Malpractice Insurance Incentives for. Teamwork Training via Simulation

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1 Malpractice Insurance Incentives for Teamwork Training via Simulation HEATT 2014 Orlando, FL August 22-24, 2014 Roxane Gardner MD MPH DSc Assistant Professor of Ob/Gyn, Brigham and Women s Hospital Director of the Visiting Scholars and Fellowship Program Co-Director of the Labor and Delivery Program Center for Medical Simulation

2 Disclosure I have no financial relationship with a commercial entity producing healthcare related products or services.

3 Objective Discuss the partnership between a malpractice insurer, a simulation center and insured healthcare institutions in promoting patient safety, teamwork and communication

4 CRICO/RMF CRICO (Controlled Risk Insurance Company) o Captive insurance company created in 1976 o Insures all primary and affiliate institutions associated with the Harvard medical community o ~29 institutions, ~12,000 physicians, ~4,000 residents/fellows ~25 hospitals and ~120,000 employees Risk Management Foundation of the Harvard Medical Institutions (RMF) o Membership organization created in 1979 o Claims management, loss prevention, patient safety services o CRICO Strategies - provides similar services to organizations outside of the Harvard community o Healthcare Safety Research Institute (HSRI) educational foundation supporting teaching programs to improve patient care o Academic Medical Center Patient Safety Organization (AMC PSO) to convene clinicians and health care organizations and share data and experiences in a secure environment to inform patient safety efforts

5 Center for Medical Simulation Vision Experiential healthcare learning that never puts a patient at risk Mission Using simulation to improve safety, quality and education in healthcare

6 A Leap of Faith CRICO took a leap of faith investing in simulation... and discovered a means to change relationships and culture

7 CRICO Team Training Initiatives Anesthesia Obstetrics Surgery Emergency Medicine

8 Motivating Engagement CRICO Malpractice Premium Incentives Anesthesiology Incentive Obstetrical Incentive Fundamentals of Laparoscopic Surgery o Surgical incentive program reimbursing program fees + one-time bonus Surgical Incentive Emergency Medicine Incentive o Incentive provided to organizations to implement interprofessional learning via simulation and didactic team training

9 Center for Medical Simulation Historical Highlights 1992 Pilot anesthesia simulation course for Anesthesia Chiefs 1993 Center for Medical Simulation (CMS) established 1994 First anesthesia simulation course 2001 First insurance premium incentive for anesthesia simulation training 2002 First Obstetrical team training pilot course 2003 First insurance premium incentive for obstetric simulation training 2003 Simulation training required for anesthesia faculty recredentialing at MGH 2010 First OR teamwork instructor course and OR team training pilot course 2010 First insurance premium incentive for surgeons participating in OR team training 2011 Simulation training required for obstetric faculty recredentialing at BWH 2011 First Emergency Medicine teamwork instructor course 4 th floor, 13,000 sq ft Boston MA

10 CRICO Anesthesia Incentive Program Voluntary program launched in 2001 with a 6% incentive 7+ hr course with 4-7 anesthesia faculty & 4 high-fidelity simulated cases with immediate post-case debriefings Topics addressed supervision, rescue, ethical dilemmas, speaking up, teamwork and leadership Course completion was required every 3 years Premium differential increased to 19% in 2007 Actuarial analysis in ~2008 showed a 24% lower risk for claims As of 2014, mandatory participation required every 2 years for all CRICO-insured anesthesiologists Bonus: the course was approved in 2010 for Maintenance of Certification for Anesthesia (MOCA )

11 Rate of Anesthesia Cases before and after simulator training began in % premium rate differential for anesthesiologists with simulator training vs. those without training Shannon DW. How a Captive Insurer Uses Data and Incentives to Advance Patient Safety. PSQH. Nov/ Dec 2009.

12 Change Management Partnership Expands CRICO Members ~ 25,000 deliveries/year Atrius Health Harvard Vanguard Cambridge Health Alliance CareGroup BIDMC & MAH Partners HealthCare System BWH, MGH, NSMC & NWH, and now Martha s Vineyard and Nantucket Cottage

13 DRC Study of OB Closed Claims 2001 Impact of teamwork and communication commissioned by CRICO Study Sample Source Sample Size CRICO Closed Claims across 4 Hospitals % Cases Better Teamwork Could Prevent or Mitigate Error Estimated Costs avoided by preventing or mitigating error 49 21/49 (43%) $11.57 Million total $551,000 average per case where teamwork could have had an impact 13

14 The CRICO OB Incentive Program 6 Entry Requirements for Year 1 Team Training: didactic or simulator-based Safety Climate Survey Ob Guidelines Test On-Line CME: EFM & Shoulder Dystocia Physician Satisfaction Survey 4 Maintenance Requirements for Years 2 & 3 Team training refresher 2 On-Line CME courses YR2: Pass Ob Guidelines Test YR3: Participate in Ob Safety Drills Launched in June 2003

15 CRICO Ob Incentive Program Impact* Simulation Team Training 48 Months Prior 48 Months After Total Number of Claims Total Number High Severity 40 (75%) 22 (71%) Final Indemnity Reserve $ 62.6 Million $44.7 Million *March 2009: Pre-training loss dates 7/1/99 6/30/03; Post-training loss dates 7/1/03 6/30/07. Shannon DW. How a Captive Insurer Uses Data and Incentives to Advance Patient Safety. PSQH. Nov/ Dec 2009.

16 OB Risk Reduction Program Evolution OB Incentive Program Initiated % premium reduction as cash incentive Program requirements completed over 3-year cycle result: reassuring claim and actuarial trends 2011 OB Risk Reduction Program High-risk OB Premium Premium =$65,699 All Ob MD providers who do not complete the program requirements within the calendar year as prescribed Low-risk OB Premium Premium=$55,215 All Ob MD providers who complete the program requirements within the calendar year as prescribed 16% Premium differential Cash incentives discontinued

17 1 7 NUMBER OF CASES OB Claims Trend Downward After Implementation CRICO Predictive Analyitics Show Benefits of Risk Reduction Program Actual cases, pre-program Projected cases, based on pre-program actual cases RISK REDUCTION PROGRAM Actual cases, post-program Projected cases, post-program Trend of post-training cases OCCURRENCE YEAR

18 OB Patient Safety Program 2012 Two-year cycle program 1) CRICO approved training program 6 hour course completed every 2 years Curriculum must include simulation-based activities 1-2 hour team training refresher/ob safety drills completed in the interval year 2) Complete and pass the Ob Guidelines Test yearly Institution/Departmental requirements 1) provide OB drills/team training sessions 2) Credentialing program participation included as a term of credentialing at CRICO-insured institutions

19 Obstetrical simulation-based team training Clinical Topics Introductory Level o Maternal code o Shoulder dystocia o Surgical error o Difficult conversations o Feedback advocacy/inquiry Advanced Level o Maternal code o Shoulder dystocia o Post partum hemorrhage o Surgical error o Disclosure & apology o Maternal seizure o Breech Delivery o Operative Vaginal Delivery o Diagnostic Problemsolving o Checklists

20 A Leap of Faith and a means to change relationships and culture o CRICO took a leap of faith investing in simulation o Investment provided CRICO with favorable data o 25% premium rate differential for anesthesiologists o 16% premium rate differential for Obstetricians o Data/premium reductions convinced clinical leadership to require simulation for privileging and credentialing

21 Surgery Incentive Pilot Program Launched in 2010 Surgery at high risk for claims Technical Errors Communication Failed or lack of response CRICO aimed to build resilient teams that react promptly, correctly

22 Overarching Goals 1) Train high risk surgical teams in teamwork via simulation 2) Build infrastructure by developing core faculty at each hospital 3) Improve the culture of safety

23 Voluntary Overview of the Program 10% premium incentive annually for 3 years for participating surgeons Requirements: o 1 st year: simulation-based team training course (4-6 hours) o 2 nd year: OR safety drill based at the institution o 3 rd year: requirement to be determined Grant provided directly to organizations in support of facility use and interprofessional team learning involving nurses, anesthesiologists, and simulation staff Became a CRICO-wide program as of 2012 impact will be evaluated in future years

24 Specific Training Goals Focus of training sessions: Goals: o Assertiveness/speaking up o Closed loop communication o Correct use of the safe surgery checklist o Improve teamwork and communication o Improve patient outcomes

25 Code outside of OR The Scenarios o Unfamiliar environment levels the field for all participants o Everyone out of their usual roles Hemorrhage Catastrophe in the OR o At the discretion of the institution

26 Conclusion An insurer-supported, multi-institutional simulation-based team training program for clinicians in high risk areas such as anesthesia, obstetrics and surgery is feasible Meaningful collaboration between an insurer, a simulation center and the insured healthcare institutions promotes patient safety, teamwork and communication; and translates into appreciable reductions in claims and safer patient care Modest institutional compensation by an insurer supports involvement by nursing and other support staff and helps make up for lost work time Participants have found such coursework has a meaningful impact on their clinical practice

27 Attribution & Acknowledgements To provide a superior medical malpractice insurance program to our members, and to assist them in delivering the safest health care in the world Experiential healthcare learning that never puts a patient at risk All primary and affiliate institutions comprising the Harvard medical community who care for a diverse community and are committed to leadership in alleviating human suffering caused by disease

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