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

2000

4000

6000

8000

10000

12000

14000

16000

On

set

Lo

cati

on

Rad

iati

on

AA

A R

isk

Ab

d. E

xam

Det

aile

d A

bd

.

Mas

s

Pu

lses

Rec

tal

Gu

aiac

Rep

eat

VS

CT

Tim

ed F

/U

Ret

urn

Co

nd

ord

ance

Res

olv

ed

Bed

in 1

5

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

est

Pai

n

C-S

pin

e

Fra

ctu

re

Ab

d.P

ain

Hea

dac

he

Hea

d I

nju

ry

Vag

.Ble

ed

E L

acer

atio

n

Ch

ild

w/F

ever

Ab

d.

Pn

. P

t. >

50

Abdominal Pain Patient Abdominal Pain Patient 50 Yrs. & Older Indicators50 Yrs. & Older Indicators

On

set

Lo

cati

on

Rad

iati

on

AA

A R

isk

Ab

d.

Exa

m

Det

ail

Ab

d

Mas

s

Pu

lses

Rec

tal

Gu

iac

Rep

eat

VS

CT

Tim

ed F

/U

Ret

urn

Co

nco

rdan

ce

Res

olv

ed

Bed

in

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

Thank You