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Center for Patient and Professional Advocacy at Vanderbilt Patient Advocacy Reporting System (PARS ® )Project: Experiences of peer messengers who deliver.

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Presentation on theme: "Center for Patient and Professional Advocacy at Vanderbilt Patient Advocacy Reporting System (PARS ® )Project: Experiences of peer messengers who deliver."— Presentation transcript:

1 Center for Patient and Professional Advocacy at Vanderbilt Patient 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 1

2 Center for Patient and Professional Advocacy at Vanderbilt It Takes a Team – Thanks To: Jeff Jay Peggy Westlake Dr. Janis Karrass Robert Wohlfarth Nik Zakrzewski Dr. Tom Catron Dr. Jerry Hickson Dr. Ilene Moore Marbie Sebes Kelly Blumenberg Sue Garey Heather Pottkotter Stephanie Marks Heather Gillespie Brittney Jenkins Cindy Butts, Ann Loffi Debbie Toundas Carol Farina 2

3 Center for Patient and Professional Advocacy at Vanderbilt 3 The PARS ® Project Fair, systematic process involves surveillance for all professionals; IDs & intervenes with outliers: Promotes professionalism, 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

4 Center for Patient and Professional Advocacy at Vanderbilt The PARS ® Project Overview PARS® identifies and supports interventions on high- malpractice-risk physicians (and healthcare facilities) using nationally-benchmarked scores derived from unsolicited patient complaints Results of >1,800 initial and follow-up interventions in practices ranging from rural hospitals to metropolitan medical centers show substantial: Reduction in malpractice claims Return on Investment (Patient Advocacy Reporting System) 4

5 PARS® Sites Development Sites Prospective Sites Major Educ. Sites

6 Center for Patient and Professional Advocacy at Vanderbilt 1-6%+ hospital patients injured due to negligence ~2% of all patients injured by negligence sue ~2-7x more patients sue without valid claims Non-$$ factors motivate patients 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 Medical Malpractice Research Background Summary 6

7 Academic vs Community Medical Center 35-50% are associated with NO concerns Hickson et al., SMJ. 2007; Hickson et al., JAMA Jun 12;287(22): % of concerns associated with 9-14% of Physicians

8 Center for Patient and Professional Advocacy at Vanderbilt 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?

9 Center for Patient and Professional Advocacy at Vanderbilt 9 Who would you want to deliver the message to you? And “when”?

10 Apparent pattern Single “unprofessional" incidents (merit?) Promoting Professionalism Pyramid "Informal" Peer (or ?) Cup of Coffee Intervention Level 1 "Awareness" Intervention by Peer Level 2 “Guided" Intervention by Authority Level 3 "Disciplinary" Intervention by HR/legal Pattern persists No ∆ Vast majority of professionals - no issues - provide feedback on progress Adapted from Hickson GB, Pichert JW, Webb LE, Gabbe SG, Acad Med, Nov, 2007 Mandated Reviews

11 Center for Patient and Professional Advocacy at Vanderbilt A Committee of “Messenger” Physician Peers is formed to deliver the data Committee Members: Are committed to confidentiality, fairness, respect Are respected by colleagues Are 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 (Under Existing QA/Peer Review)

12 Center for Patient and Professional Advocacy at Vanderbilt 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 12

13 Center for Patient and Professional Advocacy at Vanderbilt Representative Concerns 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 He 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 state Communication He did not keep us informed about my daughter’s condition…and didn’t answer our questions 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 13

14 Center for Patient and Professional Advocacy at Vanderbilt What are these interventions all about? First, some philosophy, process. Then we’ll see a PARS ® intervention. 14

15 Center for Patient and Professional Advocacy at Vanderbilt PARS® Level 1 “Awareness” Intervention “Messengers” agree to share data profiles Make high risk providers aware of data via letter; messenger makes visit to share scores, benchmarks, de- ID’d complaint reports No diagnoses or prescriptions, rather encourage creative thinking, problem solving Info is confidential beyond those designated to know; confidentiality is a high priority Annual follow-ups promote accountability If no change, “Level 2” involves authorities, supports those authorities with data Moore, Pichert, Hickson, Federspiel, Blackford. Vanderbilt Law Review

16 Center for Patient and Professional Advocacy at Vanderbilt 16

17 17 Messenger Committee Co- chairs assign folders Messengers meet with physicians, share data, complete debriefing report, report to Co- chairs PRN; Co-chairs track intervention completion Messenger physicians well trained to deliver interventions Well trained messengers; CPPA provides 6 hrs well tested intervention training Debriefing report tracking & follow-up with messengers; CPPA tracks meeting completion and outcomes, provides info to Co-chairs Carefully considered assignments; CPPA provides guidelines/experience for matching The PARS® ProcessWhat is Required?

18 Center for Patient and Professional Advocacy at Vanderbilt Importance of Messenger Debriefing Reports Used for tracking the overall institutional progress of PARS® Informs CPPA if meeting occurred and physician reaction Helps CPPA determine if additional materials need to be provided as follow-up Send the form back to CPPA regardless of what happens at your meeting  If the meeting occurs, tell us how it went  If 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

19 Center for Patient and Professional Advocacy at Vanderbilt PARS® 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? 19

20 Center for Patient and Professional Advocacy at Vanderbilt PARS® Messenger Experiences Date range 1/1/2005 – 12/31/2009: 5 years Interventions Possible = 1151 No 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 authorities Interventions with data = 919 # indiv human beings to be intervened upon = 554 # messengers = 233, most did 1-6 interventions 20

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22 Center for Patient and Professional Advocacy at Vanderbilt Length of Interventions First interventions: Range (min)5-90 Mean Length(minutes)33 Median30 Followup interventions: Range (min)2-120 Mean Length(minutes)30 Median30

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25 Center for Patient and Professional Advocacy at Vanderbilt Why might your practice stand out?

26 Center for Patient and Professional Advocacy at Vanderbilt Does Messenger Agree with “Issues” 26 Agree (%)Disagree (%)Uncertain (%) First Meeting Follow Up All 58129

27 Center for Patient and Professional Advocacy at Vanderbilt Does Messenger Agree with “Issues” 27 Agree (%)Disagree (%)Uncertain (%) First Meeting Follow Up All F-U Good9 F-U Bad8 F-U Mixed/ Neutral 5899

28 Center for Patient and Professional Advocacy at Vanderbilt High Risk Physician “Receptivity” 28 PositiveNegativeNeutral First-Time81.8%2.3%16% Follow-Up75.6%1.9%23%

29 Center for Patient and Professional Advocacy at Vanderbilt High Risk Physician “Receptivity” 29 PositiveNegativeNeutral First-Time81.8%2.3%16% Follow-Up75.6%1.9%23% "Bad news"17.0%0.4%6% "Good news"27.0%0.4%5% "Mixed" "Neutral" "Recidivist"

30 Center for Patient and Professional Advocacy at Vanderbilt High Risk Physician “Receptivity” 30 PositiveNegativeNeutral First-Time81.8%2.3%16% Follow-Up75.6%1.9%23% "Bad news"17.0%0.4%6% "Good news"27.0%0.4%5% "Mixed"14.0%0.0%4% "Neutral"15.7%0.8%7% "Recidivist"

31 Center for Patient and Professional Advocacy at Vanderbilt High Risk Physician “Receptivity” 31 PositiveNegativeNeutral First-Time81.8%2.3%16% Follow-Up75.6%1.9%23% "Bad news"17.0%0.4%6% "Good news"27.0%0.4%5% "Mixed"14.0%0.0%4% "Neutral"15.7%0.8%7% "Recidivist” (n=15)60.0%6.7%33%

32 # Follow-Up Interventions Needed to Reach "Visits Suspended”

33 33 Follow-up: feedback to high risk physicians--do scores improve or, if not, initiate the process to move intervention to next level Construct & deliver follow- up data/materials; CPPA provides yearly data and recommendations (based on 10+ years exp) The PARS® Process Keep key leaders informed about risk score stats over time, promote process Periodic Risk Mgmt experience reviews Prepare & deliver present’ns to key leaders; defend fairness of process as needed; CPPA provides presentation templates and data; special requests within reason CPPA supports several risk mgmt and quality initiatives What is Required?

34 Center for Patient and Professional Advocacy at Vanderbilt Composite Physician Intervention Results on Complaints: 34 Hospitals/Med Groups 34

35 Center for Patient and Professional Advocacy at Vanderbilt Total # of high complaint physicians706 Departed after initial intervention48 First follow-up later in 2011 – Total with follow-up results524 Results for those with follow-up data: Good – Intervention visits suspended24948% Good – Anticipate suspension in % Some improvement – Still need tracking326% Subtotal for those doing better37572% Unimproved/worse10720% Departed Unimproved428% Total follow-up results524 PARS ® Progress Report 35 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

36 Center for Patient and Professional Advocacy at Vanderbilt Total # high complaint physicians97 Departed after initial intervention6 First follow-up in Total with follow-up results84 Results for those with follow-up data: Good – Intervention Visits suspended46(56%) Good – Anticipate suspension in 20127(8%) Some Improvement—still needs tracking7(8%) Subtotal60(72%) Unimproved/worse12(14%) Departed Unimproved12(14%) Total follow-up results84 36 VUMC PARS ® Progress Report 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

37 Center for Patient and Professional Advocacy at Vanderbilt What about those who don’t improve? Departed: 34% Continuing to receive feedback: 60% Currently at “Level 2 Authority”: 6% 37

38 Center for Patient and Professional Advocacy at Vanderbilt Level 2 Historical Outcomes N = 68 N = 22 (32%) first L2 this year, no follow-up data Improved: 28 (41%) Remain unimproved: 18 (27%) 38

39 Center for Patient and Professional Advocacy at Vanderbilt But does the PARS® Program produce a Return on Investment (ROI)? We began with a pilot RCT… 39 Confidential and privileged pursuant to the provisions of Peer Review Statutes.

40 40 (p = 0.15) RMF Openings with Expenditures per Physician-Exposure Year

41 Malpractice Claims (per 100 MDs) FY1992 – 2009 * 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.

42 Number of Suits per MM RVUs* *trends continue, data pending expiration of statutes of limitations in two states represented

43 Center for Patient and Professional Advocacy at Vanderbilt Summary, limitations and discussion Messengers can be recruited and trained; they will serve over time Training 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? 43

44 Center for Patient and Professional Advocacy at Vanderbilt It Takes a Team – Thanks To: Jeff Jay Peggy Westlake Dr. Janis Karrass Robert Wohlfarth Nik Zakrzewski Dr. Tom Catron Dr. Jerry Hickson Dr. Ilene Moore Marbie Sebes Kelly Blumenberg Sue Garey Heather Pottkotter Stephanie Marks Heather Gillespie Brittney Jenkins All the messengers 44


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