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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

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

the pars project
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

slide3

PARS® SitesDevelopment Sites

Prospective Sites

Major Educ. Sites

Cogent Healthcare

med mal research background summary
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

four hypotheses
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

perceptions of care during l d
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.

slide8
Can high risk physicians be identified by means other than counting lawsuits?Unsolicited complaints link to malpractice risk.
patient complaints
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.”
academic vs community medical center 50 of concerns associated with 9 14 of physicians
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

predictors of risk outcomes
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.

incurred expense by risk category
Incurred Expense By Risk Category

* In multiples of lowest risk group

Moore, Pichert, Hickson, Federspiel, Blackford. Vanderbilt Law Review, 2006

major medical center s claims analysis claims data 2000 2008
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

slide14

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
professionalism and self regulation
Professionalism and Self-Regulation
  • Professionalism demands self-regulation
    • Personal
    • Discipline specific
    • Group
    • Systems focused
  • All require the skills to provide and receive feedback
critical questions
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?

mmc forms a committee
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

intervention on dr
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

representative complaints by category
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

slide20

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

slide21

But does any of this

actually work?

observations
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
slide23

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.

pars claims experience
PARS® & Claims Experience

What about the impact of a peer-based intervention process on claims experience?

pars claims experience1
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)
slide26

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.

pars claims experience2
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
slide28

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.

pars claims experience3
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
slide30

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.

slide31

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.

comments and questions now or later

Comments and QuestionsNow or Later

www.mc.vanderbilt.edu/cppa

Gerald.Hickson@Vanderbilt.edu

slide33

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