Dispelling urban myths in healthcare risk management

2 J O U R N A L O F H E A L T H C A R E R I S K M A N A O C M I N T

Dispelling Urban Myths in Healthcare Risk Management

By Janice Moore, MPH,

Director, Data Analysis

Services, and Dorothy

Berry, RN, BSN, HRM,

Vice President, both of

Healthcare Information

Services, MMI Risk

Management Resources,

Inc., an MMI Company,

Deerfield, IL, and

G. Eric Knox, MD,

Medical Director, MMI

Companies, Deerfield, IL,

Director, Perinatal

Center, AbboH-

Northwestern Hospital,

and Professor,

Department of Obstetrics

and Gynecology,

University of Minnesota,

Minneapolis, MN.

Abstract: Applied research to explore and challenge myths in healthcare risk management is pivotal to the growth of the profession. The authors demonstrate this process through exploring patient safety and malpractice issues on weekdays compared with on weekends and holidays. Analysis suggests that claim volume is driven by service volume.

Introduction Every profession is built on a unique foundation of experiences which become that profession’s history, myth and tradition. This informal knowledge is useful in that it creates loyalty and sets the profession apart from. all others. In this way, the institutional memory of the profession gets passed on from group to group and generation to generation. The lessons of the past are transferred by both written and verbal means. Despite contemporary efforts made to ensure the accuracy and integrity of the “things everyone knows,” at times these experiences are passed along without being challenged to determine their current relevance. As a result, urban myths - notions that are commonly agreed on as true, but that generally are not based on demonstrated evidence - can enter into the nomenclature and wisdom of the profession.

Consider the urban myths of healthcare that have been dispelled in recent times. Just a few generations ago, smoking was thought to be medicinal and patients with heart attacks were placed on bed

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rest for a month or longer. Recently, healthcare organizations have begun to face intense pressure to cut costs and increase efficiency. This pressure has forced a reevaluation of many of the underlying assumptions of care delivery, including those concerned with risk, quality and safety. It is an era that has stimulated a drive toward evidence-based evaluation of the key decisions made daily in medical care.

Healthcare risk management is in its second generation as a profession. We are now just beginning to understand the need to self-evaluate the underlying assumptions within the profession. Questions are being raised at a national level, as well as within provider organizations, as to what are truths on which operational decisions can be made. As these questions become more defined, they can be tested empirically and more evidence-based practices for healthcare risk management will emerge, driving improvements much like what has occurred overall in the healthcare profession.

As a small but interesting example of the concept of how urban myths need to be. uncovered and evaluated objectively in our own profession, consider the questibn, “Is there more liability risk on holidays?” The first reaction of the clinical panel members of one of our publication editorial boards was “yes” based on their individual experiences as healthcare providers and their memories of short staffing, unexpected weather and patient emergencies.

This opinion, along with a review of the literature, which provided no clear direction, led to a review of our claims data to see if we could answer this question. The intuitive feeling that

holidays correspond to decreased staffing levels, increased error, risk of patient injury, and subsequent malpractice claims needed further evaluation. This article discusses steps we took to question the assumption that there is more liability risk during holidays, using our currently available staff time and resources. We report on this undertaking to encourage others to identify and address myths in their own environment and share it with other professionals to expand the body of knowledge in healthcare risk management.

Defining the Question Framing any question empirically into a form that can be answered is always a formidable task. Researchers from all disciplines have found that if this first step is not well constructed, the work that follows can become unfocused and unnecessarily draining of resources. The challenge is to state the hypothesis in as simple a statement as possible. For this particular question, some initial analysis was necessary to be able to frame it in a way that to answer it would be useful. Since a single denominator of volume would not easily fit all healthcare services, a distribution of claim files (more than 8,400) by the type of day and location was performed. Claims were defined for the purpose of this analysis as any assertion for money damages. Both open and closed cases were included. Occurrence years 1992 to 1994 were chosen and combined as the period of study to balance the need for concurrent data with the natural delay in time from the date of occurrence to date of claim reporting (Figure 1). Three types of days were defined: weekday (Monday through Friday), weekend (Saturday and Sunday), and holidays (New Year’s Day, Memorial Day, Fourth of July, Labor Day, Thanksgiving, and Christmas Day).

4 J O U R N A L O F H E A L T H C A R E R I S K M A N A G E M E N T

Figure 1

Percent of Claim Files by Type of Day and by Location for Occurrence Years 1992 to 1994 Combined

Emergency Area

MedicaUSurgicai Unit

Intensive Care Unit (ICU)

Outside Grounds

Labor/Delivery Unit

Physician’s Office

17.4% 2%

0.0% 5.0% 10.0% 15.0% 20.0%

This initial analysis identified a notable difference in the location of claims by type of day. A far greater’percentage of emergency area claims occurs on holidays and weekends than on weekdays. The break- down of claims occurring in the emergency area was 23.7 percent for holiday claims, 32.4 percent for weekend claims, and only 14.4 percent for weekdays. Analysis of each year separately confirmed the overall higher rate of claims in the emergency department (ED) on weekends and holidays for each year analyzed.

Since staffing resources may vary by the size of the healthcare organization, we also reviewed the percentage of claims

32.4%

BWeekends

25.0% 30.0% 35.0%

filed and the percentage of claims losses by location of the claims and by type of day for three hospital size categories. We found that the placing of data into these categories created too small a cell size to study holiday claims alone, especially in smaller organizations. Figure 2 displays the combined percentage of weekend and holiday claims by organizational bed size. Further, it was recognized that service demands as well as staffing patterns are different on weekendsholidays, and that service demand or volume of ED visits alone may account for a disproportionate number of ED claims on weekendsholidays.

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Figure 2

80.0%

60.0%

Y E a“ 2 40.0%

20.0%

0.0%

I /Porcont of Claims by Type of Day and Bed Size for Emergency Area for Occurrence Years 1992 to 1994 Combined

45.4%

<loo 100-250

Bed Sue

Weekdays WeekendsRlolidays 1

over 250

Armed with this new information, we focused our efforts first to explore the ED and created the null hypothesis: The per- ,

cent of ED claims by day of the week will fol- low closely the percent of ED visits by day of, ’ the week.

Scope of Resources and Time Frame An often understated but important issue to address early on when exploring an empirical question is resources. There is always more to do than time permits. Setting the priority of the project and the extent of effort that can be afforded prevents false starts and delving into interesting but unanswerable questions. Estimating resources necessary to provide new knowledge is not a linear or perfect process, because often it is hard to estimate the unexpected obstacles in data analysis that always seem to occur.

Since most research is done as part of an operational unit, rather than a pure research unit, the realities of normal operational demands lengthen the duration of a project because research has to “fit in” after the real work is done. Finally, no matter how rich any internal database, supplemental data using exter- nal sources are often needed. Commonly, resources such as the AHA Guide and the National Center for Health Statistics (NCHS) are available, and these types of resources should be explored and utilized to support internal data.

Literature Search Knowing what has already been written about the topic of interest is helpful in refining the question in hand along with the methodology for analysis. As healthcare risk management builds its body of


unique knowledge regarding risk and safety, literature searches will become more useful. While we found supportive information that reinforced our intent to go forward with analysis, few of the articles were directly related to our topic. For example, R.A. Rusnak published articles relating missed diagnosis and litigation in the ED, but did not use the day of the week as a studied variable. These were mainly from sources dealing with more general hospital and physician staffing, although most were related to emergency care and a few were found specific to a weekendholiday or day of the week per- spective (but not in the emergency area). A synopsis of the articles appears below.

Long Shifts and Erratic Schedules “Off hours,” including evenings, weekends, and holidays, are periods when regular or more experienced emergency staff may be off-duty and much of the staff may be working overtime or extended shifts. Some staff may also be “moonlighting” outside their regular job or area of expertise.

Since the Libby Zion case in 1984, issues of staffing in EDs have been examined more intensely. In that case an 18-year-old woman died after seeking treatment in the ED of a New York hospital. The resident was reportedly unaware of the numerous medicines the patient had already taken for fever and headache and gave her an injection of a narcotic for pain. The resident who treated Libby Zion had been on duty 18 consecutive hours when he examined her.

Studies demonstrate that overly long shifts and erratic schedules, sometimes considered part of the rite of passage in physician training, can lead to excessive fatigue and errors in judgment. While comparisons of performance of rested house staff with the performance of sleep- deprived ones have generally found only

small differences in psychomotor func- tions, a prospective, time-series study of actual patient care versus artificial tests found clear differences. The effects of a change from a traditional rotational overnight call schedule to a schedule designed to reduce sleep deprivation was studied in a before-and-after design. Patient care before and after the change in schedules was compared on length of stay, number of laboratory tests, and medication errors. With more rest under the new schedule, resident physicians ordered fewer lab tests, kept patients in for shorter stays, and committed fewer medication errors (ref. 1).

Lack of Attending Physician Supervision Another risk of ED care in off-hours is lack of attending physician supervision. Especially before the Libby Zion case, ED care in major teaching hospitals was often rendered by unsupervised residents and interns. Sometimes attending physicians would be on call but not actually present in the emergency services area. This lack of supervision may be more likely on the weekends and evenings.

In 1987, a large urban teaching hospital changed its ED staffing to include a board-certified attending physician at all times. The attending physician supervised residents, independently evaluated patients, and was responsible for the final disposition of all ED patients. The hospital assumed that these changes would result in improved quality of care and reduced malpractice claims. To test this assumption, the hospital compared its claims and losses for 1985-1987, the two years preceding the ED changes, with those occurring from 1987-1989. Malpractice claims decreased by 18.5 percent and losses decreased by 80 percent for the first two years after full-time attending physician coverage was implemented.

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While the claim rate was lower but not significantly different between the before- and-after period, the average losses were significantly lower after the policy went into effect. The average cost per closed claim dropped from $39,353 in 1985-1987 to $17,143 in 1987-1989. Full-time attending physician coverage in the ED appeared to reduce the risks of severe injuries and substantial malpractice losses (ref. 2).

Inadequate Staffing Inadequate staffing and excessive workloads are also potential contributing factors to the vulnerability of EDs to error during off-hours. Delays in providing diagnosis/assessment and treatment are frequent allegations in ED malpractice claims. While triage is the accepted means of sorting patients according to the urgency of their conditions, the triage process itself has to be adequately staffed and monitored. In a case involving the death of a two-year-old child, a hospital was found to have violated its own policy to provide ED patients with an assessment by a nurse or paramedic within 15 minutes of arrival. Because of workload and staffing problems, the toddler was not evaluated for 90 minutes and died later that day. As part of an investigation by the Health Care Financing Administration (HCFA), the hospital agreed to increase nursing staff in the triage area and to monitor compliance with the triage policy on a daily basis (ref. 3).

Error Rates and Volume Other studies have also looked at error rates in relation to volume. In a study on the accuracy of dispensing in an outpatient pharmacy program, the authors devised a systematic approach to identify errors by using auditing pharmacists who reviewed 9,846 prescriptions over 12 weekdays. The study found 12.5 percent of prescriptions had errors and 1.6 percent had potentially serious errors, findings comparable in other published reports.

Hourly error rates were compared with hourly workloads, but there were no significant correlations. The hourly error rate was relatively consistent even though the workload varied greatly throughout the day. The dispensing pharmacists produced errors at the same rate; when workloads peaked, the same processes of dispensing were apparently in place and the stress of high workloads did not change the process and increase the error rates (ref. 4).

In a study to determine whether hospital workers experienced higher exposure rates to biological hazards at different times of the day, the researchers matched each reported exposure by location with hourly employee counts in order to calculate exposure rates. Analysis identified that more absolute exposures occurred between 9 a.m. and 11 a.m., but the exposure rate expressed as a function of the number of workers or the number of procedures performed did not vary throughout the day. Parallel to the outpatient pharmacy study, the number of absolute exposures varied significantly, but the exposure rates were not significantly increased during the hours with peak exposures (ref. 5).

Analysis Emergency Services The review of the literature did suggest vulnerabilities of emergency services with the potential to create errors, which con- tributes to the belief that there should be more errors during “off-hours” such as weekends and holidays. Emergency service claims are a substantial proportion of total malpractice losses, averaging about 20 percent of all hospital claims for many insurers (ref. 3). For MMI, which provides risk management services and liability insurance to over 400 healthcare organizations and thousands of physicians, emergency services claims account for about 24 percent of all claims in 1996 (ref. 6).


Day of the Week

For this assumption to be true, an increase in errors should be reflected in increased patient injuries and increased malpractice claims on weekends and holidays when healthcare organizations, especially hospitals, are more vulnerable to staffing

NCHS visit % by day MMI claim % by day of week of week

Emergency service claims are a substantial

proportion of total malpractice losses,

averaging about 20 percent of all hospital

claims for many insurers.

constraints. Malpractice claims may be a bellwether for changes underlying vulnerabilities to error and injury. In using the Harvard Study whereby there was a demonstrated one-in-seven proportion between patient injury and claim, we assumed that this was a constant proportion, which does not vary by day of the week for the purpose of this analysis (ref. 7).

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Significance Level

We analyzed 2,300 dosed ED claims from our insured base of physicians and healthcare organizations between 1993 and 1995, and used chi-square tests to compare the proportions of ED claims by day of the week against ED visit volume proportions derived from the 1994 ED summary of the NCHS National Hospital Ambulatory Medical Care Survey. As

15.3 15.9

14.5 13.5

14.0 13.5

13.8 12.8

13.5 13.6

13.7 14.3

15.2 16.4

p =.7659

Table 1. Emergency Department Claims

summarized in Table 1, we found that the proportions of ED claims are not significantly different from the proportions of ED visits by day of the week (significance was defined as p< .05).

The higher proportion of ED claims on weekendsholidays apparently occurs because of the higher ED visit volume. The null hypothesis was accepted.

Perimtal Services Once this finding was discovered, we decided to pursue analysis in another high-risk area to determine whether this result would be reproducible. Perinatal services was a natural choice for two rea- sons. It is a known high-loss area and data on births by day of the week were avail. able to correlate with our internal claims data to produce a parallel analysis. We analyzed 960 claims for 1992 through 1994 and compared proportions of perinatal claims by day of the week against the proportion of births by day of the week derived from the NCHS 1992 Vital Statistics, Volume 1 - Natality, the most recent data available. These results are summarized in Table 2.

The result of this analysis also showed that the higher proportion of perinatal claims by day of the week closely relates to volume of service required.

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Day of the Week

Table 2. Perinatal Services Claims

NCHS % of births by day MMI claim % by day of week of week

Sunday

Monday

Tuesday ’

Wednesday

Thursday

Friday

Saturday

Significance Level

11.2 13.3

13.8 13.5

15.8 15.8

15.6 14.8

15.5 12.7

15.3 16.0

12.1 13.8

p =.2151

Discussion While this research isn’t definitive in answering all questions, the data do pose some interesting concepts. Since it does not appear that malpractice claims occur at different rates during different days of the week, perhaps emergency and perinatal departments could be naturally compensating for the perceived potential deficiencies in care thought to be occurring at those times. Adopting this view would suggest that special attention to management of risk and patient safety is not necessary during holidays and , I

weekends.

Alternately, these data may be used as a demonstration that patient injury resulting in malpractice occurs at a constant rate of patient encounter - irrespective of changes in personnel, hours of day, or presence of attending coverage. This latter view fits more closely with the model of healthcare accident production put forth by contemporary researchers in the patient safety arena. If this view is correct, then the prevention of error and patient injury requires further understanding of the underlying system factors that lead to patient injury, rather than continuing to concentrate on symptoms (staffing, work hours, coverage) related to individual performance.

This exercise seems to dispel a long standing myth that there is more risk on weekends and holidays. While readers may draw their own conclusions related to the significance of this finding, we offer the following as the main learning points that we experienced: Many assumptions currently form the basis for much of the practice of risk management. It is possible in the course of normal business to begin to separate fact from fiction.

W e acknowledge the assistance of Dianne Jacobsen, Brenda Stenger, and the Resource Center staff in preparing this article.

Reference. s 1. Gottleb, D.J., Parenti, C.M., Peterson, C.A., and Lofgren, R.E Effect of a change in house staff work schedule on resource utilization ED patient care. Archives of lntemal Medicine. 151:2065-2070, 1991. 2. Press, S., Russell, S.A., Cantor, J., and Herez, E. Attending physician coverage in a teaching hospital’s emergency department: effect on malpractice. Journal of Emergency Medicine. 12:89-93, 1994. 3. Emergency Department Liability. ECRI: HRC Risk Analysis, January 1996.

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4. Kistner, U.A., Keith, M.R., Sergeant, K.A., and Hokanson, J.A. Accuracy of dispensing in a high-volume, hospital- based outpatient pharmacy. American Journal of Hospital Pharmacy. 5 1:2793-97, 1994. 5. Macias, D., Hafner, J., Brillman, J., and Tandberg, D. Effect of time of day and duration into shift on hazardous exposures to biological fluids. Academic Emergency Medicine, 3:605-610, 1996. 6. Transforming Insights into Clinical Practice Improvements: A 12-year Data Summary Resource. Deerfield, IL: MMI Companies, Inc., 1998. 7. Brennan T.A., and others. Incidence of adverse events and negligence in hospitalized patients: Results of the Harvard medical practice study. New England Journal of Medicine. 324:370-84, 1991.

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Dispelling urban myths in healthcare risk management