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Patient Advocacy Reporting System (PARS®)Project: Experiences of peer messengers who deliver uncomfortable news to physician colleagues James W. Pichert,

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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:

1 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

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

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 Added in “Helps Satisfy” in place of Satisfies per Dr. Moore and Joint commission reviewer comment 3

4 The 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 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

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

6 Medical 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 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 6 6

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

8 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 Who would you want to deliver
the message to you? And “when”? 9

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

12 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 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 Should include the patient complaint narrative highlighted

14 What are these interventions all about? First, some philosophy, process. Then we’ll see a PARS® intervention. 14

15 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

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17 The PARS® Process What is Required?
Well trained messengers; CPPA provides 6 hrs well tested intervention training Messenger physicians well trained to deliver interventions Carefully considered assignments; CPPA provides guidelines/experience for matching 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 Debriefing report tracking & follow-up with messengers; CPPA tracks meeting completion and outcomes, provides info to Co-chairs

18 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 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?

20 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 Length of Interventions
First interventions: Range (min) 5-90 Mean Length(minutes) 33 Median 30 Followup interventions: Range (min) 2-120

23

24

25 Why might your practice stand out?

26 Does Messenger Agree with “Issues”
Disagree (%) Uncertain (%) First Meeting 59 10 6 Follow Up All 58 12 9

27 Does Messenger Agree with “Issues”
Disagree (%) Uncertain (%) First Meeting 59 10 6 Follow Up All 58 12 9 F-U Good 67 F-U Bad 51 23 8 F-U Mixed/ Neutral

28 High Risk Physician “Receptivity”
Positive Negative Neutral First-Time 81.8% 2.3% 16% Follow-Up 75.6% 1.9% 23%

29 High Risk Physician “Receptivity”
Positive Negative Neutral First-Time 81.8% 2.3% 16% Follow-Up 75.6% 1.9% 23% "Bad news" 17.0% 0.4% 6% "Good news" 27.0% 5% "Mixed" "Neutral" "Recidivist"

30 High Risk Physician “Receptivity”
Positive Negative Neutral First-Time 81.8% 2.3% 16% Follow-Up 75.6% 1.9% 23% "Bad news" 17.0% 0.4% 6% "Good news" 27.0% 5% "Mixed" 14.0% 0.0% 4% "Neutral" 15.7% 0.8% 7% "Recidivist"

31 High Risk Physician “Receptivity”
Positive Negative Neutral First-Time 81.8% 2.3% 16% Follow-Up 75.6% 1.9% 23% "Bad news" 17.0% 0.4% 6% "Good news" 27.0% 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 Periodic Risk Mgmt experience reviews
The PARS® Process What 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 level Prepare & deliver present’ns to key leaders; defend fairness of process as needed; CPPA provides presentation templates and data; special requests within reason Keep key leaders informed about risk score stats over time, promote process Periodic Risk Mgmt experience reviews CPPA supports several risk mgmt and quality initiatives

34 Composite Physician Intervention Results on Complaints:
34 Hospitals/Med Groups 34

35 PARS® Progress Report Total # of high complaint physicians 706
Departed after initial intervention 48 First follow-up later in 2011 –2012 134 Total with follow-up results 524 Results for those with follow-up data: Good – Intervention visits suspended 249 48% Good – Anticipate suspension in 94 18% Some improvement – Still need tracking 32 6% Subtotal for those doing better 375 72% Unimproved/worse 107 20% Departed Unimproved 42 8% Total follow-up results Updated kpb 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 35 35 35

36 VUMC PARS® Progress Report
Total # high complaint physicians 97 Departed after initial intervention 6 First follow-up in 2012 7 Total with follow-up results 84 Results for those with follow-up data: Good – Intervention Visits suspended 46 (56%) Good – Anticipate suspension in 2012 (8%) Some Improvement—still needs tracking Subtotal 60 (72%) Unimproved/worse 12 (14%) Departed Unimproved Total follow-up results Updated kpb 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 36

37 What about those who don’t improve?
Departed: 34% Continuing to receive feedback: 60% Currently at “Level 2 Authority”: 6%

38 Level 2 Historical Outcomes
N = 68 N = 22 (32%) first L2 this year, no follow-up data Improved: 28 (41%) Remain unimproved: 18 (27%)

39 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 RMF 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

41 Malpractice 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 Interventions Claims Awareness Meetings: Department chairs made aware every 3-4 months of status of all claims associated with member physicians 2005 – Specific goals and progress transparently presented system-wide every quarter; all goals tied to leadership incentive bonus plan Training on “the how and when of communicating about unexpected adverse outcomes and errors” for Faculty begins 2008 (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.

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

43 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?

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


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