulatory
      centers (Imaging, Cardiology, GI,
      Surgery,etc)
    • 23 years of Data
    • 22 FTE‟s, (4 MD, 1 RN/JD, 10 RN‟s, 3
      Healthcare administrators, support staff),
      plus consultants

2008 NPSF Patient Safety Congress          Connect, Communicate, Commit
                              COPIC MODEL

    • Direct relationship between claims and
      professional liability premiums.
    • Distributions over $120 M over time, $12M
      in 2008.
    • Physicians- ERS points system for
      discount
    • Hospitals- premium credit for favorable
      experience

2008 NPSF Patient Safety Congress       Connect, Communicate, Commit
        OVERCOMING THE BARRIERS

    • Practice Quality Initiative
    • 3Rs initiative
    • Educational seminars- 425 in 2007.
    • Resident Education- 120 in 2007, more in
      2008.
    • Other Initiatives- OB, EMed, Team
      Training


2008 NPSF Patient Safety Congress   Connect, Communicate, Commit
        OVERCOMING THE BARRIERS

    • Reporting Encouraged/ Required
    • Disclosure Encouraged/ Strongly
      Recommended
    • ERS points




2008 NPSF Patient Safety Congress   Connect, Communicate, Commit
                                    Does it work?

    •   Practice Quality Process
    •   Every 2 years, ALL office practices
    •   Electronic Report at time of visit
    •   Interrater Reliability and Standard Criteria
    •   Feedback Loop




2008 NPSF Patient Safety Congress                   Connect, Communicate, Commit
                  Practice Quality Criteria

    • 2002 thru 2007– P/F Scoring on Level
      One Criteria
    • Letter for follow-up and revisit




2008 NPSF Patient Safety Congress     Connect, Communicate, Commit
           LEVEL ONE RISK
       MANAGEMENT GUIDELINES
   DOCUMENTATION ISSUES
      Legibility
      Medical Records Alterations
      Allergy Flag
      Prescription Medication List
      Informed Consent Documentation
      Telephone Charting
   TRACKING AND REMINDER ISSUES
      Appointment Tracking
      Test Tracking
      Review/Signing of Incoming Reports

         Test Follow-Up Contact System



2008 NPSF Patient Safety Congress           Connect, Communicate, Commit
    Improvement in Practice Quality Evaluation Scores
             Following Feedback Process




2008 NPSF Patient Safety Congress       Connect, Communicate, Commit
                 ACTUARIAL ANALYSIS

    • METHOD
          – Rate relative risk, adjusted by specialty,
            FT/PT, exposure years for each score cohort
            vs. entire population serving as control




2008 NPSF Patient Safety Congress          Connect, Communicate, Commit
                 ACTUARIAL ANALYSIS

    •   10/10                   -23.95%
    •   9/10                    -24.58%
    •   8/10                    -5.71%
    •   7/10                    -0.84%
    •   6/10                    +12.64%
    •   5 or less               +10.71%



2008 NPSF Patient Safety Congress         Connect, Communicate, Commit
         Use Team Approach With
       Patients, Staff and Colleagues
    • With Patients
      Address concerns and include them in
      decision-making process
    • Be clear about plan and f/u (timelines) and
      ensure comfort with decisions made
    Discuss risks of not following up and
      document this
    “Informed Refusal

2008 NPSF Patient Safety Congress    Connect, Communicate, Commit
                       Communication with
                         Patients/Family
                   Health Illiteracy
       • 25% of adults function below 5th
         grade reading level (front page of the
         newspaper); another 25% at or barely
         above that level
       • Ask directed questions to make sure
         the patient/family member
         understands


2008 NPSF Patient Safety Congress     Connect, Communicate, Commit
             Use Team Approach With
            Patients, Staff and Colleagues
    • With Staff
          – Develop Protocols
          – Standardize Processes
          – Empowerment and Assertiveness
    • With Colleagues
          –   Provide Hx to Radiologists and Pathologists
          –   Clarify issues for w/u and f/u - “who‟s carrying flag?”
          –   Hand-offs
          –   Standardized Consent Forms
          –   Informed Refusals
          –   Document these discussions


2008 NPSF Patient Safety Congress                     Connect, Communicate, Commit
              DOCUMENTATION ISSUES

             Legibility
             Medical Record Alterations
             Allergy Flags
             Prescription Medication List
             Informed Consent Documentation
             Telephone Charting




2008 NPSF Patient Safety Congress              Connect, Communicate, Commit
       LEGIBILITY IN AN ELECTRONIC
                WORLD
    • CO Data from office site visits 24.7% reported EMR
    • In 2007, no demonstrable difference in PQ scores EMR
      vs. non-EMR
    • Beware the „Incredible‟ record.
    • Know what is shown on all views/screens and assure
      that input populates the views/screens used in the
      workflow
    • Fraud can be inadvertent, know what a macro, a
      keystroke, a click generates in the record
    • Allow for learning environment for all with input from all.
      EMR highlights the teamwork when used properly.


2008 NPSF Patient Safety Congress                 Connect, Communicate, Commit
             TRACKING AND REMINDER
                    ISSUES

       Appointment Tracking
       Test Tracking
       Review/Signing of Incoming Reports
       Test Follow-Up Contact System Critical follow-
        up
          – Office lab, xray, consults
          – Pre-operative data
          – Communications


2008 NPSF Patient Safety Congress          Connect, Communicate, Commit
                                New for 2008

    • Now 12 Level One
          – Added Problem List
          – Added Vital Sign Documentation


    • Electronic Staff Ambulatory Safety
      Attitudes Questionnaire (adapted from
      AHQ)
    • Electronic Patient Satisfaction Survey

2008 NPSF Patient Safety Congress              Connect, Communicate, Commit
                        PRACTICE QUALITY




2008 NPSF Patient Safety Congress     Connect, Communicate, Commit
                                    Research

    • Which Level One is most associated with
      adverse claims experience?
    • Are office SAQ‟s correlated?, If so, which
      questions?
    • Are patient satisfaction scores correlated?
    • Do adverse events and claims arising from the
      office setting decrease with this intervention?
    • Does EMR reduce malpractice claims? What is
      temporal relationship to implementation?

2008 NPSF Patient Safety Congress              Connect, Communicate, Commit
                               3Rs program
                                Overview

            A disclosure and an early intervention reimbursement
            program designed to preserve the physician patient
            relationship

                                            Voluntary, non-fault
              Program began in 2000           based program




2008 NPSF Patient Safety Congress                     Connect, Communicate, Commit
                               3Rs program
                   Program goals
                   Preserve doctor-patient relationship
                   Assist patient to physical, emotional and financial
                    wellness
                   Learn from experience
                   Encourage open/honest communication including
                    disclosure of unanticipated event
                   Encourage expressions of concern including an apology
                    when appropriate
                   Meet patients’ needs at crucial time
                   Reduce litigation expenses
                 Patient does NOT sign any waiver




2008 NPSF Patient Safety Congress                          Connect, Communicate, Commit
                                3Rs benefits

                 Addresses the needs of this patient
                     Information
                     Emotional support
                     Financial assistance
                     Early return to function
                     Protect and preserve the
                       patient/physician relationship




2008 NPSF Patient Safety Congress                Connect, Communicate, Commit
                                    Exclusions
                 Death
                 Formal written demand for compensation
                 Obvious substandard care– The National Quality
                  Forum ―Never Events‖
                  (e.g., wrong site/wrong level surgery)
                 Summons and complaint
                 Attorney involvement
                 Request for BME involvement
                 Physician has ―right of refusal‖




2008 NPSF Patient Safety Congress                     Connect, Communicate, Commit
          3Rs program background
                 COPIC’s claim philosophy



                 Compensate only negligently injured patients
                 Minimize waste of resources in tort system
                 Defend defensible medicine regardless of cost




2008 NPSF Patient Safety Congress                      Connect, Communicate, Commit
          3Rs program background
            Traditional claim system broken

                Ineffective and inefficient
                Adversarial
                Patient/Physician relationship shattered
                Unfair compensation
                Expensive
                Drawn out
                Does not reliably identify substandard care




2008 NPSF Patient Safety Congress                        Connect, Communicate, Commit
              3Rs program case study


              65 y/o female undergoes attempted lap
               assisted vaginal hysterectomy
              Path=minimally invasive Grade I endometrial
               cancer
              Path=segment Left ureter excised
              Options discussed, underwent Left
               Nephrectomy
              Reimbursed airfare from Massachusetts for
               son and $150 in gardening bills
              Physician/patient relationship preserved

2008 NPSF Patient Safety Congress              Connect, Communicate, Commit
  Lessons learned from patients                                  Financial

                Poor                             No Information
                                    Confusion
             Communication                           or Help




                          ANGER          Frustration




                          Financial                     Legal
                           Trauma                      Consult
    Break In Relationship Build-up
    Physical                                 Social             Emotional
                                            Pressure
2008 NPSF Patient Safety Congress                      Connect, Communicate, Commit
              3Rs program case study
               6y/o male present to ortho with femur fx and
                is placed in hip spica cast
               F/u x-ray shows angulation/shortening
               Parents seek second opinion, pt undergoes
                external fixation
               Parents are reimbursed $8,575 for unpaid
                medical and loss of time
               Very appreciative of assistance




2008 NPSF Patient Safety Congress                Connect, Communicate, Commit
                 3Rs program specifics

           • Program consideration
           • Obtain I’m sorry legislation
           • Protects health care providers
             expressions of concern regarding
             an unanticipated medical outcome
             from being used ―against interest‖
             in a lawsuit
           • Signed into law 5/03




2008 NPSF Patient Safety Congress         Connect, Communicate, Commit
          Available patient benefits
 • Reimbursement of related out-
   of-pocket medical expenses up
   to $25,000
 • $100 per day, up to 50 days, to
   recognize extended loss of time
   from normal activities
 • Reimbursement received in a
   timely fashion




2008 NPSF Patient Safety Congress    Connect, Communicate, Commit
             Other issues / incentives


      • Incentive for Participation-ERS point
      • No waiver or release requested from patient
      • No Reporting to NPDB or BME




2008 NPSF Patient Safety Congress      Connect, Communicate, Commit
                                    3Rs process
                Patient perspective
                  – Informed of program by physician
                  – Given 3R document explaining program
                     • Signs no waiver
                     • May pursue legal action, if desired
                     • May complain to the BME
                  – Contacted by program administrators




2008 NPSF Patient Safety Congress                 Connect, Communicate, Commit
              3Rs process (continued)
                            COPIC perspective
                 Incident meets 3Rs criteria
                 Physician and 3Rs
                  administrator agree to proceed
                 Expression of concern +
                  apology
                 Explanation
                 Plan
2008 NPSF Patient Safety Congress               Connect, Communicate, Commit
           Physician responsibilities
         • Recognize and report incidents per
           usual procedure
         • Respond to patient/family questions
         • Explain injury (not a fault/blame
           discussion)
         • Express concern, regret, empathy,
           apology
         • Project future needs-hospital, meds,
           surgery, disability, etc.
         • Assist with further RX, rehab, etc...

2008 NPSF Patient Safety Congress     Connect, Communicate, Commit
                 3Rs program specifics
                 Physician responsibilities 3445 in CO,
                               490 in NE
           Investigate and implement practice alterations
            designed to avoid injury in the future
           Continue to address patient’s physical and
            emotional needs
           Allow 3Rs Administrator to assist patient with
            financial needs
           Be willing to attend COPIC’s educational seminars
            addressing physician/patient communication


2008 NPSF Patient Safety Congress             Connect, Communicate, Commit
       After an incident is resolved
              Feedback from subjective evaluations
             Patient and physician complete questionnaire
             Physician/Patient relationships almost always
              still in tact
             Medical Director Call to discuss outcome,
              surveys, lessons learned, and value of early
              reporting
             Patient’s evaluations all favorable except
              patient’s perception of most physician’s
              communication skills not favorable
             Physician’s false perception of their own
              communication skills


2008 NPSF Patient Safety Congress              Connect, Communicate, Commit
              3Rs program case study
               55 y/o judge undergoes takedown gastric
                bypass, ventral hernia repair, develops
                enterocutaneous fistula
               Missed 6 months work, underwent 8
                procedures, extensive parenteral nutrition
               Reimbursed $30,000 for loss of time and
                unpaid medical
               Patient very grateful; offered to sign release
               Maintains relationship with physician




2008 NPSF Patient Safety Congress                  Connect, Communicate, Commit
              3Rs program case study
               68y/o male presents to ER with colon perf and
                undergoes primary repair
               Repair fails requiring return to OR for sigmoid
                colon resection
               Pt required extended hospitalization
               Reimbursed $11,167 for unpaid medical
                expenses and loss of time
               Grateful for assistance




2008 NPSF Patient Safety Congress                 Connect, Communicate, Commit
                                    3Rs survey

          Survey of patients paid in 3Rs program post-closure of case

              98% would recommend program to others
              96% rate case manager as acceptable or
               excellent
              70% satisfied with physician
               (COPIC goal: improve patient satisfaction)
              99% of physicians are satisfied with the
               program




2008 NPSF Patient Safety Congress                     Connect, Communicate, Commit
           3Rs program advantages /
                   lessons
          Adverse event from the patient’s perspective


               Results of focus group interviews
               3Rs Program patients interviewed in
                collaboration with UCHSC researcher
               Identified patient experiences/needs
               Worries
               Traumas - physical, emotional, financial
               Frustrations



2008 NPSF Patient Safety Congress                        Connect, Communicate, Commit
            3Rs program advantages /
                    lessons
            Patient testimonials

        •    ―We are simply overwhelmed at receiving such a positive and
             helpful response to our situation…with your and COPIC’s help it
             was not nearly as traumatic as it may have been.‖
        •    ―Thank you - it is an excellent program.‖
        •    ―This is an excellent alternative for settling medical misfortunes.
             The positive nature of the program allowed all of us to heal
             rather than to grieve.‖
        •    ―This program really helped us financially when I couldn’t work
             and needed it most.‖




2008 NPSF Patient Safety Congress                              Connect, Communicate, Commit
          3Rs program advantages /
                              lessons
          Physician testimonials
     •   ―3Rs Program helps defuse unexpected outcomes at same time
         giving support and additional source of caring to patients; money
         well spent. I’m personally grateful for the 3Rs Program and feel it
         likely averted litigation.‖
     •   ―Thanks, this is a great idea. Communication and understanding are
         key. This patient is still my patient.‖
     •   ―Rapid attention to patient’s concerns defused the situation.‖
     •   ―Both the patient and her mother have elected to continue care with
         me and my office. I consider this to be the ultimate sign of a
         successful resolution.‖
     •   ―I feel this may be the most helpful program I’ve seen a malpractice
         carrier implement. Fantastic.‖




2008 NPSF Patient Safety Congress                          Connect, Communicate, Commit
     3Rs Physician participation
     by specialty Procedural vs.
          non-procedural
                      CO data              NE data

             Procedural 80%        • Procedural 49%
             Non- Procedural       • Non-Procedural
              37%                     40%




2008 NPSF Patient Safety Congress           Connect, Communicate, Commit
           3Rs program—Disclosure
                   training
             3282 doctors voluntary participation
             34 communication seminars 1010
              attendees
             95 disclosure workshops 2351 attendees




2008 NPSF Patient Safety Congress        Connect, Communicate, Commit
          3Rs physician participation (voluntary)
                Most common specialties
            By physician # (CO)             By 3Rs $ paid (CO)

               Family Medicine (all) 531
               Emergency Med 388              OBGYN and GYN $1.34M
               Internal Med(not GI) 331       General Surgery $891K
               Ob-GYN& Gyn 321                Ortho Surgery $677K
               Orthopedic Surgery 238         GI $380K
               Radiology 223                  Family Medicine $330K
               Pediatrics 204                 Emergency Med $175K
                General Surgery 175           IM not GI $109K
                                               Radiology $94K
               Gastroenterology 104
                                               Pediatrics $26K




2008 NPSF Patient Safety Congress                     Connect, Communicate, Commit
             3Rs cases paid summary
                  1025 Occurrences paid and closed in
                   3Rs
                  366 Occurrences paid and in progress
                   in 3Rs
                  1391 Total 3Rs occurrences with 3Rs
                   payments
                  Average payment $5300 for paid and
                   closed in 3Rs; $5.8 M since inception




2008 NPSF Patient Safety Congress            Connect, Communicate, Commit
 3Rs cases paid and proceeded
 to claims (not formal litigation/
              suits)
                20 occurrences progressed into claims
                 (not in formal suit)
                13 paid in 3Rs, subsequently closed in
                 claims
                2 additional Indemnity $350K total
                Only $31K LAE for these 13
                7 paid in 3Rs, subsequently open in
                 claims $TBD



2008 NPSF Patient Safety Congress                Connect, Communicate, Commit
    3Rs cases paid and proceeded to
         formal litigation (suits)
             14 occurrences paid in 3Rs subsequently
                 progressed into formal suit
             7 of these subsequently closed
             3 settled $226K indemnity (1 Plastics, 1 Ob-gyn)
             1 defense verdict, >$170K LAE (Opth refractive
                 case)
             3 dropped, 0 additional indemnity (Gyn
                 complications)
             7 of these open suits
             2 cases are gyn complications
             1 case is GS appy complication
             1 case is Opth blepharoplasty complication
                 $TBD
2008 NPSF Patient Safety Congress               Connect, Communicate, Commit
       Occurrences not paid in 3Rs
            estimate of total
               $ incurred
            Compare 3Rs average of $5300 plus additional
             resolution costs for cases requiring further
             claims intervention
            Estimate $6000/occurrence for 3Rs pd cases.
            Estimate average total Incurred for average
             occurrences of all COPIC occurrences=
             $10,000+ (Indemnity and ALAE
             average/occurrence) plus administrative
             expense


2008 NPSF Patient Safety Congress             Connect, Communicate, Commit

				
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