what’s risk management got to do with it?
DESCRIPTION
What’s Risk Management Got to Do With It?. What's Risk Management Got to Do With It?. MODERATOR : Paul Greve , JD, RPLU, Executive Vice President/Senior Consultant, Willis Healthcare Practice Mark DeFrancesco , MD, MBA, Medical Director, Women’s Health USA - PowerPoint PPT PresentationTRANSCRIPT
2008 Medical Professional 2008 Medical Professional Liability SymposiumLiability Symposium
Chicago, Illinois ~ March 11 & 12, 2008
What’s Risk Management Got What’s Risk Management Got to Do With It?to Do With It?
What's Risk Management What's Risk Management Got to Do With It? Got to Do With It?
• MODERATOR: Paul Greve, JD, RPLU, Executive Vice President/Senior Consultant, Willis Healthcare Practice
• Mark DeFrancesco, MD, MBA, Medical Director, Women’s Health USA
• Bruce W. Dmytrow, BA, MBA, CPHRM, Vice President, U.S. Specialty Lines,
CNA Healthcare • Charles Kolodkin, MBA, JD, CPCU, DFASHRM,
Executive Director, Enterprise Risk,Cleveland Clinic
• Daniel Sullivan, MD, JD, President & CEO, The Sullivan Group
Risk Management Comes Risk Management Comes to the Forefrontto the Forefront
• IOM Report (2000)• Leapfrog• IHI 100,000 Lives Campaign• AHRQ Evidence-Based Patient Safety
Practices• JCAHO Patient Safety Standards
Sentinel Events Root Cause Analysis
• Federal & State Legislation- Patient Safety
The Purpose of Risk The Purpose of Risk ManagementManagement
• Protect the Assets of the Healthcare Organization
The Purpose of Patient The Purpose of Patient SafetySafety
• Freedom from Injury or Illness Resulting from the Processes of Care
Definition of Patient Safetyby National Quality Foundation
Risk Management FocusRisk Management Focus
• Broader Focus than Patient Safety
• Risk Financing and Risk Control
• Pre-Claim and Post-Claim
Patient Safety FocusPatient Safety Focus
• Improving Care by Improving Systems• Creating a Culture Where Everyone can Speak Up
and Suggest Improvements• Not Looking to Blame Individuals for Patient Harm –
Look for the System Failure• Rewarding Individuals Who Reveal
Incidents of Harm Near Misses System Weaknesses
• Improving Patient Hand-Offs
Source: OHIC Insurance Company, 2007
Healthcare Risk Healthcare Risk Management - HistoryManagement - History
1970s: Arose Out of the First Malpractice Crisis
1980s: American Society for Healthcare Risk Management (ASHRM) Created
1980s: JCAHO Standards Created for Quality Assurance and Risk Management
1990s: Beginnings of the Patient Safety Movement
Patient Safety - HistoryPatient Safety - History
By 2003, Federal and state governments, professional organizations, national business coalitions and JCAHO had entered the patient safety arena, establishing patient safety standards and indicators, required sentinel/serious adverse event reporting and compliance with safe practices
Source: OHIC Insurance Company
Examples of Risk Management Examples of Risk Management and Patient Safety Initiativesand Patient Safety Initiatives
• Technology EMR/CPOE Bar Coded Medication Systems eICUs
• Patient Safety Rapid Response Teams Simulation Lab Programs
• Labor and Delivery Fetal Heart Monitoring Training Remote Access of FHM Strips Pitocin Protocols
CMS Ceases Payment for CMS Ceases Payment for Medical Errors Effective Medical Errors Effective
10/1/0810/1/08
• Urinary Tract Infections from Catheters• Bloodstream Infections Caused by Catheters• Falls• Decubitus Ulcers• Foreign Objects Left During Surgery• Blood Incompatibility• Mediastinitis After Heart Surgery• Air Embolism
TDC Study, 2007TDC Study, 2007
Systemic Errors Cause 30% of Settled Claims• Medication Errors• Communication Errors• Healthcare – Associated Infections• Medical Record Errors• Identification/Wrong Site Surgery
Source: The Doctors Company, 2007
Risk Management in Support Risk Management in Support of Successful Underwritingof Successful Underwriting
What is the Ideal Medical What is the Ideal Medical Professional Liability Insured?Professional Liability Insured?
• The ideal insureds are those individuals and organizations that make quality patient care in a safe environment their ultimate priority
Searching for the Ideal Searching for the Ideal InsuredInsured
• Delivers services in accordance with its mission statement and vision
• Demonstrates creative leadership with recognition of staff abilities and empowers patient care workers
• Seeks providers who view patients as individuals with feelings and preferences
• Emphasizes development of human resources & fosters a culture of professional excellence
• Provides a reward system that promotes compassion, loyalty & innovative thinking
• Nurtures a holistic approach to patients, families and communities
Redesigning the Redesigning the Environment of CareEnvironment of Care
• Evidence of organizational commitment transforming healthcare to meet the diverse needs of all patient populations
• An adaptive corporate culture that values proactive and innovative approaches to changes in populations and healthcare delivery systems
• Reputation in the healthcare industry rests on the successful delivery of care in a safe and secure environment.
• Leadership goals that result in an emotional atmosphere that is warm and welcoming, and where employees and providers are proficient at Listening and hearing Looking and observing Treating and caring
Transformational Drivers for Transformational Drivers for Acute Medical ServicesAcute Medical Services
Patient-driven vs. Cost-driven & convenience-driven
Everyone is a leader vs. Order-takers and order-givers
Professional, individualized care vs. Regimented care and treatment
Humanity as major motivator vs. Pure efficiency/profitability motive
Individual empowerment vs. Blind obedience
Flexibility (patient’s way) vs. Control (provider’s way)
Appointments accommodate working adults
vs. Appointments limited to Monday-Friday, 9-5
Friendly, helpful staff vs. Overworked, irritable staff
Attractive, inviting, environment vs. Institutional mint-green environment
Transformational Drivers Transformational Drivers for Aging Servicesfor Aging Services
Resident- and family-driven vs. Cost-driven and staff-convenience-driven
Nurse assistants as team members
vs. Nurse assistants as order-takers
Tender, loving care vs. Institutional care
Humanity as major motivator vs. Pure efficiency/profitability motive
Individual empowerment vs. Behavioral restraint
Flexibility (resident’s way) vs. Control (facility’s way)
Dining vs. Feeding
Creative expression vs. Tim-killing activities
Inter-generational community vs. Segregated senior “ghetto”
Open and vibrant vs. Tightly scheduled and hushed
Acute Care Enterprise Risk Acute Care Enterprise Risk Measures – Risk and Measures – Risk and
DefensibilityDefensibility
Enterprise Domains• Clinical
Medication management Behavioral health services Emergency medical services Perinatal services Surgical/anesthesia services Other clinical services Documentation
• Human Capital Executive leadership Medical staff Nursing and allied healthcare professional staff
Acute Care Enterprise Risk Acute Care Enterprise Risk Measures – Risk and Measures – Risk and
DefensibilityDefensibility
Enterprise Domains• Legal/Regulatory
Accreditation survey results Contract management State/federal survey results
• Operational Patient safety program Quality management program Risk management program Environment of care Awards/recognition
• Strategic Marketing and public relations
Aging Services Enterprise Risk Aging Services Enterprise Risk Measures – Risk and Measures – Risk and
DefensibilityDefensibility
Enterprise Domains• Clinical
Skin integrity Fall prevention Elopement Medication management Abuse prevention Infection control Other clinical risks Documentation
• Human Capital Leadership/executive functions Nursing services – Skilled Nursing Facilities, Assisted
Living Facilities Customer service
Aging Services Enterprise Risk Aging Services Enterprise Risk Measures – Risk and Measures – Risk and
DefensibilityDefensibility
Enterprise Domains• Legal/regulatory
Survey history Contract management
• Operational Resident rights/dignity/grievance process Admission, transfer and discharge processes Quality assurance/quality improvement/performance improvement Resident safety Risk management/adverse event management/claims management Credentialing Organizational manuals and files/policies, procedures and practices
• Strategic Marketing and public relations
Achieving Customer Achieving Customer LoyaltyLoyalty
• Relationships! Relationships! Relationships!• Flexible products/services with long-term viability • Accessibility and ease of doing business• Customer-centric• Share market intelligence • Supportive services to enhance risk posture• Experience- understand the healthcare industry• Expertise in risk assessment and education in
healthcare specialties• Insurance products that respond to customer
needs
Presentation to Presentation to UnderwritersUnderwriters
AgendaAgenda
• Financial & Operational Overview
• Risk Management & Quality Update
• Claims Discussion
• Reinsurance Program• 2007 Structure• 2008 Objectives
Financial and Operational Financial and Operational OverviewOverview
• Financially: Stable Earnings; Strong Balance Sheet Estimated 2007 Net Revenue: $4.7 Billion Assets: $6.7 Billion
• Continued High Occupancy levels and Market Share• Capital Investment in Facilities and Technology
Main Campus Regionally
• International Initiatives• Improving the Patient Experience• Formation of Institutes
Quality and Risk Quality and Risk ManagementManagement
• Enhanced Review & Decision Making Process
• Full Implementation of SERS (Event Reporting)
• Root Cause Analysis
• Patient Concerns Review (Vanderbilt Project)
• Emmi Solutions
• Remote Central Monitoring Unit
Challenges Faced by Challenges Faced by Healthcare IndustryHealthcare Industry
• Declining Reimbursements
• Caring for the Uninsured
• Personnel Shortages
• Maintaining Necessary Capital Investments
• Regulatory Compliance
• High Cost of Insurance
• Patient Satisfaction
Improving the Patient Improving the Patient ExperienceExperience
• Emergence of the Patient Safety Movement
• Standardization of Quality Data
• Patient Centered
• Improved Communication
• Transitioning away from Silos
• Formation of Institutes
Cleveland Clinic: Specialty Cleveland Clinic: Specialty Institutes*Institutes*
• Neurological Institute• Medicine Institute• Pediatrics Institute & Children’s Hospital• Orthopedic & Rheumatologic Institute• Eye Institute• Urological and Kidney Institute• Heart and Vascular Institute• Cancer Institute
* (not all inclusive)
What’s Changed?What’s Changed?
• The Culture
• Patient Expectations
Risk Management in a Risk Management in a Large Ob Gyn GroupLarge Ob Gyn Group
The CultureThe Culture
• “Lawsuit-happy” environment• Anecdotally… very few lawsuits years ago• Today:
Neighbors sue neighbors Employees sue employers Would-be employees sue would-be employers
• Fact of Life: 90% of ObGyns get sued at least once
• Overall average of 2.6 cases per Ob/Gyn
The CultureThe Culture
• You’ve seen the ads: “If you have an accident, we’ll help you
get the money you deserve” says the Trial Attorney’s TV commercial.
There is an underlying theme: • “Someone has to pay…”• “That’s why they have insurance…”• Etc., etc., etc.
Patient ExpectationsPatient Expectations
• Have never been higher• We all want perfect babies• We all want perfectly accurate tests• No one should ever get cervical cancer
if they get Pap smears• Mammos should never miss a lesion• MRIs should REALLY never miss a
lesion
What’s New?What’s New?
• Doctors have more “skin in the game” Premiums are thru the roof More at stake than ever before
• Real Tort Reform is unlikely
• More reasons to reduce the number of cases going to court
• More reasons to focus on patient safety
What’s New?What’s New?
• Electronic Tools: E-prescribing EMRs Secure Messaging
• Can increase safety
• Can increase efficiencies – saving practices money
What’s New?What’s New?
• Alternative Dispute Resolution COPIC’s 3 R’s Early intervention Arbitration
• Health Courts
• Reduce the caseload in traditional courts
• Let’s get it away from Juries
What Can We Do?What Can We Do?
• Support e-tool adoption Subsidize cost of hardware/software Premium credits for use of tools
• Encourage alternative strategies Early intervention Structure settlements
Women’s HealthWomen’s Health
• 155 ObGyns (1/3 of CT’s ObGyns)
• 35 collaborative providers (CNMs, APRNs)
• Merged in 1997
• THEARK Indemnity Company, Limited
• Internal Peer Review and Risk Management program
Women’s HealthWomen’s Health
• PR/RM Program Review all incidents and sentinel events Intervene if indicated (retire some, limit
practice of others, supervise or rehab where possible, etc.)
Practice Guidelines Compliance Created Quality Agenda with ongoing QA
studies and monitoring of key indicators
Women’s HealthWomen’s Health
• Premium “Debits and Credits” 5 years no cases: 3% credit Use of EMR: 3% credit Several cases: 5% surcharge More cases: 7.5% surcharge Most cases: 10% surcharge
Women’s HealthWomen’s Health
• “Provider Report Card” in development Guideline compliance Participation in Risk Management activities CMEs Use of E-tools Claims experience Patient satisfaction
A Risk and Safety Program?A Risk and Safety Program?Getting Physician Buy InGetting Physician Buy In
• Improved practice, based on the evidence.
• Data. Up close & personal.• Proven record of improvement in morbidity
and mortality.• Success rate in reducing adverse events,
medical errors, and litigation.
• You’ve got their attention!
Developing a System Developing a System SolutionSolution
• Research: Over 2000 medical malpractice lawsuits against
emergency physicians / hospitals Over 1000 morbidity & mortality cases from
academic EM programs Two years of focused medical/legal research in all
EM high-risk areas. Ongoing analysis of adverse outcomes &
allegations of malpractice The most complete profile of EM errors and
adverse outcomes available. Next step…
Abdominal Pain Patients > 50 Abdominal Pain Patients > 50 (n = 16,000 Patients)(n = 16,000 Patients)
Annals of Emergency Medicine, Vol. 36:4; October 2000
0
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Tim
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/U
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History Physical Exam Discharge
MD Results Cases Reviewed
Abdominal Pain Patient 50 yrs. & Older Indicators Across the Department
Vital Signs – Gather DataVital Signs – Gather DataIdentify National ProfileIdentify National Profile
• We looked at vital signs in 90,000 patients.• 16% of patients with very abnormal vital signs
are discharged without a single repeat.
• Extrapolate to the nation. The related morbidity & mortality is staggering.
Risk & Safety Web-Based Risk & Safety Web-Based Curriculum – Step 1Curriculum – Step 1
Intelligent Medical Records Intelligent Medical Records – Step 2– Step 2
Tendon Testing Tendon Testing IllustrationsIllustrations
Extensor Carpi Ulnaris Testing
Tendon Insertion
Palpate tendon just past distal edge of ulna.
Radial Deviation
Force
Tendon inserts at the base of the fifth metatarsal, dorsum (back) of the hand. Tendon inserts at the base of the fifth metatarsal, dorsum (back) of the hand. To test tendon function, ask the patient to ulnar deviate the wrist and palpate To test tendon function, ask the patient to ulnar deviate the wrist and palpate the tendon just past the distal edge of the ulna. Apply a radial deviation force the tendon just past the distal edge of the ulna. Apply a radial deviation force
with your finger on the tendon to test tendon strength.with your finger on the tendon to test tendon strength.
Risk & Safety Audit –Step 3Risk & Safety Audit –Step 3
Facility Emergency DepartmentEMRI Overall Risk Score by %
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
EMRI Overall Risk Score by %
= % compliance
with all indicators
26% Non Compliance
74% Compliance
Hospital ED Cycle 1 Risk Hospital ED Cycle 1 Risk ProfileProfile
= % compliance with all indicators
Drill down on abdominal pain patients over 50 years old
Facility Risk Profile by %
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Ch
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Ch
ild
w/F
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. P
t. >
50
Abdominal Pain Patient Abdominal Pain Patient 50 Yrs. & Older Indicators50 Yrs. & Older Indicators
On
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ce
Res
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15
0
5
10
15
20
25
30
MD Results Cases Reviewed
HCA ED Frequency Trends HCA ED Frequency Trends Reported Claims Per 100,000 Reported Claims Per 100,000
Visits Accident YearVisits Accident Year
8.5
9.2
8.1
7.7 7.8 7.8
6.9
5.8
4.6 4.5
3.8
3
4
5
6
7
8
9
10
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Reduced ClaimsFrequency by 50%
Triad Audit Scores Improved Triad Audit Scores Improved Significantly From 2003 To Significantly From 2003 To
20052005
49%
80%83%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2003 2005 2003 2005
Compliance with RepeatingVery Abnormal Vital Signs
Compliance with Risk Factors
40%
Triad ED Frequency Trends Triad ED Frequency Trends Reported Claims Per 100,000 Reported Claims Per 100,000
VisitsVisits
Patient Visits (100,000s) Claims Per 100,000 Patient Visits
6.3
5.3
3.5
4.9
0
1
2
3
4
5
6
7
8
9
10
0
200
400
600
800
1000
1200
2001 2002 2003 2004 2005
6.4
Claims Frequency Declined Over 40% Since 2003
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