Partnering with technology to reduce OB losses

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1 Claims Management Partnering with technology to reduce OB losses By Larry L. Smith, JD, and Dorothy Berry, RN, BSN, HRM, CPHRM Following a catastrophic birth injury that occurred as a result of deviations from the expected standards of care, the OB Risk Reduction Task Force of a healthcare network identified criteria to transform care at the bedside from theory to practice: 1) protocol-driven, real-time alerts to help healthcare providers meet clinical guidelines; and 2) the ability to produce reliable data to monitor and measure adherence to accepted standards of care. The group selected a technological solution to achieve that end. This case study illustrates how a strong partnership model between healthcare and technology solution providers can achieve much when both parties are focused on the same goals of performance improvement and active risk reduction. INTRODUCTION In 2001, MedStar, a community-based network of seven non-profit hospitals and other healthcare services in the Baltimore/Washington corridor, recognized the need to invest in approaches to enhance patient safety, prevent errors and reduce risk as a business imperative. A challenge was issued to Risk Management to identify a network-wide patient safety initiative that was clinician- and data-driven, and would measurably improve MedStar s professional liability profile. The initiative had to take into account MedStar s corporate culture, which respects the autonomy of operating units while capitalizing on the power and collaborative energy of the entire delivery operation. (For background, MedStar Health offers primary and specialty care, home care, pharmacy, access to clinical research and education, and long-term care.) MedStar determined that its risk management data composed a rich source from which to identify quality and safety issues for focus, as these had a direct connection to liability costs incurred by the organization. To determine its first corporate-wide effort, MedStar reviewed 10 years of professional liability claims experience. Although the experience at each MedStar hospital varied, it became clear that obstetrics provided the greatest opportunity for improvement in patient safety in every category: claim frequency, claim severity, impact on reputation and standing within the community, and impact on patients and their families. Therefore, obstetrics was selected by the senior executive team to become the object of MedStar s first network-wide patient safety effort. Once the appropriate executive and board endorsements were established, MedStar s senior administrative and clinical leadership began discussing how to support this initiative. In response, in September 2001 the OB Risk Reduction continued next page JOURNAL OF HEALTHCARE RISK MANAGEMENT VOLUME 27, NUMBER 4 25

2 Task Force was chartered to minimize the risk of avoidable patient injury in MedStar s Labor and Delivery units. The following goals were established: Identify specific, measurable risk reduction efforts to reduce the number and cost of professional liability claims; Identify and implement appropriate system-wide standards of care and practice protocols, congruent with nationally accepted, evidence-based guidelines; Make individual hospitals responsible for developing methods to attain compliance with standards; Oversee and coordinate system-wide activities intended to maximize high-quality, patient-centered care while minimizing risk and liability. The membership guidance for this task force was critical, yet simple: delegate responsibility to those most directly responsible for managing the clinical environment with alignment of responsibility, authority and accountability for the results. The group included the OB/GYN Department chairs and the obstetrical nursing directors from those MedStar hospitals that offered OB services, risk management staff and MedStar internal consulting group personnel with expertise in clinical change management. The initial objective of the task force was to better understand the clinical issues underlying the obstetrical injuries. A more detailed review and Pareto analysis of the five prior claims years revealed that clinical judgment issues were by far the most problematic, with documentation issues as the next largest grouping. (Figure 1) Their results were consistent with those more recently reported by Studdert, et al., who presented his preliminary findings that obstetrical claims errors are disproportionately more cognitive than technical.(1) In its initial project phase, the task force began standardizing patient care across the four MedStar obstetrical centers through clinical protocols (such as Oxytocin management), terminology for fetal monitoring, clinician education and other activities. The group considered it a significant achievement when the network-wide standards and guidelines were developed but then a costly catastrophic birth injury occurred in 2003 as a result of multiple deviations from the expected standards of care. The injury was deemed avoidable and the claim was promptly settled for $4 million. With this event, the weaknesses of more traditional approaches to patient safety improvements were made clear. The task force realized that it would need to be innovative to achieve a higher level of success. The group looked to technology as a possible solution. In exploring technological solutions, the task force created the following two core criteria to transform care at the bedside from theory to practice. The selected solution must have: 1. Protocol-driven, real-time alerts to help healthcare providers meet clinical guidelines; and 2. The ability to produce reliable data to monitor and measure adherence to accepted standards of care. The search for technological solutions to complement their efforts in obstetrics led the task force to explore the capabilities of the Intelligent Patient Record for Obstetrics (IPROB) (hereinafter referred to as the system ), developed and distributed by E&C Medical Intelligence. As part of the due diligence for selecting the right solution, a prospective evaluation was conducted to assess its potential for clinical and risk management benefits. A case simulation was conducted using the care rendered during the $4 million case mentioned above. In other words, the clinical information regarding the care provided prior to the resulting severe birth injury was entered into the system as though the patient were being cared for today. The system s clinical advice was virtually identical, in both timing and substance, to that of the retrospective reviews of the actual case conducted by three obstetrical experts. The reviewers and MedStar s Board Quality and Professional Affairs Committee concluded that the use of the technology solution would most likely have avoided both the harm to the patient and subsequent costs to the organization. This initial scenario was then followed by a more extensive evaluation using a similar simulation process on all significant OB cases for the previous 10 years. This evaluation was conducted in an attempt to quantify the impact that the system might have had on MedStar s OB liability loss experience during this 10-year timeframe, had the system been in place and used as designed. The purpose for this analysis was to enable MedStar s actuarial consultant to better assess the potential prospective medical liability savings that could be realized by utilizing such a protocol-driven, and obstetrically grounded, electronic medical record. Each case was assessed to determine the likelihood that the system would have helped to avoid the specific patient injury that was sustained. This in-depth analysis determined that use of the system could reduce MedStar s future incurred OB losses by at least $2 million annually. Based upon these findings, MedStar effected a $2 million prospective reduction in the amount allocated to its selfinsurance funding and used part of these monies to partner with the technology solution provider to deploy the system. A healthcare-technology partnership In order to realize the potential benefits of the system, based upon the criteria explained above, a partnership approach was utilized. Technology was the vehicle through which clinical transformation was to occur, facilitated by the solution provider s consultation. MedStar realized that its traditional approach would only take the process improvement so far, yet the non-technical efforts to standardize the process of care and to lay the cultural groundwork for the 26 JOURNAL OF HEALTHCARE RISK MANAGEMENT VOLUME 27, NUMBER 4

3 next level of change were important precursors to implementing the technology catalyst. The people, process and technology were aligned for the next step. Meeting Criterion #1: Protocol-driven, real-time alerts to assist healthcare providers in meeting clinical guidelines. The technology solution provided is essentially an electronic medical record (EMR) with an underlying advanced clinical decision support system (CDSS). The CDSS provides prompts and alerts to improve clinical documentation as well as to help prevent those clinical errors in real time that are likely to lead to harm. Enhanced documentation and reduction of error are both important in reducing the overall risk in an obstetrical service. Recent studies have shown that EMRs alone are not able to provide this level of support. Compliance with documentation in electronic medical records is very low when the reminders for documentation completeness are deactivated.(2) The EMR component of the solution provider s system for MedStar serves to capture the information in structured fields, while its elaborate clinical logic continually evaluates that information to deliver clinical prompts along the course of care. Both provider and nursing documentation are contained in a single system, thereby allowing for an integrated view, or more complete picture, of the patient s care which can then be rendered in a coordinated fashion. The goal of CDSS is twofold. Simply stated, it works to make doing the right things easier and to make doing the wrong things harder. Advanced clinical decision support contains all of the following components: Is based on best practice protocols; Is relevant to the specific patient condition; Is presented to the clinician in real time ; and Contains a continuous feedback loop of reevaluation with each new piece of information entered; Adjusts the priority of each suggestion based on what is most urgent to address at the present time. While no tool can prevent every bad outcome, a good one can help ensure that protocols are followed, or at least considered. In this case, the system tracks the course of care (prenatal, antepartum, labor/delivery and postpartum) against the appropriate protocols, prompting reevaluation of the plan of care when indicated by trends in clinical findings. In the labor and delivery setting, it interacts with the fetal monitor surveillance and archiving system, which is available to clinicians on the same workstation. Interfaces are created to ensure that the system interacts with other major IT systems in use within the organization. continued next page Figure 1: Underlying Issues in OB Injuries 50% of the Risk Management Issues in MedStar s 48 Obstetric Claims for Loss Years have to do with Clinical Judgment and Documentation Problems JOURNAL OF HEALTHCARE RISK MANAGEMENT VOLUME 27, NUMBER 4 27

4 Figure 2 Improving Quality Measures 25% Improvement Sustained over time Figure 3 Malpractice ROI: Cumulative Direct Financial Impact of System 28 JOURNAL OF HEALTHCARE RISK MANAGEMENT VOLUME 27, NUMBER 4

5 Figure 4 Claims Experience Since Implementing System Figure 5 Time from Loss Date To Assert Date for Obstetric Claims and Suits for Fiscal Loss Years JOURNAL OF HEALTHCARE RISK MANAGEMENT VOLUME 27, NUMBER 4 29

6 Meeting Criterion #2: The ability to produce reliable data to monitor and measure adherence to accepted standards of care. Having information about each action and step in the process of care available in digital form opens up a world of opportunity in clinical performance measurement. Currently, obstetrics is primarily measured by volume statistics (number of births, VBACs, etc.) and selected outcomes (maternal deaths, neonatal deaths, third- to fourth-degree lacerations, etc.) as reflected by CMS, ORYX and other measurements. More particularly as it relates to obstetrics, there exists a gap in process measures that allow a better understanding between the two. Furthermore, it is the process of care where intervention can best occur, particularly in a clinical service where cognitive mistakes are more prominently connected to harm than technical ones. To address the second criterion at MedStar, a set of clinical process measures was identified to serve as a basis for monitoring. These measures were monitored over time to establish current practice patterns and determine which would be candidates for the highest level of priority in user prompting. A Compliance Adherence Mechanism (CAM) feature was created and applied to selected measures. The CAM process included a timing feature whereby if an issue were not addressed by a certain point of care, the user would be required to either address the item or document and explain why the item was not addressed. As shown in Figure 2, this feature resulted in improvement in performance in those selected measures across all four MedStar organizations simultaneously, and has been sustained for more than two years. Additional performance measures are monitored and discussed periodically to assist the OB clinical leadership in determining even more effective methods of improving clinical performance through further refinement of the rules of the system, the user interface and reinforcement and training for the clinicians. In addition, information from the system can now provide the missing link of making visible how those errors that could lead to harm are effectively blocked from occurring in real time. It always has been difficult in clinical risk management to successfully demonstrate what did not occur as a result of its efforts. Now, near misses can be captured and reported. For example, when an action is about to be taken, and the system alerts that a contraindication exists; it is possible to capture when the clinician refrains from taking the action through the period of time in which it is contraindicated. This occurred once every three to four births in one quarter alone for this facility. The risk management and business impact MedStar measures the risk management and business impact of the project twice yearly by an actuarial review of the prospective reduction in self-insurance funding. Based on recent valuations, these reviews reinforced that the initial reduction in funding was sound. The funding reductions covered the cost of the investment in the system, plus the internal costs for hardware, software, staff and resources to implement and maintain the system. Based upon this factor, the return on investment of the system has been demonstrated over a three-year period. (Figure 3) More recently, MedStar set out to more specifically examine the effects of the system on its asserted obstetrical claim results since implementation in Full obstetrical case maturity may take 10 years or longer; therefore, MedStar looked for an alternative approach to assess where it stood compared to where it would have expected to be had system implementation not taken place. To accomplish this, based on MedStar s past OB claims experience, an informed assumption was created as follows: Based on historical claim assert patterns for OB, MedStar expected that about 40 percent of all claims/suits ultimately asserted, would be asserted within one year of the loss event. This translated to a range of between 2 to 8 claims made within one year of loss period $1 million to $5 million incurred within one year of loss period. Next, MedStar compared this assumption across different time periods, resulting in the ability to look at what would be expected versus its actual experience to date. Figures 4 and 5 suggest the system resulted in greater safety to MedStar s obstetrical patients and generated less severity in the MedStar obstetrical medical malpractice profile. CONCLUSION Working within a strong partnership model, healthcare and technology solution providers can achieve much when both parties are focused on the same goals of performance improvement and active risk reduction. A commitment to continuous improvement and sharing of lessons learned foster a healthy relationship that brings benefits to both parties, and ultimately to the patients they mutually strive to serve. REFERENCES 1. Studdert, D., et al. Keynote presentation at the American Society for Healthcare Risk Management Annual Conference, Oct Haberman, et al Obstetrics and Gynecology July 2007;Vol 110 No1, pp ABOUT THE AUTHORS Larry L. Smith, JD, is vice president, Risk Management services, MedStar Health, Baltimore. Dorothy Berry, RN, BSN, HRM, CPHRM, is vice president, E&C Medical Intelligence Inc., Arlington Heights, IL 30 JOURNAL OF HEALTHCARE RISK MANAGEMENT VOLUME 27, NUMBER 4

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