September 2002

Grant Results

National Program

Improving Malpractice Prevention and Compensation Systems

SUMMARY

From 1996 to 2001, staff at Vanderbilt University Medical Center implemented and evaluated a model program to identify and intervene with health care providers at high risk of generating malpractice claims.

In the project, researchers identified physicians — at Vanderbilt and at four community hospitals in Alabama — who had generated a high level of complaints. They randomly assigned them to either an intervention group that received counseling from mentor physicians or to a control group that received no counseling.

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

Key Results

  • Project staff developed a patient complaint analysis system to identify and improve the performance of high-complaint physicians.

Key Findings
Preliminary evaluation findings indicated that:

  • The Vanderbilt high-complaint physicians assigned to the intervention group generally responded constructively to the initial interventions.
  • The complaint index for the physicians in the intervention group improved.

Funding
RWJF supported this project through a two grants totaling $1,365,592.

 See Grant Detail & Contact Information
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THE PROBLEM

Medical malpractice studies in Florida conducted by VUMC researchers indicated that physicians who lack interpersonal skills are more likely to be sued. The studies indicated that patient perception of a physician's interest, accessibility, and communications ability was more important than the technical quality of care as a predictor of the physician's malpractice claiming experience. The research also suggested that physicians who are frequently sued generate higher rates of complaints even from patients who do not suffer an adverse outcome.

In light of these findings, the project director hypothesized that patient complaints about interpersonal aspects of care could serve as an "early warning" for physicians and service units at increased risk of generating malpractice claims.

Project staff designed a plan to use patient complaints and other data to identify providers at high risk of malpractice claims and to counsel them on improvements in the interpersonal aspects of their practice. Peer physicians would conduct the first phase of intervention. Where necessary, the plan envisioned a second phase involving higher-ranking supervisory personnel and a third phase employing more serious steps, such as an increase in malpractice insurance premiums and revocation of selected privileges.

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THE PROJECT

These two grants from RWJF supported implementation and evaluation of a model program to identify and intervene with providers at high risk of generating malpractice claims. The first grant (ID# 028592) funded the model's development and testing at VUMC in Nashville, Tenn. and the second grant (ID# 033572) funded its demonstration at four community hospitals in Alabama: East Alabama Medical Center in Opelika; Southeast Alabama Medical Center in Dothan; Providence Hospital in Mobile; and St. Vincent's Hospital in Birmingham.

Grant ID# 028592

The project objectives under the first grant were to:

  1. Develop and implement — at an academic medical center — a model program to identify health professionals and service units whose profiles of patient complaints are similar to those shown by research to be associated with high-frequency malpractice claiming.
  2. Create a Quality Care/Risk Management (QC/RM) Committee composed of physicians to intervene with persons or units found to be at increased risk of malpractice claiming.
  3. Evaluate the model's ability to classify correctly persons or units according to their risk for malpractice claiming and to assess the success of the interventions in reducing patient complaints and adverse financial outcomes.
  4. Identify community hospitals willing and able to participate in a follow-up study that would demonstrate the model's utility in non-academic medical facilities.

To accomplish these objectives, the project team:

  • Obtained more than 30,000 complaints reported to Vanderbilt's offices of Patient Affairs and Risk and Insurance Management since July 1990, and coded each according to the type of complaint (e.g., "poor communication," "made me worry," "incompetent," and "rough handling") and the health professional responsible for generating it.The project team developed a patient complaint analysis system that allowed non-medically trained personnel to perform the coding. The system, which included new software for capturing complaint data, was tested and revised during the course of the project, and copyrighted under the name PARS (for Patient Advocates Reporting System).
  • Used the data to identify VUMC physicians who generate a high level of complaints. A "patient complaint profile" or "report card" was produced showing each physician's complaint score relative to all other VUMC physicians and a list of the types of complaints most commonly made against the physician. High-complaint physicians were randomly assigned to an intervention group or a control (non-intervention) group.
  • Identified senior Vanderbilt physicians willing to serve on the QC/RM Committee, and developed a written guide and a series of structured role-plays to train them to mentor physicians in the intervention group.The committee members conducted the first round of intervention visits in 1998.
  • Conducted statistical analyses of pre- and post-intervention complaint data in order to track physicians' progress in reducing patient dissatisfaction. The team also studied the link between complaint generation and risk management activity.
  • Traveled to Alabama and — working with an Alabama-based medical malpractice insurer, The Medical Assurance Co., Inc. — identified four community hospitals as suitable demonstration sites for the early-warning model. The four, which are named above, are located in geographically distinct areas of the state.

Grant ID# 033572

The purpose of the second grant was to demonstrate the model's applicability and adaptability when translated from an academic medical center to community hospitals. The objectives were to:

  1. Implement the model at each of the four Alabama facilities identified under the first grant.
  2. Compare patient complaint outcomes of the intervention and control groups of high-complaint physicians at the four sites.
  3. Analyze The Medical Assurance Co.'s claim and expenditure data for the high-complaint physicians as well as physicians in 10–13 additional, nonparticipating Alabama hospitals.

Activities replicated those undertaken in the Vanderbilt trial. At each hospital, the project team oversaw collection and coding of complaints reported to the patient affairs office and the formation and training of a QC/RM Committee. Other activities included travel to the hospitals to explain the project to administrators and medical staff — and, at one facility, to respond to staff concerns about participation. Additionally, a consulting agreement between Vanderbilt and the hospitals was developed to ensure the hospitals of data confidentiality.

In addition to the two RWJF grants, the project's support included $100,000 from Vanderbilt and in-kind contributions in data and personnel time from Vanderbilt and the four Alabama hospitals.

Project activities, including interventions and evaluation, remained underway through 2001. At VUMC, the project team expected interventions to continue through the third phase with the support of Vanderbilt funding. At the Alabama sites, the project team expected the RWJF grant to cover completion of the first phase of interventions. The project director said it would then be up to each hospital to decide whether to continue into the second phase on its own.

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RESULTS

Preliminary results included the following findings:

  • Project staff identified 76 high-complaint physicians at VUMC, and 52 of them were randomly assigned to intervention and control groups. The other 24 physicians were excluded from the intervention study because they had retired, moved, or were about to retire. At the Alabama hospitals the number of high-complaint physicians identified and randomized for study ranged from 4 to 10 at each hospital.
  • QC/RM committee members undertook interventions with high-complaint physicians at VUMC and the four Alabama hospitals, permitting evaluation of the effect of peer mentoring. The project director reported in early 2001 that the QC/RM Committee at VUMC had conducted more than 70 first-phase interventions and one second-phase intervention. At the Alabama hospitals, the initial round of first-phase interventions had occurred.
  • Researchers developed and deployed a patient complaint analysis system to identify and improve the performance of high-complaint physicians. Three hospitals not involved in the project — Emory Clinic, Atlanta, Ga.; St. Johns Medical Center, Springfield, Mo.; and Loyola University of Chicago Medical Center, Chicago, Ill. — have instituted PARS, and the project team reported 10 additional facilities were interested in instituting the system. Also, according to the project director, several medical malpractice insurance carriers, including St. Paul Fire & Marine Insurance, were offering rebates to medical groups that use PARS.

Findings

The following were among preliminary findings reported during the course of the project:

  • VUMC complaint data showed that a small proportion of physicians accounted for a large proportion of patient complaints. In the combined Winter & Spring 1997 issues of Law and Contemporary Problems, project team members reported that of 717 VUMC physicians, 90 percent (641) were named in fewer than 10 patient complaints during the study period. The remaining 10 percent (76) — who were classified as high-complaint physicians — accounted for two-thirds of patient complaints overall and approximately two-thirds of each type of patient complaint.
  • Preliminary analysis indicated an association between high-complaint physicians and risk-management outcomes. The project team reported to RWJF that at VUMC the 10 percent classified as high-complaint physicians accounted for 40 percent of both actual malpractice claims and potential claims and just over 50 percentx of dollars paid out in incidents with closed files. Additionally, raw data indicated that "high-complaint MDs were associated with more high-dollar cases."
  • VUMC high-complaint physicians assigned to the intervention group generally appeared to respond constructively to the initial interventions. Although one physician refused intervention, "a preliminary analysis of the data suggested that of 24 physicians remaining in the intervention group, the complaint index improved for 14," the project team told RWJF. Subsequently in an interview, the project director said that half of the physicians in the VUMC intervention group registered "significant improvement." Additionally, the project team reported preliminary indications that "the intervention group generated fewer complaints on average than the control group" during the eight months following the initial interventions. Also, the team cited anecdotal reports of efforts by intervention-group physicians to reduce complaints.

Communications

Project team members published 14 journal articles and made more than a dozen presentations analyzing aspects of patient dissatisfaction and explaining the purpose and design of the early-warning system. A 1997 article in Law and Contemporary Problems reported preliminary findings of the VUMC complaint analysis. Articles reporting more recent findings were in preparation at the time this report was written. (See the Bibliography for a full listing of communications activities.)

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AFTER THE GRANT

Project staff is seeking to expand PARS' use to additional nonproject sites, initially targeting large medical centers but hoping eventually the system will be applied to smaller operations, even individual physician offices.

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GRANT DETAILS & CONTACT INFORMATION

Project

Early Identification and Response Model for Malpractice Prevention

Grantee

Vanderbilt University Medical Center (Nashville,  TN)

  • Amount: $ 647,609
    Dates: January 1996 to December 2001
    ID#:  028592

  • Amount: $ 717,983
    Dates: January 1998 to December 2001
    ID#:  033572

Contact

Gerald B. Hickson , M.D.
(615) 936-2425
Gerald.Hickson@mcmail.vanderbilt.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.)

Books

Pichert JW and McClanahan S (eds.). Guide to Promote Quality Health Care, 2nd edition. Nashville, TN: Vanderbilt University Office of Risk Management, 1996.

Book Chapters

Pichert JW and Hickson GB. "Communicating Risk to Patients and Families." In Clinical Risk Management, 2nd ed., C Vincent (ed.). London: BMJ Publishing Group, 2001.

Articles

Hickson GB. "Pediatric Practice and Liability Risk in a Managed Care Environment." Pediatric Annals, 26(3): 179–185, 1997.

Hickson GB. "Physician Behaviors That Promote Malpractice Claims." The Digest, 25(1): 1–5, 1997.

Hickson GB. "Ethical and Economical Issues Associated with Managed Care." Proceedings of the Fourth International Symposium on Childhood Deafness, Bill Wilkerson Center Press, 1998.

Hickson GB, Clayton EW, Miller CS, Pichert JW and Entman, SS. "Satisfaction with Obstetrical Care: Relation to Neonatal Intensive Care." Obstetrics and Gynecology, 91(2): 288–292, 1998. Abstract available online.

Hickson GB, Miller CS, Pichert JW and Entman S. "Impact of NICU Experiences on Patient Satisfaction with Care." Unpublished.

Hickson GB, Pichert JW, Clayton EW, Entman SS and Miller CS. "NICU Care, Infant Outcome and Satisfaction with Obstetrical Care." Archives of Pediatrics and Adolescent Medicine, 150(4): 109, 1996.

Hickson GB, Pichert JW, Federspiel CF and Clayton EW. "Development of an Early Identification and Response Model of Malpractice Prevention." Law and Contemporary Problems, 60(1): 7–29, 1997. Available online.

Hickson GB, Federspiel CF, Pichert JW, Miller CS, Gauld-Jaeger J and Bost P. "Patient Complaints and Malpractice Risk." Journal of the American Medical Association, 287(22): 2951–2957, 2002. Abstract available online.

Pichert JW, Federspiel CF, Hickson GB, Miller CS, Gauld-Jaeger J and Gray CL. "Identifying Medical Center Units with Disproportionate Shares of Patient Complaints." Joint Commission Journal on Quality Improvement, 25(6): 288–299, 1999. Abstract available online.

Pichert JW, Hickson GB, Bledsoe S, Trotter T and Quinn D. "Understanding the Etiology of Serious Medical Events Involving Children: Implications for Pediatricians and Their Risk Managers." Pediatric Annals, 26(3): 160–172, 1997.

Pichert JW, Hickson GB and Miller CS. "Precipitants of Patient Dissatisfaction." Practical Diabetology, 15(12): 10–13, 1996.

Pichert JW, Hickson GB and Trotter TS. "Malpractice and Communication Skills for Difficult Situations." Ambulatory Child Health: The Journal of General and Community Pediatrics, 4(2): 213–221, 1998.

Pichert JW, Miller CS, Hickson GB, Trotter TS, Gauld-Jaeger J and Hollo AH. "Identifying and Resolving Patient Dissatisfaction." Educators Forum, 1(2): 1–2, 1998.

Pichert JW, Miller CS, Hollo AH, Gauld-Jaeger J, Federspiel CF and Hickson GB. "What Health Professionals Can Do to Identify and Resolve Patient Dissatisfaction." Joint Commission Journal on Quality Improvement, 24(6): 303–312, 1998.

Presentations and Testimony

Gerald B. Hickson, "NICU Care, Infant Outcome, and Satisfaction with Obstetrical Care," at the Annual Meeting of the Ambulatory Pediatric Association, February 1996, New Orleans.

Gerald B. Hickson, "Identifying Physicians at Increased Risk for Attracting Malpractice Claims," at the St. Paul Seminar for University Healthcare Consortium Members, March 12–14, 1997, Tucson, AZ.

Gerald B. Hickson, Tinsla Trotter and James W. Pichert, "Malpractice Risk and Communication Skills for Difficult Situations," at the Annual Meeting of the Ambulatory Pediatric Association, May 6, 1997, Washington.

J. Gigante and Gerald B. Hickson, "Liability Risks and Challenges in a Managed Care Environment," at the Annual Meeting of the Ambulatory Pediatric Association, May 9, 1997, Washington.

Gerald B. Hickson, "Dealing with the Claims-Prone Physician," at the IMPACS/Duke Medical Malpractice Conference, September 12–13, 1997, Durham, NC.

Gerald B. Hickson, "Telemedicine and Implications for Medical Care," at the 1997 Mutual Assurance Health Care Conference, October 9–11, 1997, Sandestin, FL.

Gerald B. Hickson, "Managed Care — Reducing Liability Risk," at the 29th Ross Roundtable on Critical Approaches to Common Pediatrics Problems, October 25–26, 1997, Washington.

James W. Pichert, "Identification of and Intervention with MDs Who Dissatisfy Their Patients," at the AMA International Conference on Physician Health, April 1998, Victoria, B.C., Canada.

J. Gigante and Gerald B. Hickson, "Gatekeeper Liability in a Managed Care Environment," Ambulatory Pediatric Association Workshop, May 1–5, 1998, New Orleans.

James W. Pichert and Charles Federspiel, "Preliminary Results of Implementing an 'Early Identification and Response Model' of Malpractice Prevention," at "Enhancing Patient Safety and Reducing Errors in Health Care," November 8–10, 1998, Rancho Mirage, CA.

Gerald B. Hickson, member of panel discussion entitled "How Can Consumers Be Protected in the Health Care Market Place?" at the Annual Meeting of the Association for Health Services Research, June 28, 1999, Chicago.

J. Gigante and Gerald B. Hickson, "Malpractice and Communication Skills for Difficult Situations," at the Annual Meeting of the Ambulatory Pediatrics Association, May 14, 2000, Boston.

Charles Federspiel and Gerald B. Hickson, "Using Complaints about Physicians in Teaching Statistics to Medical Students," at a program of the American Statistical Association, August 12, 2000, Indianapolis.

Gerald B. Hickson, "Why Families File Malpractice Claims" and "Why Certain Pediatricians Attract a Disproportionate Share of malpractice Claims," to the American Academy of Pediatrics, March 9, 2001, Big Island, HI.

World Wide Web Sites

"Listen and Learn: Patient Complaints Can Help You Build a Better Practice," www.ahcpub.com, site of American Health Consultants.

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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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