PowerPoint PresentationUsing Simulation to Decrease Medical Liability Risk Denise W. Gee, MD
Massachusetts General Hospital
March 14, 2015
Controlled Risk Insurance Company (CRICO) • A patient safety and medical malpractice company owned by
and serving the Harvard medical community since 1976 • An internationally renowned leader in evidence-based risk
management • CRICO insures:
• 32 hospitals • 100,000+ employees (nurses, technicians, etc.)
• Provides coverage for professional liability (medical malpractice), association liability, general liability, and international medical professional liability
Claims are the tip of the iceberg…
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CRICO N=1,330 PL cases asserted 1/1/08–11/30/13. *Other includes Allied Health, Non-Clinical, and Pharmacy. Total incurred includes reserves on open and payments on closed cases.
Responsible Services in CRICO Cases
1,330 cases | $705M total incurred
$0 $5,000,000 $10,000,000 $15,000,000 $20,000,000 $25,000,000 $30,000,000 $35,000,000 $40,000,000 $45,000,000 $50,000,000
0
20
40
60
80
100
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CRICO N=371 PL cases asserted 1/1/08–11/30/13 with Surgery as the primary responsible service. Total incurred includes reserves on open and payments on closed cases.
Top Surgical Services in CRICO Cases
371 cases | $175M total incurred
402 cases | $189M total incurred
FACTOR # CASES* % CASES*
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*A case will often have multiple factors identified. N=402 CRICO PL cases asserted 1/1/08–11/30/13 with a physician specialty or responsible service of Surgery.
Top Contributing Factors
• Fundamentals of Laparoscopic Surgery certification
• Leverage the role of simulation in the area of surgical competence
• Support the surgical chairmen in using the FLS designation as a minimum qualification for granting privileges
• One-time $500 payment to surgeon participants
Improving Communication
Operating Room
Ambulatory Surgery
Physician Office/Clinic
Patient's Room
number of cases
N = 241 CRICO PL cases asserted 1/1/05 – 1/31/10 with a physician specialty or responsible service of Surgery. *Other includes Special Procedure Areas, Pathology, and Labor & Delivery.
2010 Pilot Program: Operating Room Team
Training with Simulation
• Intraoperative errors resulting in preventable patient harm caused by • Technical errors • Communication breakdowns and lapses in teamwork
• ASA/ACS closed claims studies find poor communication both
inside and out of OR to be significant cause of preventable adverse events
Lack of Communication
OR Team Training with Simulation Program
Grant funding to the institutions to build the infrastructure and premium rebate to
surgeons for participating
• Simulation-based and didactic (<20%) team training
• Instructors’ Course – to standardize and train teamwork instructors
• Three goals: • Closed loop communication • Speaking up • Use of a surgical safety checklist as a
teamwork tool
anesthesia/nursing/surgical technicians • Premium incentive to surgeons who complete all requirements
• Three case scenarios: • Hemorrhage • Cardiac arrest • Case based on the institution’s choice
Active Operating Room Staff Participating in the Pilot Program (N=221 participants)
Program Participants in the Pilot Program
26%
17%
24%
7%
10% 4% Surgeon (n=58)
Anesthesiologist (n=38) Operating Room RN (n=53) Surgical Technol (n=16) Surgery Resident (n=7) CRNA (n=7) Surgical PA (n=5) Biomed Engineer (n=8) Other (n=21) Anonymous (n=8)
Annals of Surgery 2014
Training Program
2014 Goals
• To equip surgical specialties at high risk for medical malpractice suits and their teams with simulation-based team training skills
• To improve the culture of safety in operating rooms across Harvard medical institutions
• To move simulation-based team training into the fabric of each institution
• To consider making participation in OR team training a requirement of surgeon credentialing/privileging process
Surgical Specialties
Cardiac Surgery 35 General Surgery 162
Gynecology Surgery 68
The Math…at MGH
• ~150 surgeons within the 7 high risk surgical specialties • ~75 teams (2 surgeons per team) • CRICO is providing an educational grant of $11K per training
session to build the infrastructure • > $1M in malpractice rebates (average per surgeon $4200)
Simulation Sessions
• Twice a month • ~6 hours in duration • 3 OR Scenarios each followed by debriefing • Goals
• Use of WHO OR checklist • Increase assertiveness/speaking up • Closed loop communication
In-Situ Simulation Operating Rooms
40
1
25
41
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Other Declined to Answer
29%
78%
19%
3%
Excellent
0%
20%
40%
60%
80%
100%
MGH 1 Year Data: Training Frequency
2
47 53
14 9
Never Every 2 years Yearly Every 6 months Every 3 months
CRICO’s Premium Incentive Programs
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0
5000
10000
15000
20000
25000
30000
35000
1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Annual Premium $
cash incentive Program requirements
completed over 3-year cycle
High-risk OB Premium Premium=$68,849 All OB MD providers who do not complete
the program requirements within the calendar year as prescribed*
OB Incentive Program OB Risk Reduction Program
Low-risk OB Premium Premium=$52,653 All OB MD providers who complete the
program requirements within the calendar year as prescribed
All newly hired OB MD providers
*Includes providers who may have previously qualified for low- risk premium.
2011
result: reassuring claim and actuarial trends
Reported by individual Cash incentives discontinued
• Premium rates for anesthesiologists with simulation training are 43% lower than for physicians without training
• Premium rates for OB/GYN physicians with simulation training are 26% lower than for physicians without training
• Based on most recent evaluation of 10 years of loss history
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Anesthesia Obstetrics OR/Surgery Emergency Medicine
*including nursing departments *including nursing departments
Lessons Learned at MGH
Sustaining Value Over the Long Term
• Unique longstanding partnership with CRICO • Simulation becoming an integral part of larger hospital initiative
to improve patient safety • Expanding Use of Simulation: robotic cases, OR codes • Continue to see OR culture change • Surgery malpractice claims and premium trends will hopefully
mirror OB/Anesthesia results
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Using Simulation to Decrease Medical Liability Risk Denise W. Gee, MD
Massachusetts General Hospital
March 14, 2015
Controlled Risk Insurance Company (CRICO)
Claims are the tip of the iceberg…
Responsible Services in CRICO Cases
Top Surgical Services in CRICO Cases
Top Contributing Factors
Improving Communication
OR Team Training--WHY?
Lack of Communication
Slide Number 13
Annals of Surgery 2014
2014 Goals
Surgical Specialties
MGH 1 Year Data: Years of Experience
MGH 1 Year Data: Overall Course
MGH 1 Year Data: Debriefing Impressions
MGH 1 Year Data: Training Frequency
CRICO’s Premium Incentive Programs
Anesthesia: A Safety Story in Premium History
OB Safety Program Evolution
Using Simulation to Decrease Medical Liability Risk