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SELF ASSESSMENT TOOL
MUTUAL INSURANCE COMPANY OF ARIZONA
Pain Management
®
CONFIDENTIAL & PRIVILEGED QUALITY ASSURANCE REVIEW MATERIALS P140 R.2.2018
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IntroductionMICA has developed topic specific tools to aid physicians in mitigating their risk of liability while enhancing patient safety. This Pain Management Assessment Tool provides a mechanism for physician practices to review their current operational processes for providing pain management to their patients. Additionally, the Assessment Tool will offer suggestions, resources and access to a MICA Risk Management Consultant should you wish to further develop your pain management program.
≈ The questions within the tool were developed to obtain an Always/Yes response.
≈ Any other response, (except for a response of N/A) will indicate an area of potential exposure for your practice or an opportunity to improve the quality of your program.
Quality Assurance ProcessThis tool may be used as part of your practice’s quality assurance process.
≈ Under Arizona, Colorado and Utah quality assurance statutes, a practice that performs quality assurance activities will be able to maintain the confidentiality of the process and have it protected from discovery in medical malpractice cases. However, in Arizona the quality assurance process must include written standards and criteria to obtain the quality assurance privilege of confidentiality and protection from discovery in civil litigation.
≈ Although the Colorado and Utah statutes do not have a requirement for written standards and criteria, there are benefits to having a written and consistent process. If a practice does have a written policy, it should be carefully followed to maintain the privilege.
≈ Nevada does not have a quality assurance statute that applies to physician practice, although it does have a statute that protects quality assurance that is performed in hospital, surgery center and emergency center.
If you have any questions
or concerns while going
through the tool or after
you have identified an
issue, MICA has a Risk
Management Hotline
available Monday through
Friday 9-5 MST, MST-
AZ staffed by a Sr. Risk
Management Consultant
that you may call at
602.808.2137.
SpecialtySpecific
assessmentTool
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Table of Contents
Quality Assurance Process ________________________________ 3Communication _________________________________________ 7Co-Management/Coordination of Care_______________________ 9Operational Management/Education and Training ______________ 10Medication Management _________________________________ 10Arizona _______________________________________________ 11Colorado ______________________________________________ 11Nevada _______________________________________________ 11Utah __________________________________________________ 11Emergency Preparedness/Violence Prevention ________________ 12MICA Resources ________________________________________ 13Risk Resources __________________________________________ 13Hot Topics _____________________________________________ 13Risk Advisor ____________________________________________ 13Counsel’s Corner ________________________________________ 13Webinars ______________________________________________ 13CME __________________________________________________ 13Community Resources ___________________________________ 14General Information _____________________________________ 14
CONFIDENTIAL & PRIVILEGED QUALITY ASSURANCE REVIEW MATERIALS P140 R.2.2018
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F O R E S I G H T
PIAA DATA SHARING PROJECT
P I A A D S P
I N S I D E M E D I C A L L I A B I L I T Y 9 F O U R T H Q U A R T E R 2 0 1 6
OPIOID CLAIMS AND RELATED NARCOTICS*
A REVIEW OF CLAIMS AND LAWSUITS CLOSED BETWEEN 2005 AND 2014 INTHE PIAA DATA SHARING PROJECT REPORTING PATIENT OUTCOMES OFDRUG DEPENDENCE • NONDEPENDENT ABUSE • POISONING
Contact P. Divya Parikh at [email protected] for more information.© 2016 PIAA. All rights reserved. This page may not be reproduced or distributed without express written consent from PIAA.
421101
$23M$17M51%
Closed
Paid Claims
Total Indemnity
Total Defense Cost
The majority of these claims and lawsuits were againstFamily Practice and Internal Medicine physicians.
Paid/Closed Ratio
Average Indemnity
Average Defense Cost
2005–2009 2010–2014 Difference
12.7% 36.3% 24pp
$203,321 $239,428 18%
$16,982 $67,827 300%
Psychiatrywith the highestpaid/closed ratio
EmergencyMedicine
with thesecond highest
paid/closed ratio
General Surgerywith the third highest paid/closed ratio
57%
40%
36%
*PIAA Research Notes, Volume 2, Number 2, PIAA. Copyright, 2016.
(percentage points)
ILM 4Q 2016 FRONT _Layout 1 2/24/17 10:14 AM Page 10
A review of claims and lawsuits closed between 2006 and 2014 in the PIAA Data Sharing Project reporting
patient outcomes of: Drug Dependence Nondependent Abuse Poisoning
Opioid Claims and Related Narcotics
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Practice Self Assessment Tool
CommunicationIt has been said that the single greatest error in the practice of medicine is the failure to communicate. Poor communication and psychosocial skills often interfere with medical care and increase the patient’s proclivity to sue for malpractice. Effective communication is an important skill and diagnostic tool physicians and other healthcare practitioners can utilize in the practice of medicine. Always Some- Never N/A Yes times No
1. Communication barriers, such as low health literacy, limited English proficiency are considered when planning care.
2. Patients are encouraged to speak up if they have any questions or concerns.
3. If the patient disagrees with the treatment plan, staff are trained on how to respond.
4. Staff are trained in communication techniques such as SBAR or TeamSTEPPS.
5. Diagnostic results, normal and abnormal, are communicated to the patient and documented.
6. When a patient is noncompliant or refuses care there is discussion and documentation.
7. Staff are trained in strategies that enhance communication (active listening, body language, etc.)
8. Every point of contact in the office is respectful and sensitive to the needs of the patient.
9. Patients who need interpretative services for language and hearing are provided with this service.
10. The patient knows the cause of their pain and understands the impact of their diagnosis.
≈ The questions within the tool were developed to obtain an Always/Yes response.
≈ Any other response, (except for a response of N/A) will indicate an area of potential exposure for your practice or an opportunity to improve the quality of your program.
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United States
The US accounts for
about 5% of the world’s population
yet consumes approximately 80%
of the opioid supply.
The number of
opioids prescribed per person in the US
were 3 times higher in 2015
than in 1999.
Even at low doses
the CDC states taking an opioid for
more than 3 months increases a person’s
risk of developing an addiction by 15
times.
An opioid dose of 50 MME
(Morphine Milligram Equivalent) per day
doubles the risk of opioid overdose death compared to 20 MME or lower doses
per day and a dose of 90 MME or more increases
the overdose death risk by 10 times.
There is wide variation among
counties across the US with a lack of consis-tency among practi-tioners prescribing
opioids.
From 1999 to 2015
more than 183,000 people died in the US
from prescription opioid overdoses and in 2015
opioids were involved in 33,091 deaths. Opioid
overdoses have quadrupled since
1999.
In 2014 it’s noted that
close to 2 million Americans abused or were dependent on prescription opioids and approximately 1 in 4 people on opioid
medications struggles with
addiction.
Everyday over 1,000 people are treated in ED’s
for misusing opioid
medications.
CDC Vital Signs, July 2017 cdc.gov/drugoverdose/data/overdose.html
cdc.gov/drugoverdose/data/statedeaths.html cdc.gov/nchs/data/nvsr/nvsr65/nvsr65_10.pdf
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Co-Management/Coordination of Care
The coordination of a patient’s care is a shared responsibility with accountability across different specialties. Emergency medicine physicians, hospitalists, primary care physicians and other specialists are often involved in the co-management of patients as they transition through the healthcare continuum. The involvement of multiple physicians and other clinicians has added risk to the patient’s care by creating confusion about who is in charge. This can lead to discontinuity and gaps in care resulting in significant patient harm. Co-management can perpetuate an environment where each physician assumes another is taking responsibility for a certain aspect to the patient’s care. It is important to manage the evolving communication and collaborative strategies necessary for the coordination and co-management of patient care.
As the physician, I have... Always Some- Never N/A Yes times No
1. screened patients for addictive personality traits prior to prescribing.
2. obtained family history of pain addiction prior to prescribing.
3. discussed past history of pain management the patient may have had.
4. identified all the methods for pain relief that the patient has tried for this illness/injury.
5. set behavior ground rules for patients to remain with my practice.
6. a written policy as to how non-compliant patients will be addressed.
7. obtained a detailed health and injury history before prescribing.
8. established relationships with physical therapy, psychiatry, and other alternative therapies options.
9. confirmed I am registered with the Pharmacy Monitoring Program (PMP) in my state.
10. knowledge of the exceptions for checking the PMP in my state such as hospice patients and others.
11. trained the staff delegated to check the PMP.
12. a system in place for adequate coordination of other therapies provided at the practice.
13. reviewed their notes, if physical therapy, chiropractic or alternative therapies, etc. are offered.
14. a policy in place where only the physician (MD/DO) or advanced healthcare professional (AHP) discharges a patient from care at completion or for noncompliance.
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Operational Management/Education and TrainingWritten policies and procedures provide standardized guidelines and present a clear understanding of the goals and philosophy of the group. It is important the policies and procedures are clearly communicated to the physicians and advanced healthcare professionals working with the group and that compliance is monitored.
Always Some- Never N/A Yes times No
1. As a physician I regularly obtain CMEs on this topic.
2. Staff are trained regularly on topics related to pain management.
3. Our practice utilizes patient education tools either online or in paper form.
Medication ManagementMistakes involving medications cause thousands of injuries each year and account for millions of dollars in malpractice awards and settlements. Simple or careless mistakes trigger the vast majority of drug-related claims. A system for medication management for an achievable pain management program can reduce the risk of a careless mistake resulting in devastating consequences for the patient.
Always Some- Never N/A Yes times No
1. The patient’s allergies are identified and reviewed before prescribing any medications.
2. A complete list of patient medications is obtained including OTC, herbals and supplements.
3. The patient’s understanding of the medication use, dosage and frequency is noted in the medical record.
4. The patient is advised of any driving or machinery precautions.
5. Abbreviations of medications are avoided.
6. Patients are provided with information on alternatives options for pain relief.
7. Document the pharmacy where patients want their medications sent.
8. The pain management agreement is reviewed with the patient before it is signed.
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health.utah.gov/vipp/topics/prescription-drug-overdoses/
2016 Arizona Opioid Report azhealth.gov/opioid
coloradohealth institute.org/research/
colorado-county/drug-overdose-death-rate
heathyamericans.org/reports/drugabuse2013/
Nevada
Per the CDC Nevada has some of the highest amounts of prescription opioids sold per capita.
Nevada also has the 4th highest drug overdose mortality rate in the US. From 1999 to 2013 drug overdose deaths has increased 80% from 11.5 per 100,000 to 20.7 per 100,000.
Colorado
In 2015, 472 people died in Colorado from opioid related overdoses. Between 2011 and 2014 approximately 22,000 Coloradans said they abused or were dependent on opioids. Although deaths from prescription opioids decreased somewhat in 2016 heroin deaths have been increasingly rising since 2011. It is suggested this may be in part due to the crackdown on opioid prescriptions leading patients to street drugs.
Arizona
In 2016, 790 Arizonans died from opioid overdoses. This equates to just over 2 Ari-zonans per day. The trend shows a startling increase of 74% since 2012.Deaths due to opioids among persons under age 55haveconstituted80%ofall opioid deaths in Arizona duringthelast10years.Opioidshaveasignificantimpact upon Arizona’s medical care system due to thevolumeofencountersinvolving opioids, and the costsoftheseencounters.Unique encounters are eventsforasinglepersoninvolving either hospital admission, or an emergen-cy department encounter withoutadmission.In2015there were 41,434 unique ‘opioid-related’ encounters in Arizona hospitals, with anestimatedcostof$341.5million.Theaveragecostper opioid-related unique encounter was$8,241.
Utah
From 2013-2015, Utah ranked 7th intheU.S.fordrug poisoning deaths which have outpaced deaths due to firearms, falls, and motor vehicle crashes. Every monthinUtah,23individualsdiefrom prescriptiondrugoverdoses.From2000to2015Utahhadanearly400%increase in deaths fromthemisuseand/orabuseofprescriptiondrugs.
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Always Some- Never N/A Yes times No
9. The patient is advised as to the method for taking the medication received. 10. I use a pain management agreement for every patient in the pain
management program. 11. I document each patient encounter before the close of business. 12. We have educational and informational brochures on pain relief available. 13. All chronic pain patients understand they will submit to drug testing. 14. For new patients, I obtain and utilize information from the pharmacy
databank. 15. For existing patients I check the pharmacy databank quarterly, at a
minimum. 16. I document the results of the databank query in the patient’s record. 17. Prescription refills follow a process in accordance with State
requirements. 18. The patient’s progress is clearly documented to indicate the need for
ongoing care.
Emergency Preparedness/Violence PreventionPublic health threats are always present, whether from fire or explosion, violence, severe weather conditions with flooding and power outage or extreme emergencies such as pandemics or bioterrorism. Hospitals are required by law, regulations and accreditation requirements to plan for disasters. Physician offices will also be affected and should be at the ready. If disaster strikes, a well-designed action plan will safeguard patients and staff, protect health information, minimize disruption and provide for orderly recovery. Always Some- Never N/A Yes times No
1. The practice conducts periodic drills for addressing internal and external disasters.
2. Physicians and staff are oriented to the procedures and protocols related to emergencies, such as dialing 911.
3. Staff are trained to use verbal deescalation techniques if patients become anxious or aggressive.
4. The staff, practice and drill for emergencies, fire, evacuation, utility failures and aggressive behavior for the employees and practitioners.
5. The practice utilizes a code of behavior. 6. A policy is in place communicating a “zero tolerance” for violent and
aggressive behavior. 7. A mechanism is in place to alert staff when a patient or visitor presents
with threatening behavior. 8. Staff are familiar with verbal de-escalation techniques.
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Risk ResourcesPain Management Medical Marijuana Alternative Complimentary Medicine
Hot TopicsPain Contract Violated - December 2015Intoxicated Patient June - 2016Impaired Driving Ability - May 2016Disruptive Patients - November 2016Chronic Pain Using Medical Marijuana - 2015Misdiagnosis with Chronic Pain - 2015
Risk AdvisorChronic Pain Management – March 2016Pain Management – June 2014
Counsel’s CornerRisk Advisor September/December 2004 - Counsel’s Corner questions on reporting pregnant patient and drug abuse/prescription alteration
Risk Advisors March 2011 December 2012 - Counsel’s Corner questions on medical marijuana
Risk Advisor December 2010 - Counsel’s Corner question: Is there a statutory requirement to report my patient’s drug abuse to other prescribers
Risk Advisor September 2016 - Counsel’s Corner question on prescribing opioids and monitoring site
WebinarsFebruary 2017 - Opioid Prescribing /Pain Management Agreements (Presenter: Steve Yost)
March 2016 - Pain Management Agreements (Presenter: Pam Johnson)
August 2015 - Prescribing Narcotics (Presenter: Karen Wright)
January 2016 - Medical Marijuana: managing the Regulatory and Medical Liability Risks
CMEOpioid Mortality Epidemic - What Prescribing Physicians Can Do?
MICA Resources
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General InformationAmerican Academy of Pain Managementwww.aapainmanage.org
American Chronic Pain Associationhttps://theacpa.org/
American Academy of Family Practicewww.aafp.org
Substance Abuse and Mental Health Services Administration https://store.samhsa.gov/product/SAMHSA-Opioid-Overdose-Prevention-Toolkit/SMA16-4742
Centers for Disease Control and Prevention-Opioidshttps://www.cdc.gov/drugoverdose/index.html
FDA Education Blueprint for Health Care Providers Involved in the Management or Support of Patients with Pain – May 2017https://www.fda.gov/downloads/Drugs/NewsEvents/UCM557071.pdf
American Congress of Obstetricians and Gynecologists Toolkit on State Legislations: Pregnant Women & Prescription Drug Abuse, Dependence and Addictionhttps://www.acog.org/-/media/Departments/Government-Relations-and-Outreach/NASToolkit.pdf
Don’t Be Scammed by a Drug Abuser
U.S. Department of Justice – Diversion Control Divisionhttps://www.deadiversion.usdoj.gov/pubs/brochures/drugabuser.htm
Safe Prescribing for Providershttps://www.cdc.gov/drugoverdose/prescribing/providers.html
Prescription Drug Monitoring Programs (PDMPs)https://www.cdc.gov/drugoverdose/pdmp/index.html
Infographics – National Institute on Drug Abusehttps://www.drugabuse.gov/related-topics/trends-statistics/infographics
The Face of Opioid Addiction http://addictionblog.org/infographics/the-face-of-opioid-pill-addiction-who-uses-painkillers-infographic/ Retrieved from the www.Addictionblog.org July 2017
National Institutes of Health (NIH)www.nih.gov/opioid-crisis
ArizonaArizonaoffersseveralonlineresources readily accessible fromyourcomputer.IncludedinthelistingherearethelinksfortheprescriptionmonitoringprograminArizona.Alsoincluded are resource links regarding how to manage dosing,howtodisposeofmedicationnolongerneededaswellasstatisticontheopioidcrisisinArizona.
PrescriptionDrugMonitoringProgram–ArizonaBoardofPharmacyhttps://pharmacypmp.az.gov/
Opioid Epidemic – Arizona DepartmentofHealthServices
RealtimestatewidedataandReportingRequirementshttp://www.azdhs.gov/prevention/womens-childrens-health/injury-prevention/opioid-prevention/index.php
OpioidPrescribingSafety–ArizonaMedicalAssociation–PositionPaperhttp://www.azmed.org/page/opioidrxsafety
PrescriptionDrugMisuse&AbuseInitiativeCommunityToolkitwww.RethinkRxAbuse.org
Dump the Drugs Arizona – A ListingofWhereControlledSubstancesCanbeDestroyedandPatientEducationalHandoutsDumpTheDrugsAZ.org
Community Resources
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Opioid Epidemic – Arizona DepartmentofHealthServicesRealtimestatewidedataandReportingRequirementshttp://www.azdhs.gov/prevention/womens-childrens-health/injury-prevention/opioid-prevention/index.php PreventOpioidMisuseandAbuse in Arizona – A Guide HighlightingtheUseofaPatientUtilizationReporthttp://c.ymcdn.com/sites/www.azmed.org/resource/resmgr/files/PMP_Compliance_Checklist_201.pdfArizonaTrainingandReportingResourceshttp://www.azdhs.gov/prevention/womens-childrens-health/injury-prevention/opioid-prevention/index.php#training ArizonaReportingRequirementshttp://www.azdhs.gov/documents/prevention/womens-childrens-health/injury-prevention/opioid-prevention/medsis-training.pdf ControlledSubstanceDataBaseResourcesArizonaBoardofPharmacyEMRIntegrationProgramhttps://apprisshealth.com/press-release/arizona-board-pharmacy-implements-appriss-health-solutions/ Duceyhttp://ktar.com/story/1919481/ducey-signs-arizona-law-designed-tackle-rising-opioid-crisis/Summaryhttp://azdhs.gov/documents/audiences/clinicians/clinical-guidelines-recommendations/prescribing-guidelines/chronic-pain-opiod-guidelines.pdf
UtahUtahoffersseveralonlinere-sourcesreadilyaccessiblefromyourcomputer.Includedinthelistingherearethelinksfortheprescriptionmonitoringpro-graminUtah.Alsoincludedareresource links regarding how to managedosing,lawsimpactingGood Samaritans who provide NarcanaswellasstatisticsontheopioidcrisisinUtah.UtahControlledSubstanceDatabasehttps://dopl.utah.gov/programs/csdb/ ViolenceandInjuryPreventionProgramhttp://www.health.utah.gov/vipp/topics/prescription-drug-overdoses/ UtahHouseBill11–GoodSamaritan Thislawenablesbystandersto report an overdose without fearofcriminalprosecutionforillegalpossessionofacontrolled substance or illicit drug.https://le.utah.gov/~2014/bills/static/HB0011.html NaloxoneLaw–HouseBill119Thislawpermitsphysicianstoprescribenaloxonetothirdparties(someonewhoisusuallyacaregiverorapotentialbystander to a person at risk foranoverdose)andpermitsindividuals to administer naloxonewithoutlegalliability.https://le.utah.gov/~2014/bills/static/HB0119.html UtahNaloxoneResourcewebsitehttp://www.utahnaloxone.org/ UtahPoisonControl-Opioidshttp://poisoncontrol.utah.edu/images/opioidtrend.pdf
NevadaNevadaoffersonlineaccesstotheControlledSubstanceDataBaseforprescriptionmonitoring.NevadaControlledSubstanceDatabasehttps://nevada.pmpaware.net/login Nevada Assembly Bill 474AB474isNevada’s“ControlledSubstancesAbusePreventionAct,” approved by the Gover-nor on June 16th,2017.Thisomnibusbillincludesreportingrequirementsandtrackingofdrug overdoses in the state, increasing controlled substance abusetrainingforcertainhealthcareprofessionalsandgivingcertainoccupationallicensingboardsaccesstoaprescriptiondrug monitoring database to investigatefraudulent,illegalorauthorizedprescribingpractices,among other measures.Effec-tive:January2018.https://www.leg.state.nv.us/Session/79th2017/Bills/AB/AB474_R1.pdf
Colorado ColoradooffersonlineaccesstotheControlledSubstanceDataBase–forprescriptionmonitoring.
PrescriptionMonitoringProgramhttp://www.hidesigns.com/copdmp
Colorado Department of Health Care Policy & Financinghttps://www.colorado.gov/pacific/hcpf/pain-management-resources-and-opioid-use
See also Pain Management Toolkit
Pain ManagementTOOLKIT
®MEDICAL PROFESSIONAL LIABILITY INSURANCE
©2018 MUTUAL INSURANCE COMPANY OF ARIZONA PAINMANAGEMENTSELFASSESS P140 R2.18
2602 E Thomas RdPhoenix, AZ 85016
602.956.5276 or 800.352.MICA
