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

Center for Patient andProfessional Advocacyat Vanderbilt

Patient Advocacy Reporting System (PARS®)Project:

Experiences of peer messengers who deliver uncomfortable news to physician colleagues

James W. Pichert, Ph.D. [email protected]

Center for Patient & Professional Advocacy, Vanderbilt University School of Medicine

www.mc.vanderbilt.edu/cppa1


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

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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


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)

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PARS® SitesDevelopment SitesProspective SitesMajor Educ. Sites


• 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

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Academic vs Community Medical Center

30 35 40 45 50 55 60 65 70 75 80 85 90 95 1000

25

50

75

100

Academic Med CtrCommunity Med Ctr

% of Physicians

% o

f Con

cern

s

35-50% are associated with NO concerns

Hickson et al., SMJ. 2007; Hickson et al., JAMA. 2002 Jun 12;287(22):2951-29577

50% of concerns associated with 9-14% of Physicians


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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Who would you want to deliver the message to you?

And “when”?

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


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)


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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Complaint Type SummaryDr. _____________Audit Period: Date 1 – Date 2

Complaint Type Categories

Number of Complaints Distribution of Complaints

Your Complaints

Average for Surgery

Your Complaints

Average for Surgery

Care & Treatment 19 4.5 30.2% 39.8%

Communication 15 2.9 23.8% 25.7%

Humanistic Concern 14 1.3 22.2% 11.5%

Access/Availability 9 1.9 14.3% 16.8%

Safety of Environment 0 0.0 0.0% 0.0%

Money/Payment Issues 6 0.7 9.5% 6.2%

Total # of Complaints 63 11.3

Total Number of Reports Note: each report may contain multiple complaints

Past 48 months 26 5.9

Past 12 months 6 1.7


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 showCare and Treatment• Dr.___ delay in care made my mother’s medical status worse

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What are these interventions all about?

First, some philosophy, process.Then we’ll see a PARS® intervention.

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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 dataMoore, Pichert, Hickson, Federspiel, Blackford. Vanderbilt Law Review. 2006.

Center for Patient andProfessional Advocacyat Vanderbilt16

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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® Process What is Required?


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.)

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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?

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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

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Length of Interventions

First interventions: Range (min) 5-90

Mean Length(minutes) 33

Median 30

Followup interventions: Range (min) 2-120

Mean Length(minutes) 30

Median 30


Why might your practice stand out?


Does Messenger Agree with “Issues”

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Agree (%) Disagree (%) Uncertain (%)

First Meeting

59 10 6

Follow Up All

58 12 9


Does Messenger Agree with “Issues”

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Agree (%) Disagree (%) Uncertain (%)

First Meeting

59 10 6

Follow Up All

58 12 9

F-U Good 67 9 9

F-U Bad 51 23 8

F-U Mixed/ Neutral

58 9 9


High Risk Physician “Receptivity”

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Positive Negative NeutralFirst-Time 81.8% 2.3% 16%Follow-Up 75.6% 1.9% 23%



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Positive Negative NeutralFirst-Time 81.8% 2.3% 16%Follow-Up 75.6% 1.9% 23% "Bad news" 17.0% 0.4% 6% "Good news" 27.0% 0.4% 5% "Mixed" "Neutral" "Recidivist"



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Positive Negative NeutralFirst-Time 81.8% 2.3% 16%Follow-Up 75.6% 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"



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Positive Negative NeutralFirst-Time 81.8% 2.3% 16%Follow-Up 75.6% 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%

# Follow-Up Interventions Needed to Reach "Visits

Suspended”

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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?


Composite Physician Intervention Results on Complaints:

34 Hospitals/Med Groups

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Total # of high complaint physicians 706Departed after initial intervention 48First 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 2011-2012 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 524

PARS® Progress Report

35 This material is confidential and privileged information under the provisions set forth in T.C.A. §§ 63-1-150 and 68-11-272 and shall not be disclosed to unauthorized persons


Total # high complaint physicians 97Departed after initial intervention 6First 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 7 (8%) Some Improvement—still needs tracking 7 (8%)

Subtotal 60 (72%) Unimproved/worse 12 (14%) Departed Unimproved 12 (14%) Total follow-up results 84

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VUMC PARS® Progress Report

This material is confidential and privileged information under the provisions set forth in T.C.A. §§ 63-1-150 and 68-11-272 and shall not be disclosed to unauthorized persons


What about those who don’t improve?

• Departed: 34%• Continuing to receive feedback: 60%• Currently at “Level 2 Authority”: 6%

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Level 2 Historical Outcomes

• N = 68• N = 22 (32%) first L2 this year, no follow-up

data• Improved: 28 (41%)• Remain unimproved: 18 (27%)

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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.

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Intervention Study Claims and Exposure Years Among High Risk Surgeons

0.38

0.47

0.40

0.24

0.0

0.1

0.2

0.3

0.4

0.5

Control Group Intervention Group

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anag

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with

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Pre-InterventionPost-Intervention (p = 0.15)

RMF

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ith E

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ear

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. §§ 63-1-150 and 68-11-272 and shall not be disclosed to unauthorized persons.

0

10

20

30

40

50

60

70

FY 99 FY 00 FY 01 FY 02 FY 03 FY 04 FY 05 FY 06 FY 07

Suits

per

MM

RVU

s

Academic Medical Center

Vanderbilt

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


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?

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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

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Documents

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