Use the Model to:

1

• Use the Model to
• Integrate MedMal into QI/Risk Management/Patient
  Safety initiatives
• Apply to all data sets
• Find your high-severity injurydriversthey are
  the key!

2

• Analyze
• Code/categorize
• Aggregate
• Delineate high-severity injury drivers

• Denominators
• Comparative data
• Mesh with otherdata sets
• Context

• Assessment ofcurrent risk
• Risk assessmenttools
• Focus groups

?
3

• Short-term metrics
• Sustain change

• Implement
• Educate
• Train

• Research solutions
• Create an inventory of models

4
What is the value?Why expend this effort?

• Understand contributing factors
• Stories for education, defensibility
• Process of care breakdowns, associated costs
• Organizational priorities for resource allocation
• Context of data within peer group

5
In the beginning

• Strong coding taxonomy
• Over 20 years old, over 700 clinical codes
• Nursing expertise

6
Coding Timeline
Month3660
month 1
month 6
New Claim
Coding Snapshot
First Full Coding
Expert Review
Closing
Settlement/Pre-trial Decision
Mock Trial/Focus Group
Depositions
claim fileestablished
claim letter orsuit papers
updated investigation full medical record
expert opinions
trial notes closing report
updated investigation
updated investigation
plaintiff and defense depos

• Allegation
• Responsible Service

• Clinical Summary
• Full Coding

Final Review
Coding revised based on new material
7
Case Walkthrough

• Clinical Analysis
• Access
• Assessment
• Human Factors
• Diagnosis

Middle-aged man presents to ED complaining of
chest pain.
Did the team Misdiagnose?
No
Yes

• Outcome
• Coding Results

8
Case Walkthrough

• Clinical Analysis
• Access
• Was there a delay in getting him triaged?
• Assessment
• What were the patient symptoms (chest pain, jaw
  pain, nausea?)
• Did the triage nurse appropriately prioritize the
  patients admission to the ED?
• What was the experience level of the physician?
  (new resident? appropriate supervision?)
• Were the right tests orders?
• Was EKG obtained? Were results timely?

Middle-aged man presents to ED complaining of
chest pain.
9
Case Walkthrough

• Clinical Analysis
• Human Factors
• What time of day was it? Was it a holiday?
• Was the staffing sufficient
• Were there distractions and interruptions that
  impacted care
• Was there ambiguous, incomplete or contradictory
  information that impacted decision-making
• Did the ED team function effectively? Was it
  clear who was in charge? Were handoffs managed
  properly
• Was the necessary equipment available?

Middle-aged man presents to ED complaining of
chest pain.
10
Case Walkthrough

• Clinical Analysis
• Diagnosis
• Was a differential dx identified and documented?
  Did the test results support the dx?
• Were symptoms adequately accounted for with the
  dx?

Middle-aged man presents to ED complaining of
chest pain.
11
Coding Results

• MisdiagnosisNoOutcome
• Two days after discharge patient dies at home
  of cardiac arrest
• Responsible Service Internal Med/Cardiology
• Location patients room
• Final Diagnosis MI
• Severity high
• Allegation failure to treat
• Contributing Factors
• management of consult
• delay in ordering test (cardiac cath, ETT)
• timely test results returned

• MisdiagnosisYesOutcome
• Two days later, patient presents to another ED
  with an MI resulting in excessive cardiac damage
  that restricts his future employment
• Responsible Service Emergency Department
• Location emergency department
• Final Diagnosis MI
• Allegation failure to diagnose
• Severity medium
• Contributing Factors
• premature discharge
• narrow diagnostic focus
• test result management

12
Coding Challenges

• State of claim file/medical recordpaper, scanned
• Variability in institutional document management
• Variability across claim files
• Need to read between the lines
• Missing test results
• Incomplete operative report omitting inadvertent
  puncture
• Standard of care based on when the error occurred
  vs. keeping up
• Human factors influences

13
What is the value?Why expend this effort?

• Understand contributing factors
• Stories for education, defensibility
• Process of care breakdowns, associated costs
• Organizational priorities for resource allocation
• Context of data within peer group

14

• Analyze
• Code/categorize
• Aggregate
• Delineate high-severity injury drivers

• Denominators
• Comparative data
• Mesh with otherdata sets
• Context

• Assessment ofcurrent risk
• Risk assessmenttools
• Focus groups

?
15
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16
Peer Comparison High-Severity CasesTop
Responsible Services
N(Inst. A)91 high severity PL cases asserted
1/1/02-12/31/06. N(CRICO Peers)185 high severity
PL cases asserted 1/1/02-12/31/06. N(CBS
Peers)271 high severity PL cases asserted
1/1/02-12-31/06 CRICO Peers are Institution B and
Institution C. CBS Peers are Stanford, Washington
Hospital Center, Georgetown University Hospital
and UMass Medical Center.
17
Vulnerabilities from the Past Hypotheses of
Risk in the Present

• Are you still at risk for
• Unreliable receipt of critical test results?
• Narrow diagnostic focus?
• Unclear management of specialty referrals?
• Retained foreign bodies?
• Technical performance issues with laparascopic
  procedures?
• Wrong-site surgeries?

• Tools
• Office Practice Evaluations (including chart
  audits)
• Validation through other data sources (e.g.,
  quality indicators, adverse event data, pt.
  complaints)
• FOCUS GROUPS

18
Identifying Patient Safety Priorities

• Evidence from the past
• adverse events
• patient complaints
• quality indicators
• themes from malpractice
• It is the coming together of the evidence from
  the past with the perspectives of the present
  that should define an organizations patient
  safety priorities

19
Organizational Attributes a Patient Safety Model

• Sources of Data
• adverse events
• near misses
• RCAs, FMEAs
• patient complaints
• staff / safety surveys
• walk rounds
• quality indicators
• malpractice claims

DataHub
Leadership
Culture
Identify/Prioritize Risk
chiefs/leaders can act on critical issues
20
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21
Case Walkthrough

• Clinical Analysis
• Cardiac DiagnosisYes
• Was patient admitted in timely fashion?
• Were test results available for review?
• Was cardiac consult ordered and completed?
• Was treatment plan established and appropriate
  for the patient?
• Was it communicated to the patient?
• Was follow-up timing appropriate?
• Were discharge instructions communicated
  properly?
• Were medications discussed with the patient and
  family?
• Outcome
• Two days after discharge patient dies at home
  of cardiac arrest

Middle-aged man presents to ED complaining of
chest pain.
22
Case Walkthrough

• Clinical Analysis
• Cardiac DiagnosisNo
• What is differential dx? Lung? Gastro?
• Were all the test results returned?
• Were discharge instructions clear?
• Was the follow-up plan documented and
  communicated?
• Outcome
• Two days later, patient presents to another ED
  with an MI resulting in excessive cardiac damage
  that restricts his future employment.

Middle-aged man presents to ED complaining of
chest pain.
23
Coding Challenges

• Standard of care must be evaluated based on loss
  year
• Expert biases
• Human factors influences
• Keeping current with medicinediagnoses,
  procedures, medications
• Keeping current with policies and practices
  across facilities
• Finding out whats new in the claim file/med
  record as the investigation processes over a 35
  year life
• Understanding jurisdictional differences
• Inter-rater reliability
• The person responsible is sometimes not named