Presentation on theme: "Patient Advocacy Reporting System (PARS®)Project: Experiences of peer messengers who deliver uncomfortable news to physician colleagues James W. Pichert,"— Presentation transcript:
1Patient Advocacy Reporting System (PARS®)Project: Experiences of peer messengers who deliver uncomfortable news to physician colleagues James W. Pichert, Ph.D. Center for Patient & Professional Advocacy, Vanderbilt University School of Medicine
2It Takes a Team – Thanks To: Jeff JayKelly BlumenbergPeggy WestlakeSue GareyDr. Janis KarrassHeather PottkotterRobert WohlfarthStephanie MarksNik ZakrzewskiHeather GillespieDr. Tom CatronBrittney JenkinsDr. Jerry HicksonCindy Butts, Ann LoffiDr. Ilene MooreDebbie ToundasMarbie SebesCarol Farina
3The PARS® ProjectFair, systematic process involves surveillance for all professionals; IDs & intervenes with outliers:Promotes professionalism, fair/just cultureAddresses and reduces malpractice risk/cost and unprofessional behaviorHelps satisfy regulatory requirementsCan help improve interactions among pts and care providers, leading to better outcomesHelps competitive advantage by IDing and helping address threats to reputation and patient safetyAdded in “Helps Satisfy” in place of Satisfies per Dr. Moore and Joint commission reviewer comment3
4The PARS® Project Overview (Patient Advocacy Reporting System)PARS® identifies and supports interventions on high-malpractice-risk physicians (and healthcare facilities) using nationally-benchmarked scores derived from unsolicited patient complaintsResults of >1,800 initial and follow-up interventions in practices ranging from rural hospitals to metropolitan medical centers show substantial:Reduction in malpractice claimsReturn on Investment
5PARS® Sites Development Sites Prospective Sites Major Educ. Sites Updated
6Medical Malpractice Research Background Summary 1-6%+ hospital patients injured due to negligence~2% of all patients injured by negligence sue~2-7x more patients sue without valid claimsNon-$$ factors motivate patients to sueSome MDs/units attract more suitsHigh risk today = high risk tomorrowUnsolicited comment/concerns predict claimsPARS® risk profiles make effective intervention tools66
7Academic vs Community Medical Center 50% of concerns associated with 9-14% of Physicians35-50% are associated with NO concernsHickson et al., SMJ. 2007; Hickson et al., JAMA Jun 12;287(22):
8Critical 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?
9Who would you want to deliver the message to you?And “when”?9
10Promoting Professionalism Pyramid Adapted from Hickson GB, Pichert JW, Webb LE, Gabbe SG, Acad Med, Nov, 2007Level 3 "Disciplinary" Intervention by HR/legalNo ∆Pattern persistsLevel 2 “Guided" Intervention by AuthorityApparent patternLevel 1 "Awareness" Intervention by Peer"Informal" Peer (or ?) Cup of Coffee InterventionSingle “unprofessional" incidents (merit?)Mandated ReviewsVast majority of professionals - no issues - provide feedback on progress
11(Under Existing QA/Peer Review) A Committee of “Messenger” Physician Peers is formed to deliver the data(Under Existing QA/Peer Review)Committee Members:Are committed to confidentiality, fairness, respectAre respected by colleaguesAre willing to serve (8 hours of training)Most have risk scores below the intervention threshold (but at several sites physicians intervened upon are messengers)Agree to review, then take data to outliers at request of messenger committee chair
12Intervention on Dr. __Letter with standings, assurances prior to & at meeting“You are here” graph with 4-yr Risk ScoresComplaint Type Summary“Concerns bullet list”Redacted narrative reports12
13Representative Concerns by Category Concern for Patient/FamilyI never felt like he cared whether [my spouse] lived or died. He does NOT live up to your mottoHe may be famous worldwide for his surgery, but I have to tell you that he’s also famous among the patients in his waiting room—and they come from all over—for being the rudest, crudest, most arrogant jerk doctor in this stateCommunicationHe did not keep us informed about my daughter’s condition…and didn’t answer our questionsPt upset with lack of info from Dr. __...no one is able to tell him what his x-rays showCare and TreatmentDr.___ delay in care made my mother’s medical status worseShould include the patient complaint narrative highlighted
14What are these interventions all about? First, some philosophy, process. Then we’ll see a PARS® intervention.14
15PARS® Level 1 “Awareness” Intervention “Messengers” agree to share data profilesMake high risk providers aware of data via letter; messenger makes visit to share scores, benchmarks, de-ID’d complaint reportsNo diagnoses or prescriptions, rather encourage creative thinking, problem solvingInfo is confidential beyond those designated to know; confidentiality is a high priorityAnnual follow-ups promote accountabilityIf no change, “Level 2” involves authorities, supports those authorities with dataMoore, Pichert, Hickson, Federspiel, Blackford. Vanderbilt Law Review
17The PARS® Process What is Required? Well trained messengers; CPPA provides 6 hrs well tested intervention trainingMessenger physicians well trained to deliver interventionsCarefully considered assignments; CPPA provides guidelines/experience for matchingMessenger Committee Co-chairs assign foldersMessengers meet with physicians, share data, complete debriefing report, report to Co-chairs PRN; Co-chairs track intervention completionDebriefing report tracking & follow-up with messengers; CPPA tracks meeting completion and outcomes, provides info to Co-chairs
18Importance of Messenger Debriefing Reports Used for tracking the overall institutional progress of PARS®Informs CPPA if meeting occurred and physician reactionHelps CPPA determine if additional materials need to be provided as follow-upSend the form back to CPPA regardless of what happens at your meetingIf the meeting occurs, tell us how it wentIf it doesn’t occur, tell us how far you got in the process (i.e. sent letter, contacted multiple times with no response, delivered materials but meeting did not occur, etc.)18
19PARS® Messenger Experiences Will Messengers agree to serve, be trained, serve over time?To what do high risk docs attribute their status?Does “matching” of Messenger with High Risk physician matter? (Physician specialty, other demographics)Does high flyer “outcome” correspond to their response at time of the intervention?What does this add to understanding of Physician change?
20PARS® Messenger Experiences Date range 1/1/2005 – 12/31/2009: 5 yearsInterventions Possible = 1151No meeting (refused, left, no report found) = 89 (7.9%)Letter only: “done well…interventions suspended,” so no regular debriefing= 143 (12.4%)No L2s included as these are done by authoritiesInterventions with data = 919# indiv human beings to be intervened upon = 554# messengers = 233, most did 1-6 interventions20
32# Follow-Up Interventions Needed to Reach "Visits Suspended”
33Periodic Risk Mgmt experience reviews The PARS® ProcessWhat is Required?Construct & deliver follow-up data/materials; CPPA provides yearly data and recommendations (based on 10+ years exp)Follow-up: feedback to high risk physicians--do scores improve or, if not, initiate the process to move intervention to next levelPrepare & deliver present’ns to key leaders; defend fairness of process as needed; CPPA provides presentation templates and data; special requests within reasonKeep key leaders informed about risk score stats over time, promote processPeriodic Risk Mgmt experience reviewsCPPA supports several risk mgmt and quality initiatives
34Composite Physician Intervention Results on Complaints: 34 Hospitals/Med Groups34
35PARS® Progress Report Total # of high complaint physicians 706 Departed after initial intervention48First follow-up later in 2011 –2012134Total with follow-up results524Results for those with follow-up data:Good – Intervention visits suspended24948%Good – Anticipate suspension in9418%Some improvement – Still need tracking326%Subtotal for those doing better37572%Unimproved/worse10720%Departed Unimproved428%Total follow-up resultsUpdated kpbThis material is confidential and privileged information under the provisions set forth in T.C.A. §§ and and shall not be disclosed to unauthorized persons353535
36VUMC PARS® Progress Report Total # high complaint physicians97Departed after initial intervention6First follow-up in 20127Total with follow-up results84Results for those with follow-up data:Good – Intervention Visits suspended46(56%)Good – Anticipate suspension in 2012(8%)Some Improvement—still needs trackingSubtotal60(72%)Unimproved/worse12(14%)Departed UnimprovedTotal follow-up resultsUpdated kpbThis material is confidential and privileged information under the provisions set forth in T.C.A. §§ and and shall not be disclosed to unauthorized persons3636
37What about those who don’t improve? Departed: 34%Continuing to receive feedback: 60%Currently at “Level 2 Authority”: 6%
38Level 2 Historical Outcomes N = 68N = 22 (32%) first L2 this year, no follow-up dataImproved: 28 (41%)Remain unimproved: 18 (27%)
39But does the PARS® Program produce a Return on Investment (ROI)? We began with a pilot RCT…39Confidential and privileged pursuant to the provisions of Peer Review Statutes.
40RMF Openings with Expenditures per Physician-Exposure Year We began with a pilot study. The pilot involved 31 Vanderbilt surgeons who were identified in 1998 as high-risk by their calculated Risk Scores. Following the Institutional Review Board’s approval, surgeons were randomly assigned to an intervention group (physicians received awareness messages) or to a control group (no messages). Given the relatively infrequent nature of being named in Risk Management Files with Expenses (RMFEs), the study was conducted to generate data for power calculations and gain insight into the intervention process. Surgeons in the study group received initial and follow-up interventions beginning in 1998 through RMFEs for six years preceding and subsequent to initial interventions were tracked.In addition to reducing complaint numbers, the intervention group experienced almost 50% fewer RMFEs compared with no change for the control group surgeons. However, given the cohort size and frequency of risk events, the difference constituted a trend (p=0.15), which means we can “only” be 85% confident that the result is a real difference not due to chance.(p = 0.15)40
41Malpractice Claims (per 100 MDs) FY1992 – 2009 Comparison of claims trends over time reveal a slight upwards trend for Middle Tennessee physicians as compared to a 75% decline in claims for Vanderbilt physicians (p<0.01), a highly statistically significant result.Of course it is important to recognize that Vanderbilt launched several system-wide initiatives (indicated by arrows) designed to promote quality, enhance patient safety, and control unnecessary claims experience. Combined with the outcomes of the randomized trial, these results support the effectiveness of the PARS® intervention process to reduce the risk of individual physicians and the group’s collective risk.The arrows in the figure refer to the start of the following initiatives:Ended study; Started general InterventionsClaims Awareness Meetings: Department chairs made aware every 3-4 months of status of all claims associated with member physicians2005 – Specific goals and progress transparently presented system-wide every quarter; all goals tied to leadership incentive bonus planTraining on “the how and when of communicating about unexpected adverse outcomes and errors” for Faculty begins2008 (July 2007) - Start of Rebate Program: Risk Management incentivizes departments to have all physicians trained on disclosure, do early event reporting, identify physician quality/safety officers, etc.2008 (May 2008) – Certificate of Merit Bill signed: a tort reform legislation passed in the state of TN.* Data used with permission, State Volunteer Mutual Insurance Company, a mutual insurer of 10,500 TN non-VUMC physicians of all specialties, 29% to 33% who practiced in Middle TN during the target date.This material is confidential and privileged information under the provisions set forth in T.C.A. §§ and and shall not be disclosed to unauthorized persons.
42Number of Suits per MM RVUs* *trends continue, data pending expiration of statutes of limitations in two states representedAnother site, an academic medical center in a far more litigious community than Nashville, began using the Vanderbilt intervention process in That organization’s lawsuit trend appears in this Figure. Vanderbilt data are provided to illustrate jurisdictional differences in litigation risk. However, both institutions have experienced a similar downward trend in their claims experience.
43Summary, limitations and discussion Messengers can be recruited and trained; they will serve over timeTraining needs to prepare for a range of reactions, assertions and questions (“push-backs”)High risk physicians “blame” external forces twice as often as internal issues—(and may be correct)Need more drill down re “matching”Limitations: self reported data, what else?What does this add to our understanding of just culture and Phys/HCP change?
44It Takes a Team – Thanks To: Jeff JayMarbie SebesPeggy WestlakeKelly BlumenbergDr. Janis KarrassSue GareyRobert WohlfarthHeather PottkotterNik ZakrzewskiStephanie MarksDr. Tom CatronHeather GillespieDr. Jerry HicksonBrittney JenkinsDr. Ilene MooreAll the messengers