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Here is an example of how RMF Strategies evidence-based techniques have demonstrated value.

Situation

ObGynCare, a group practice, wanted to know why its malpractice insurance premiums were increasing. The clinicians suspected that most of their claims stemmed from post-term pregnancies and issues with night shift staffing, but they could not be certain of the specific reason or reasons. They contacted their insurer.

Using Data as Evidence

The insurer quickly responded using the Decision Support System. First, they ran a ten-year claims history with the Advanced Report Writer. Next, they conducted an analysis of those claims with the Executive Information System (EIS), to study the nature and cost of the claims experience over time. EIS produced a simple graphic display of the findings. Finally, they benchmarked the actual claims and event history of ObGynCare against other group practices nationwide. The entire process took just a few minutes.

The system provided evidence that the practice incurred a much higher rate of expenditure than did the rest of the insured population. Case details indicated that birth asphyxia was a common diagnosis in most of the hospital-based cases. However, the risk manager also learned that Ob/Gyn Associates, another local practice, had a much lower rate of birth asphyxia claims. The insurer contacted the obstetrical chief at Ob/Gyn Associates, and found that the practice had a successful, three-year-old program aimed at preparing expectant parents for bad outcomes when initial fetal assessment dictates such a discussion.

Findings

The insurer also found a troubling trend in office-based claims, many of which alleged a failure to diagnose or delay in diagnosis of cancer. To confirm these findings, they scheduled RMF Strategies Office Practice Evaluation (OPE) site visits at each of the ObGynCare patient care locations. The site surveyor, an experienced risk manager, found that ObGynCare did not have an effective way to follow up on Pap smear results and mammograms. The office records often lacked evidence that the physicians had reviewed the lab results and/or imaging, and did not indicate the results were discussed with the patient.

The insurer showed ObGynCare that failure to prompt, encourage, and monitor patients through recommended health screenings reduces the opportunity for early detection of treatable conditions. Where health-screening protocols are well established, such as cervical cancer prevention and breast care, allegations of failure to guide patients through those protocols proved difficult to defend in the courtroom.

Action

The ObGynCare physician's original suspicion about overnight supervision issues as a causal factor in claims experience was also confirmed by the analysis. Losses were most frequently attributed to issues in communication, teamwork, and documentation. Armed with evidence and resources from the RMF Strategies library, the physicians outlined a training plan for all members of the practice and the clinicians at the hospitals where they had admitting privileges. They instructed everyone that when teamwork is determined to be an issue, procedural changes for hand-offs and supervision, particularly in the off-hours, would be implemented to improve provider continuity and reduce communication-based errors.

Using a video program "preparing for a difficult outcome" as part of the in-service training program was effective in reducing communication-related malpractice claims. Rather than the standard message of "more documentation", the clinicians were able to add specific elements of documentation, which resulted in improved defensibility of claims and lawsuits.

Results

By implementing better tracking processes to follow up with ordered tests and results, the office reduced allegations of failure to diagnose cancer by 50 percent. Use of a Breast Care Algorithm designed by Risk Management Foundation of the Harvard Medical Institutions improved the primary care at ObGynCare. Women at risk for breast cancer who did not fit the typical profile now stand an improved chance of early detection. Since each paid breast cancer claim cost approximately $750,000, there were obvious financial benefits to improving the care rendered by the practice.

Return on Investment

The average loss associated with a birth asphyxia case over a 10-year period for the insurer was $660,000. The average loss of a communication-related claim was even higher. The reduction in just a single claim in each of those target areas in any one-year would save $1.3 million. Improved defensibility of documentation-related claims would prove to save nearly twice that amount over the next three years.