Diagnostic Malpractice Risk
Learning from the worst-of-the-worst…
Robert Hanscom JD
CRICO Strategies / CRICO-Risk Management Foundation
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Signals from the Tip of the Iceberg:
The “skeptics” on coding medical malpractice claims
UNIQUE EVENTS
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
Not-so-unique underlying issues
Failure to monitor physiological status
Failure to follow protocol
Inadequate communication
Unique Convergence—
• Codes beyond the “headline”
• Provides common causation factors
• Breaks down “silos” of individual
analysis
Narrow diagnostic focus
Lack of adequate assessment
Failure to ensure patient safety
Resident supervision
Failure/delay ordering diagnostic test
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Diagnosis
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15,873 cases | $3B total incurred
National Malpractice Landscape:
Top Major Allegations
Diagnosis-related claims round out the top three most prevalent case types
20%
15%
30%
17%
N=15,873 coded PL cases asserted 1/1/07–12/31/11.
% = Total incurred dollars
Comparative Perspective: Diagnosis-related allegations
are more prevalent in the Community Hospital setting…
All Cases: Top Major Allegations
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.
3,316 cases | $941M total incurred
No Surprise: General Medicine is the most
frequently named “responsible service”
Diagnosis-related Cases: Top Responsible Services
TOP SERVICES
% OF
CASES
% OF
DOLLARS
General Medicine
55%
53%
Cardiology
8%
8%
Gastroenterology
8%
7%
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.
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3,606 cases | $1.1B total incurred
The majority of diagnosis-related cases
originate in the outpatient setting…
Diagnosis-related Cases: Claimant Type
ED
Inpatient
Outpatient
(excl. ED)
N=3,606 coded PL cases asserted 1/1/06–12/31/10 with a diagnosis-related major allegation.
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1,851 cases | $523M total incurred
Distribution of Diagnoses – and Cancer
Types – in Ambulatory Cases
Ambulatory Diagnosis-related Cases: Final Diagnosis
Breast
19%
Other
Cancer
Diagnoses Diagnoses
52%
48%
Other
Cancers
52%
Colorectal
12%
Lung
12%
5%
Prostate
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.
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1,851 cases | $523M total incurred
Where in the course of care are errors most
prevalent in outpatient diagnosis-related cases?
Ambulatory Diagnosis-related Cases: Diagnostic Process of Care
NUMBER
OF CASES*
PERCENT
OF CASES*
TOTAL
INCURRED
2%
$11,785,303
477
26%
$204,781,699
8. Referral management
374
20%
$128,312,131
9. Patient compliance with follow-up plan
256
14%
$56,902,226
STEP
1. Patient notes problem and seeks care
2. History/physical and evaluation of symptoms
3. Order of diagnostic/lab tests
4. Performance of tests
5. Interpretation of tests
6. Receipt/transmittal of test results
7. Physician follow up with patient
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Process of Care
Clusters
causative
factors
into
916
49%
$352,419,854
steps
from access
issues
67 of care 4%
$24,916,093
in 585
seeking care,
to$229,164,998
reporting
32%
test153 results 8%and appropriate
$49,074,074
215 up including
12%
$96,056,943
follow
referrals.
*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.
Hypotheses of Risk
General Medicine and Emergency Medicine
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Hypotheses of Risk
Diagnostic Error
• 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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The Tension
• 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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Strategies and Models
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The Model Methodology: Data into Action
Capture 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
Diagnostic Errors
Prevention ofof
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”)
• Presence of
health I.T.
system with all
features
• All features are
turned on
• Providers
trained
• Record audits –
are features
being used?
• Ongoing, interval-based education of clinicians to avoid
fixation, narrow diagnostic focus
• Record audits:
differentials
documented?
• Decision-support guidelines/algorithms embedded
into I.T. system so providers can access them in the flow
of patient care
• Adherence w/
decision
support
guidelines
CRICO’s Reinvestment in Patient Safety
• 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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Need More Reliable Test Follow-up,
Referral Management, Pt. Follow-up
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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Better Ways to Calibrate Accuracy and
Competence; Need Pt. Feedback
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 followup 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 factor
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Role of Patients (and Pt’s Family) in
Helping to Make the Diagnosis
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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