Onsite visits identify ED-specific issues
Onsite visits by risk-management personnel can reduce liability risks for your facility and/or individual practice, says Craig Self, MBA, director of practice operations for Premier Health Care Services, based in Dayton, OH. "Through this process, we reduce risk exposure for our physicians and, in turn, for our hospital clients," he says.
There are eight components to the group’s risk-management program:
Section 1: Physicians and physician assistants attend a nationally sponsored risk management course.
Section 2: A biannual, high-risk topic seminar is held for all ED physicians in the organization. Category 1 CME activities include [learning about] actual clinical cases from the group’s practice, which are presented by the attending physician involved and then compared to similar cases in the court system. Past topics have included chest pain, sepsis, abdominal pain, and trauma.
Section 3: A incident reporting system is utilized at the ED sites and reviewed by the medical director in cooperation with the hospital’s risk manager.
Section 4: Occurrence screening is coordinated to allow high-risk areas to be periodically screened to make sure the "system" is working properly. This has included areas such as equipment failure and treatment/procedure complications.
Section 5: Our credentialing department coordinates efforts with the hospitals and monitors licenses and the national practitioners’ database.
Section 6: A comprehensive customer service and complaint management program complemented the risk management program. Collection of data from the EDs is annually assessed and trends noted. The customer service training program provides on-site presentations to physicians.
Section 7: On-site ED evaluation tours are conducted to uncover potential risk management issues.
Section 8: The group’s documentation improvement initiative is coordinated by a physician led task force and reviewed locally by medical directors.
On-site ED evaluation visits result in reduced risks, with more than 40 areas targeted, Self reports. Key areas include: x-ray and EKG overreads, patient care policy and procedures, staff responsibilities, EMTALA [requirements] , treatment times, discharge instructions, quality improvement projects, and specialist coverage.
Site visits are divided into two components: an interview session and a review of documents section. "During the interview period, we discuss operational issues that, based on previous experiences, may provide some exposure for the physicians or our hospital clients," says Self. Pertinent issues are discussed with the medical director, ED manager, hospital risk manager, and other administrators.
Some of the topics discussed include credentialing, informed consent, EMTALA, documentation, patient satisfaction, and safety/security. "Rather than reviewing specific cases from the past or present experience of that particular ED, we focus more on current trends and best practices’ which will reduce the medicolegal risks for that ED and hospital," says Thomas Syzek, MD, FACEP, the group’s associate director for risk management.
The document review process includes double-checking credentials in employee files and reviewing charts for select high-risk patients, the hospital’s mission statement, disaster plans, and departmental policy and procedure manuals.
Several patterns have been identified from the onsite visits. "Although a Level-1 trauma center and an ED that sees 6000 patients per year each have different exposure areas, we have identified some common themes," Self notes. These include immediate availability of dictations, informed consent, medication mishaps, documentation, telephone advice, and discharge instruction consistency.
Many variables affect the cost of malpractice insurance, including past claims experience (i.e., number, frequency, and severity of claims and suits brought against the group), location (this accounts for regional differences in claim frequency and severity, as well as any state laws limiting or controlling malpractice lawsuits), size of group, census and acuity of patients seen, type and amount of insurance coverage, amount of deductible and any self-insurance, and a whether or not there is a comprehensive risk management program, says Syzek.
This corporate-wide approach is less than two years old and significant statistics or trends are not yet available, says Self. "However, since we developed this in cooperation with our malpractice carrier, they have recognized our efforts and our current average cost per patient is well below the national average. Based on level of service, our cost ranges from $2 to $3 per patient," he reports.
Reducing legal risks with onsite assessments cut costs of malpractice insurance, says Syzek. "Claims, suits, and settlements are costly, so our ED groups pay out lower premiums," he says. "Detailed risk management assessments in the ED will result in cost containment. It’s a collaborative effort between the hospital administration and the ED staff to reduce risk, reduce cost, and increase patient satisfaction," says Syzek.
The site assessments improve patient care and reduce risk and liability for the hospital, says Self. "By evaluating areas we have discussed, departments can focus on minimizing their exposure," he stresses. "Including risk management education as an important component to a continuing education program for the entire ED staff is also important."
A team approach is crucial, Self emphasizes. "We are also planning to start a Risk Management Topics’ newsletter and quarterly mailing to our physicians regarding key issues, recent publications, or generalized information that would be of benefit," he says. "This can be done at any ED with input from the physicians, nurses, and hospital legal counsel."
After the site visit, a report addresses areas of strength and weakness for each ED.
"Some typical questions posed to an ED manager are How do you handle x-ray overreads, EKG overreads, and positive lab results that come back after the patient has left?’" says Sizek. "If you have missed a fracture and do not have a process for that, it may result in poor patient outcomes and increased liability," he explains.
High-risk areas are identified, such as chest pain, missed fractures, pediatric fever, foreign bodies in wounds, and ectopic pregnancies. "We target these areas and look for processes to address these risks, and reduce the number of lawsuits," says Sizek. "We have the lowest suit rates of any group in the country. As a result, we are able to negotiate very competitive rates with our insurance carriers."
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