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Diagnostic Malpractice RiskLearning from the worst-of-the-worst…

Robert Hanscom JDCRICO Strategies / CRICO-Risk Management Foundation

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Small “n”—• Emphasis on most severe injuries• Relatively large number of rare

events• CBS multiplies the value

A look to the past—• Richer details available for

analysis and learning • Trends related to significant

events often lost in “fix-and-move-on” process

Unique Convergence—• Codes beyond the “headline” • Provides common causation

factors• Breaks down “silos” of individual

analysis

Signals from the Tip of the Iceberg: The “skeptics” on coding medical malpractice claims

Resident supervision

Failure/delay ordering diagnostic test

Failure to monitor physiological status

Narrow diagnostic focus

Inadequate communication

Lack of adequate assessment

Failure to follow protocol

Failure to ensure patient safety

UNIQUE EVENTS

Not-so-unique underlying issues

Diagnosis

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Diagnosis-related claims round out the top three most prevalent case types

N=15,873 coded PL cases asserted 1/1/07–12/31/11.

National Malpractice Landscape: Top Major Allegations

15,873 cases | $3B total incurred

20% 15

% 30%

17%

% = Total incurred dollars

CBS AMC N=2,716 coded CBS PL cases asserted 1/1/07–12/31/11.CBS Community N=2,462 coded CRICO PL cases asserted 1/1/07–12/31/11.

Comparative Perspective: Diagnosis-related allegations are more prevalent in the Community Hospital setting…

All Cases: Top Major Allegations

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N=3,316 coded PL cases asserted 1/1/07–12/31/11 with a diagnosis-related major allegation.Total incurred includes reserves on open and payments on closed cases.

No Surprise: General Medicine is the most frequently named “responsible service”

3,316 cases | $941M total incurred

Diagnosis-related Cases: Top Responsible Services

TOP SERVICES % OF CASES

% OF DOLLARS

General Medicine 55% 53%

Cardiology 8% 8%

Gastroenterology 8% 7%

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Diagnosis-related Cases: Claimant Type

N=3,606 coded PL cases asserted 1/1/06–12/31/10 with a diagnosis-related major allegation.

The majority of diagnosis-related cases originate in the outpatient setting…

Outpatient(excl. ED)

InpatientED

3,606 cases | $1.1B total incurred

48%52%

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Ambulatory Diagnosis-related Cases: Final Diagnosis

N=1,851 coded PL cases asserted 1/1/07–12/31/11 involving outpatients (excluding ED location) and with a diagnosis-related major allegation.

Distribution of Diagnoses – and Cancer Types – in Ambulatory Cases

Cancer Diagnoses

Other Diagnoses

1,851 cases | $523M total incurred

19%

12%

12%

5%

52%

Breast

Other Cancers Colorectal

Lung

Prostate

Ambulatory Diagnosis-related Cases: Diagnostic Process of Care

*A case will often have multiple factors identified.N=1,851 coded PL cases asserted 1/1/07–12/31/11 involving outpatients (excluding ED location) and with a diagnosis-related major allegation.Total Incurred=reserves on open and payments on closed cases.

Where in the course of care are errors most prevalent in outpatient diagnosis-related cases?

STEP NUMBER OF CASES*

PERCENT OF CASES* TOTAL INCURRED

1. Patient notes problem and seeks care 29 2% $11,785,303

2. History/physical and evaluation of symptoms 477 26% $204,781,699

3. Order of diagnostic/lab tests 916 49% $352,419,854

4. Performance of tests 67 4% $24,916,093

5. Interpretation of tests 585 32% $229,164,998

6. Receipt/transmittal of test results 153 8% $49,074,074

7. Physician follow up with patient 215 12% $96,056,943

8. Referral management 374 20% $128,312,131

9. Patient compliance with follow-up plan 256 14% $56,902,226

1,851 cases | $523M total incurred

Process of Care

Clusters causative factors into steps of care from access issues in seeking care, to reporting test results and appropriate follow up including referrals.

Hypotheses of RiskGeneral Medicine and Emergency Medicine

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• Cognitive variability plays a significant role• It is confounded – even magnified – by imperfect processes• It is made even more challenging by the lack of feedback

• -- and missed cancer cases miss our reporting systems...• It is not productive to divide diagnostic failure into camps, e.g.

“cognitive” vs. “systems” – look instead at entire set of diagnostic steps

• Relying on human memory is not a viable strategy for making correct diagnoses

• ….Too many parts, too many data points, too many perspectives

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Diagnostic ErrorHypotheses of Risk

• The Third-Party Payers: “Less Tests”!• Lower cost care, more efficiently delivered, but raise the

“quality”• Avoid defensive medicine…

• The Malpractice Defense Insurers: “More Tests”!• Lower cost care, more efficiently delivered, but raise the

“quality”• When in doubt, order more diagnostic tests…

What’s the answer? Will this tension ever be resolved?

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The Tension

Strategies and Models

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The Model Methodology: Data into ActionCapture vulnerabilities as they occur

• Contemporaneous analysis of asserted malpractice cases

Put them into context • Integration of relevant denominator data and peer comparative data

Are you still vulnerable? • Assessment of present-tense risk through risk assessments, focus groups,

and through validation by other data sets

Determine potential solutions • Continuous identification of relevant models, processes, education, and

training programs that address key risk areas

Implement, educate, train: the “reinvestment”• Championship by high-level leadership to effect real change and to sustain

it; leverage by insurer to accelerate movement

Measure/Metrics• Measure the impact in the near term (with a predictive eye for the long

term)

Prevention of Missed/Delayed Diagnoses

• Reliable office-based systems or processes that support—• Routine updating of family history• Receipt of test results by ordering providers

(including critical test results)• Tracking/managing follow-up steps related

to pt.’s subsequent care• “Close-the-loop”

management/accountability of specialty referrals

• Communication of all test results to patients, including routine chest x-rays (“incidental findings”)

• Ongoing, interval-based education of clinicians to avoid fixation, narrow diagnostic focus

• Decision-support guidelines/algorithms embedded into I.T. system so providers can access them in the flow of patient care

• Presence of health I.T. system with all features

• All features are turned on

• Providers trained

• Record audits – are features being used?

• Record audits: differentials documented?

• Adherence w/ decision support guidelines

Prevention of Diagnostic Errors

• Algorithms and Guidelines• Symposia dedicated to Diagnostic Risk• Improving reliability in systems: emphasis on test results• ANCR: Radiologists can find accountable provider (vs. the

“ordering provider”)• Processes to ensure closing the loop on referrals• Exploration of cognition simulation• Office Practice Evaluation (OPE)

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CRICO’s Reinvestment in Patient Safety

General Medicine• There is a business case for I.T. systems that can cleanly do

these things• Accountability for follow-up should be identified and plainly

visible• Gaps should be flagged

Emergency• Reliable follow-up mechanisms for patients following ED care• Close communication with PCP, reliability in specialist referrals• Mechanism for test results that return after pt. has left ED• Standardized, clear discharge instructions

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Need More Reliable Test Follow-up, Referral Management, Pt. Follow-up

General Medicine• Asking “how confident are you in your answer?”• Need culture where one can (a) feel free to admit uncertainty, (b) not

get blamed because of the uncertainty, and (c) get support in a practical, logistical way

• Feedback from pts. is often lacking, leading to “overconfidence” that right diagnosis was reached

• Automate patient feedback – make it simple

Emergency• Standard follow-up / QA nurse call; if findings in hospital or at follow-

up visit differ from initial ED diagnosis, develop an I.T.-based way to consistently provide that feedback

• Build into the sign-out across shifts an uncertainty factor18

Better Ways to Calibrate Accuracy and Competence; Need Pt. Feedback

General Medicine and Emergency• Patient portals: teach them what to look for• Allow them to be proactive in looking for their test results• Teach pts. to be “keen observers” (e.g., reporters) of their

symptoms• Give them assigned reading, open the door for them to be

better informed• Recruit the family for support• Emphasize the need for compliance, both in showing up for

appts and in doing what they need to do (e.g., taking their meds)

• Develop relevant, easy-to-absorb patient/family education materials

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Role of Patients (and Pt’s Family) in Helping to Make the Diagnosis