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Identifying and Intervening on High Risk Physicians: The PARS® Project

Identifying and Intervening on High Risk Physicians: The PARS® Project. Gerald B. Hickson, MD Director, Center for Patient and Professional Advocacy Associate Dean for Clinical Affairs Center for Patient & Professional Advocacy Vanderbilt University School of Medicine

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Identifying and Intervening on High Risk Physicians: The PARS® Project

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  1. Identifying and Intervening on High Risk Physicians: The PARS® Project Gerald B. Hickson, MD Director, Center for Patient and Professional Advocacy Associate Dean for Clinical Affairs Center for Patient & Professional Advocacy Vanderbilt University School of Medicine Gerald.Hickson@Vanderbilt.edu www.mc.vanderbilt.edu/cppa

  2. The PARS® Project Fair, systematic process involves surveillance for all professionals; IDs & intervenes with outliers: Promotes fair/just culture Addresses and reduces malpractice risk/cost and unprofessional behavior Helps satisfy regulatory requirements Can help improve interactions among pts and care providers, leading to better outcomes Helps competitive advantage by IDing and helping address threats to reputation and patient safety 2

  3. PARS® SitesDevelopment Sites Prospective Sites Major Educ. Sites Cogent Healthcare

  4. 1-6%+ hosp. pts injured due to negligence ~2% of all pts injured by negligence sue ~2-7 x more pts sue w/o valid claims Non-$$ factors motivate pts to sue Some MDs/units attract more suits High risk today = high risk tomorrow Unsolicited comment/concerns predict claims PARS® risk profiles make effective intervention tools Med Mal Research Background Summary 5

  5. Four Hypotheses Physicians who attract a disproportionate share of malpractice claims: Attract a litigation-prone population Attract medically high-risk patients Are technically incompetent Have difficulty “connecting” with pts

  6. Perceptions of Care During L&D (Open-Ended Questions) Communication 8 18 27* Care/treatment 5 15 22* Access/availability 7 11 15* Humaneness of Phys 5 6 17* Phys Lawsuit Hx Patient Concerns (%) 0 1-3Freq * Statistically significant difference Hickson GB, et al. JAMA 1994; 272:1583-1587.

  7. Can high risk physicians be identified by means other than counting lawsuits?Unsolicited complaints link to malpractice risk.

  8. Patient Complaints • “I had questions about my medical condition and treatment. Dr.__ looked up and asked, ‘Are you illiterate?’ I said, “No.” Dr.__ responded, ‘Oh, I just gave you several pamphlets that explain all of this. Since you didn’t get it, I thought that maybe you were illiterate.’” • “Dr. __ was rude. I was 7 minutes late and apologized. He looked at his watch and said, ‘That’s 7 minutes I won’t be able to talk with you.’ He seemed very annoyed.”

  9. Academic vs Community Medical Center50% of concerns associated with 9-14% of Physicians Note: 35-50% are associated with NO concerns Cogent Healthcare Hickson, et al., SMJ, 2007; Hickson et al, JAMA. 2002 Jun 12;287(22):2951-7

  10. Predictors of Risk Outcomes (logistic regression) Predictive concordance of risk models ranges from 81-92% Gender Physician specialty Volume of service Unsolicited patient complaints Hickson et al, JAMA. 2002 Jun 12;287(22):2951-7.

  11. Incurred Expense By Risk Category * In multiples of lowest risk group Moore, Pichert, Hickson, Federspiel, Blackford. Vanderbilt Law Review, 2006

  12. Major Medical Center’s Claims AnalysisClaims Data 2000-2008 *Note: =relative weight, so Risk Score was 4.2x more predictive of claims than clinical activity for surgeons

  13. Professionalism and Self-Regulation • Conceptual Framework – Professionalism • Professionals commit to: • Technical and cognitive excellence • Professionals also commit to: • Confidentiality • Clear and effective communication • Modeling respect • Being available • Professionalism promotes teamwork

  14. Professionalism and Self-Regulation • Professionalism demands self-regulation • Personal • Discipline specific • Group • Systems focused • All require the skills to provide and receive feedback

  15. Critical Questions: If you were at high risk and there was a reliable method to identify and make you aware, would you want to know? If a member of your group was at high risk and you had a reliable system to identify and provide opportunity for improvement (and risk reduction), would you want her or him to know?

  16. MMC Forms a Committee “Messenger” Physician Peers: • (Committee formed under existing QA/Peer review) • Are committed to confidentiality • Are respected by colleagues • Are willing to serve (8 hours of training) • Have risk scores that are mostly okay (but at several sites physicians intervened upon are messengers) • Agree to review, then take data to 1-3 physicians at request of local messenger committee chair 17

  17. Intervention on Dr. __ • Letter with standings, assurances prior to & at meeting • “You are here” graph with 4-yr Risk Scores • Complaint Type Summary “Concerns bullet list” • Redacted narrative reports 18

  18. Representative Complaints by Category Concern for Patient/Family I never felt like he cared whether [my spouse] lived or died. He does NOT live up to your motto Communication He did not keep us informed about my daughter’s condition…and didn’t answer our questions “Dr. X offered no information. I felt he was hiding information. Never even tried to speak to my husband.” Pt upset with lack of info from Dr. __...no one is able to tell him what his x-rays show Care and Treatment Dr.___ delay in care made my mother’s medical status worse

  19. Risk Score vs. Percent of PARS® Physicians at all Institutions The Risk Score reflects the complaints with which each physician was associated. It is based on an algorithm that weighs complaints recorded in the past year more heavily than those recorded in prior years. Urologists (n = 268) Stimson, et al. J Urol, May 2010

  20. But does any of this actually work?

  21. Observations • More than 1,900 interventions completed • All messengers emerged intact (so far) • <5% responded with hostility • Common responses: • “I never knew…” • “It’s the system…” • “These complaints are trivial…” • “I’m overscheduled…” • ~10% go to Level II Interventions (persistent pattern needing an improvement plan) • Follow-ups ongoing

  22. PARS® Progress Report This material is confidential and privileged information under the provisions set forth in T.C.A. §63-6-219 and shall not be disclosed to unauthorized persons.

  23. PARS® & Claims Experience What about the impact of a peer-based intervention process on claims experience?

  24. PARS® & Claims Experience • Assessing an impact on claims is challenging: • Claims are relatively rare events • Changes in external environment (frequency, legislative initiatives, tort reform, etc) • Changes in internal environment (other Quality/Safety initiatives, growth, case mix, etc) • Let’s look at claims in Middle Tennessee per 100 MDs (non-Vanderbilt physicians)

  25. Malpractice Claims (per 100 MDs) FY1998 – 2009 This material is confidential and privileged information under the provisions set forth in T.C.A. §63-6-219 and shall not be disclosed to unauthorized persons.

  26. PARS® & Claims Experience 1990’s mindset: “our claims experience is above average” (in a good sense) Was our assumption correct? • We had (have) lots of physicians who wear multiple hats (teaching, research, clinical care) • Used MGMA data on RVU production to convert VUMC productivity to FTEs • Compared our claims/FTE to claims/100 MDs in Middle Tennessee

  27. Malpractice Claims (per 100 MDs) FY1998 – 2009 (We were wrong) This material is confidential and privileged information under the provisions set forth in T.C.A. §63-6-219 and shall not be disclosed to unauthorized persons.

  28. PARS® & Claims Experience • Since 1998 VUMC: • PARS® • Leadership Claims Awareness meetings • ELEVATE program (leadership program to promote core principles of excellence, integrity and ongoing improvement) • Required Disclosure training • Allocation Rebate program • And the Tennessee Medical Malpractice Notice and Certificate of Merit Bill passed

  29. Malpractice Claims (per 100 MDs) FY1998 – 2009 Malpractice Claims (per 100 MDs) FY1998 – 2009 1 2 3 4 5 6 1 - PARS® Interventions 2 - Claims Awareness Meetings 3 - ELEVATE 4 - Disclosure Training 5 - Allocation Rebate Program 6 - Certificate of Merit Bill This material is confidential and privileged information under the provisions set forth in T.C.A. §63-6-219 and shall not be disclosed to unauthorized persons.

  30. Malpractice Claims (per 100 MDs) FY1998 – 2009 - - - - - - - - - - - - - Trend Line This material is confidential and privileged information under the provisions set forth in T.C.A. §63-6-219 and shall not be disclosed to unauthorized persons.

  31. Comments and QuestionsNow or Later www.mc.vanderbilt.edu/cppa Gerald.Hickson@Vanderbilt.edu

  32. Intervention Pyramid Adapted from Hickson GB, Pichert JW, Webb LE, Gabbe SG, Acad Med, Nov, 2007 Level 3 "Disciplinary" Intervention No ∆ Level 2 “Guided" Intervention by Authority Pattern persists Apparent pattern Level 1 "Awareness" Intervention Single or isolated“unprofessional" event (merit?) "Informal" Cup of Coffee Intervention Mandated Issues Vast majority of professionals - no issues

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