September 2006

Grant Results

National Program

Improving Malpractice Prevention and Compensation Systems

SUMMARY

From 1998 to 1999, researchers from the Institute for Health Policy Studies at the University of California, San Francisco, conducted an exploratory case study of innovative practices of large capitated physician organizations aimed at improving patient safety.

To gather data, the research team interviewed managers in 23 large capitated physician organizations with advanced patient-safety processes. (Capitation refers to an arrangement whereby care is guaranteed in return for a fixed, prepaid monthly fee.)

The project was part of the Robert Wood Johnson Foundation's (RWJF) Improving Malpractice Prevention and Compensation Systems national program.

Key Findings
The findings and conclusions reported by the investigators in the Journal of Health Politics, Policy and Law include:

  • "Demand for safety comes mostly from external factors — legal, market, and professional."
  • Indications are "that the biggest improvement in patient safety would come from boosting quality-safety demand from larger group purchasers, private and public."
  • "In the most advanced organizations, physicians have begun to see errors as ordinary shortcomings to be faced and managed rather than as unacceptable moral failings."
  • "Groups most commonly sought to reduce delay in diagnosis or misdiagnosis, which was perceived as the most common source of avoidable injury."
  • "In more advanced groups, risk managers received many oral and written reports on injuries or 'near misses' from multiple sources."
  • "Often, lawsuits helped focus organizational attention on processes that enabled an injury to occur."

Funding
RWJF supported this project through a grant of $324,401.

 See Grant Detail & Contact Information
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FINDINGS

The findings and conclusions reported by the investigators in an article ("Efforts to Improve Patient Safety in Large, Capitated Medical Groups: Description and Conceptual Model") accepted for publication in the Journal of Health Politics, Policy and Law included the following:

  • "Demand for safety comes mostly from external factors — legal, market, and professional." "Organizational responses depend on internal factors — group size, scope of services, and integration; leadership and governance; professionalculture; information systems; and financial and intellectual capital."
  • Indications are "that the biggest improvement in patient safety would come from boosting quality-safety demand from larger group purchasers, private and public. Big purchasers' demands can quickly influence the internal environment of medical groups, helping managers advance quality-safety toward the top" of the decision-making process.
  • "In the most advanced organizations, physicians have begun to see errors as ordinary shortcomings to be faced and managed rather than as unacceptable moral failings." Physicians "admit and discuss mistakes so that systems changes can be developed to reduce or mitigate errors."
  • "Groups most commonly sought to reduce delay in diagnosis or misdiagnosis, which was perceived as the most common source of avoidable injury." "Each medical group put at least one clinician — often a full-time nurse — in the role of 'risk manager' who focused on reacting to potential liability cases, reducing legal exposure and reducing medical injury."
  • "In more advanced groups, risk managers received many oral and written reports on injuries or 'near misses' from multiple sources." These included reports from:
    1. The clinician involved in the incident or, in some instances, other clinicians.
    2. Patients through formal or informal patient complaints lodged with customer relations staff or, less commonly, patient satisfaction surveys.
    3. Utilization management staff through reports on unexpectedly long hospital stays or other anomalies.
    4. Inpatient nurse case managers.
  • "Often, lawsuits helped focus organizational attention on processes that enabled an injury to occur." "However, contrary to our initial hypothesis, safety improvements were not much influenced by litigation-related financial costs."

The investigators published four journal articles pertaining to the project and discussed it in a number of presentations; additionally, one investigator testified at a hearing held jointly by two US House subcommittees. Also, the principal investigator reported that a chapter in the 1999 Institute of Medicine (IOM) report on medical injuries (To Err is Human: Building a Safer Health System) drew on work done under this project. (See the Bibliography for details.)

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GRANT DETAILS & CONTACT INFORMATION

Project

Study of Institutional Liability in Large Capitated Physician Organizations

Grantee

University of California, San Francisco, Institute for Health Policy Studies (San Francisco,  CA)

  • Amount: $ 324,401
    Dates: January 1998 to October 1999
    ID#:  033501

Contact

Robert H. Miller, Ph.D.
(415) 476-8568
millerr@itsa.ucsf.edu

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Articles

Bovbjerg RR. "Medical Safety: From Stories to Policy." Health Affairs, 20(2): 241–242, 2001.

Bovbjerg RR. "Suing HMOs Won't Improve Care." Los Angeles Times, A13, January 4, 2000.

Bovbjerg RR and Miller RH. "Managed Care and Medical Injury: Let's Not Throw Out the Baby with the Backlash." Journal of Health Politics, Policy and Law. 24(5): 1145–1157, 1999.

Bovbjerg RR, Miller RH and Shapiro DW. "Paths to Reducing Medical Injury: Professional Liability and Discipline vs. Patient Safety — and the Need for a Third Way." Journal of Law, Medicine & Ethics, 29(3–4): 369–380, 2001.

Miller RH and Bovbjerg RR. "Efforts to Improve Patient Safety in Large, Capitated Medical Groups: Description and Conceptual Model." Journal of Health Politics, Policy and Law, 27(3): 401–440, 2002. Abstract available online.

Reports

Bovbjerg RR and Shapiro DW. "Protecting Voluntary Reporting Systems in Medicine from Legal Discovery." Washington: Report to the Institute of Medicine, Committee on Quality of Care in America, 1999. (This report was revised and published as Chapter 6 ("Protecting Voluntary Reporting Systems from Legal Discovery") of the Institute of Medicine's 1999 report To Err is Human: Building a Safer Health System.)

Presentations and Testimony

Randall R. Bovbjerg, "Legal Issues Related to Error Reporting Systems in Medicine," National Academy of Sciences/Institute of Medicine, Subcommittee on Creating an External Environment for Quality, June 15, 1999, Washington.

Randall R. Bovbjerg, "Alternatives to the Tort System," to the Executive Session on Medical Error and Patient Safety, Kennedy School of Government, Harvard University, June 18, 1999, Cambridge, MA.

Robert H. Miller and Randall R. Bovbjerg, "Reducing Medical Injuries in Large, Capitated Physician Organizations," to the Annual Meeting of the Association for Health Services Research, June 28, 1999, Chicago.

Robert H. Miller and Randall R. Bovbjerg, "Reducing Medical Injuries: Implications for Quality Assurance," to the staff of the National Committee for Quality Assurance, July 14, 1999, Washington.

Randall R. Bovbjerg, "Reporting Systems for Medical Error: Options and Issues," to a joint hearing on "Medical Errors: Improving Quality of Care and Consumer Information," held by the Subcommittee on Health and Environment and the Subcommittee on Oversight and Investigations of the Committee on Energy and Commerce and the Subcommittee on Health of the Committee on Veterans Affairs, US House of Representatives, February 9, 2000, Washington. Appears online.

Randall R. Bovbjerg, "How Well Would Expanded Litigation Protect Patients?" to the National Health Policy Forum, February 18, 2000, Washington.

Randall R. Bovbjerg, "The Legal Context of Patient Safety: Problems and Potential Reforms," at the Annual Meeting of the National Committee for Quality Health Care, March 2, 2000, Washington.

Randall R. Bovbjerg and Robert H. Miller, "Patient Injury and Liability Reform: The Importance of Front-Line Management and Market Forces in Truly Helping Patients," at the Annual Meeting of the American Public Health Association, November 14, 2000, Boston.

Randall R. Bovbjerg, "Professional vs. Systems Approaches to Medical Injury — and the Need for a Third Way," at the 25th Anniversary Health Law Teachers Conference of the American Society of Law Medicine & Ethics, June 2, 2001, Boston.

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Report prepared by: Michael H. Brown
Reviewed by: Robert Crum
Reviewed by: Marian Bass
Program Officer: Joel C. Cantor
Program Officer: Beth A. Stevens
Program Officer: Judith Y. Whang

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