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Center for Patient andProfessional Advocacyat Vanderbilt
Identifying and Intervening on High Risk Physicians: The PARS® Project
Gerald B. Hickson, MDDirector, Center for Patient and Professional Advocacy
Associate Dean for Clinical Affairs
Center for Patient & Professional AdvocacyVanderbilt University School of Medicine
[email protected]/cppa
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Center for Patient andProfessional Advocacyat Vanderbilt
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The PARS® Project
• Fair, systematic process involves surveillance for all professionals; IDs & intervenes with outliers:• Promotes 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
PARS® SitesDevelopment SitesProspective SitesMajor Educ. Sites
3Cogent Healthcare
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Center for Patient andProfessional Advocacyat Vanderbilt
• 1-6%+ hosp. pts injured due to negligence• ~2% of all pts injured by negligence sue• ~2-7 x more pts sue w/o valid claims• Non-$$ factors motivate pts 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
Med Mal Research Background Summary
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Center for Patient andProfessional Advocacyat Vanderbilt6
Four Hypotheses
• Attract a litigation-prone population• Attract medically high-risk patients• Are technically incompetent• Have difficulty “connecting” with pts
Physicians who attract a disproportionate share of malpractice claims:
Center for Patient andProfessional Advocacyat Vanderbilt
Perceptions of Care During L&D
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Communication 8 18 27*Care/treatment 5 15 22*Access/availability 7 11 15*Humaneness of Phys 5 6 17*
Hickson GB, et al. JAMA 1994; 272:1583-1587.
Patient Concerns (%) 0 1-3 FreqPhys Lawsuit Hx
* Statistically significant difference
(Open-Ended Questions)
Center for Patient andProfessional Advocacyat Vanderbilt
Can high risk physicians be identified by means other than counting
lawsuits?
Unsolicited complaints link to malpractice risk.
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Center for Patient andProfessional Advocacyat Vanderbilt9
Patient Complaints
• “I had questions about my medical condition and treatment. Dr.__ looked up and asked, ‘Are you illiterate?’ I said, “No.” Dr.__ responded, ‘Oh, I just gave you several pamphlets that explain all of this. Since you didn’t get it, I thought that maybe you were illiterate.’”
• “Dr. __ was rude. I was 7 minutes late and apologized. He looked at his watch and said, ‘That’s 7 minutes I won’t be able to talk with you.’ He seemed very annoyed.”
Academic vs Community Medical Center50% of concerns associated with 9-14% of Physicians
30 35 40 45 50 55 60 65 70 75 80 85 90 95 1000
25
50
75
100Academic Med CtrCommunity Med Ctr
% of Physicians
% o
f Con
cern
s
Note: 35-50% are associated with NO concernsHickson, et al., SMJ, 2007; Hickson et al, JAMA. 2002 Jun 12;287(22):2951-7 10Cogent Healthcare
Center for Patient andProfessional Advocacyat Vanderbilt
Predictors of Risk Outcomes
• Gender• Physician specialty• Volume of service• Unsolicited patient complaints
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Predictive concordance of risk models ranges from 81-92%
Hickson et al, JAMA. 2002 Jun 12;287(22):2951-7.
(logistic regression)
Incurred Expense By Risk CategoryPredicted Risk
Category# (%)
PhysiciansRelative Expense
% of Total Expense
Score (range)
1 (low) 318 (49) 1 4% 0
2 147 (23) 6 13% 1 - 20
3 76 (12) 4 4% 21 - 40
4 52 (8) 42 29% 41 - 50
5 (high) 51 (8) 73 50% >50
Total 644 (100) 100%
* In multiples of lowest risk groupMoore, Pichert, Hickson, Federspiel, Blackford. Vanderbilt Law Review, 200612
Center for Patient andProfessional Advocacyat Vanderbilt
Analysis of Claims and PARS® Risk Score
Specialty Group
# of Physicians
PARS® Risk Score
Specialty Group
Clinical Activity (RVUs)
Med n=684 = .15*** ns = .07 (p<.10)
Surgeons* n=267 = .42*** ns = .10 (p<.10)** p<.01
*** p<.001
Major Medical Center’s Claims AnalysisClaims Data 2000-2008
*Note: =relative weight, so Risk Score was 4.2x more predictive of claims than clinical activity for surgeons
Center for Patient andProfessional Advocacyat Vanderbilt14
Conceptual Framework – Professionalism• Professionals commit to:
• Technical and cognitive excellence• Professionals also commit to:
• Confidentiality• Clear and effective communication• Modeling respect• Being available
• Professionalism promotes teamwork
Professionalism and Self-Regulation
Center for Patient andProfessional Advocacyat Vanderbilt
Professionalism and Self-Regulation
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Professionalism demands self-regulation• Personal
• Discipline specific
• Group
• Systems focused
All require the skills to provide and receive feedback
Center for Patient andProfessional Advocacyat 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?
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Center for Patient andProfessional Advocacyat Vanderbilt
MMC Forms a Committee
• Are committed to confidentiality• Are respected by colleagues• Are willing to serve (8 hours of training)• Have risk scores that are mostly okay (but at several
sites physicians intervened upon are messengers)• Agree to review, then take data to 1-3 physicians at
request of local messenger committee chair
“Messenger” Physician Peers:
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(Committee formed under existing QA/Peer review)17
Center for Patient andProfessional Advocacyat 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
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Center for Patient andProfessional Advocacyat Vanderbilt
Representative Complaints 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 mottoCommunication• He did not keep us informed about my daughter’s condition…
and didn’t answer our questions• “Dr. X offered no information. I felt he was hiding information.
Never even tried to speak to my husband.”• Pt upset with lack of info from Dr. __...no one is able to tell him
what his x-rays showCare and Treatment• Dr.___ delay in care made my mother’s medical status worse
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0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%0
25
50
75
100
125
150
175
200
Urologists
All Non-Uro Surgeons
Percentage of Surgeons
Ris
k S
co
re
Risk Score of 114 puts Dr. __ in the top 3% of urologists
Risk Score vs. Percent of PARS® Physicians at all Institutions
Stimson, et al. J Urol, May 2010
Urologists
The Risk Score reflects the complaints with which each physician was associated. It is based on an algorithm that weighs complaints recorded in the past year more heavily than those recorded in prior years.
(n = 268)
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Center for Patient andProfessional Advocacyat Vanderbilt
But does any of this
actually work?
Center for Patient andProfessional Advocacyat Vanderbilt
Observations
• More than 1,900 interventions completed• All messengers emerged intact (so far)• <5% responded with hostility• Common responses:
• “I never knew…”• “It’s the system…”• “These complaints are trivial…”• “I’m overscheduled…”
• ~10% go to Level II Interventions (persistent pattern needing an improvement plan)
• Follow-ups ongoing22
Center for Patient andProfessional Advocacyat Vanderbilt23
Total # of high complaint physicians 666Departed after initial intervention 41First follow-up later in 2011 –2012 136
Total with follow-up results 489 Results for those with follow-up data: Good – Intervention visits suspended 218 45% Good – Anticipate suspension in 2011-2012 99 20% Some improvement – Still need tracking 35 7%
Subtotal 352 72% Unimproved/worse 95 19% Departed Unimproved 42 9%Total follow-up results 489
PARS® Progress Report
This material is confidential and privileged information under the provisions set forth in T.C.A. §63-6-219 and shall not be disclosed to unauthorized persons.
Center for Patient andProfessional Advocacyat Vanderbilt
PARS® & Claims Experience
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What about the impact of a peer-based intervention process on claims
experience?
Center for Patient andProfessional Advocacyat Vanderbilt
PARS® & Claims Experience
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Assessing an impact on claims is challenging:• Claims are relatively rare events• Changes in external environment (frequency,
legislative initiatives, tort reform, etc)• Changes in internal environment (other
Quality/Safety initiatives, growth, case mix, etc)
Let’s look at claims in Middle Tennessee per 100 MDs (non-Vanderbilt physicians)
This material is confidential and privileged information under the provisions set forth in T.C.A. §63-6-219 and shall not be disclosed to unauthorized persons.
Malpractice Claims (per 100 MDs)
FY1998 – 2009
Center for Patient andProfessional Advocacyat Vanderbilt
PARS® & Claims Experience
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1990’s mindset: “our claims experience is above average”
(in a good sense)Was our assumption correct?
• We had (have) lots of physicians who wear multiple hats (teaching, research, clinical care)
• Used MGMA data on RVU production to convert VUMC productivity to FTEs
• Compared our claims/FTE to claims/100 MDs in Middle Tennessee
This material is confidential and privileged information under the provisions set forth in T.C.A. §63-6-219 and shall not be disclosed to unauthorized persons.
(We were wrong)
Malpractice Claims (per 100 MDs)FY1998 – 2009
Center for Patient andProfessional Advocacyat Vanderbilt
PARS® & Claims Experience
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Since 1998 VUMC:• PARS®• Leadership Claims Awareness meetings• ELEVATE program (leadership program to promote
core principles of excellence, integrity and ongoing improvement)
• Required Disclosure training• Allocation Rebate program
And the Tennessee Medical Malpractice Notice and Certificate of Merit Bill passed
Malpractice Claims (per 100 MDs)
FY1998 – 2009
Malpractice Claims (per 100 MDs)
FY1998 – 2009
6 - Certificate of Merit Bill
This material is confidential and privileged information under the provisions set forth in T.C.A. §63-6-219 and shall not be disclosed to unauthorized persons.
1
3
45
6
2
5 - Allocation Rebate Program 4 - Disclosure Training 3 - ELEVATE 2 - Claims Awareness Meetings 1 - PARS® Interventions
Malpractice Claims (per 100 MDs)FY1998 – 2009
This material is confidential and privileged information under the provisions set forth in T.C.A. §63-6-219 and shall not be disclosed to unauthorized persons.
- - - - - - - - - - - - - Trend Line
Center for Patient andProfessional Advocacyat Vanderbilt
Comments and QuestionsNow or Later
www.mc.vanderbilt.edu/cppa [email protected]
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Apparent pattern
Single or isolated“unprofessional"
event (merit?)
Intervention Pyramid
Mandated Issues
"Informal" Cup of Coffee Intervention
Level 1 "Awareness" Intervention
Level 3 "Disciplinary" Intervention
Pattern persists
No ∆
Vast majority of professionals - no issues
Adapted from Hickson GB, Pichert JW, Webb LE, Gabbe SG, Acad Med, Nov, 2007
Level 2 “Guided" Intervention by Authority
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