How a Captive Insurer Uses Data and Incentives to - Risk ...

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ADVANCING PATIENT SAFETYchange. We’d like to be able to use the data, the educationalcontent, and the impact from the educational content to makethe business case to the chiefs of service or hospital-based leadership,that these educational core components shouldbecome a term of credentialing. That’s where we’d like to seethe tipping point.”Being able to provide highly specific data to administratorsand providers is a significant boon to engaging them in creatingand sustaining solutions. Because CRICO/RMF maintainscentralized, in-house data collection services, claims data arecoded according to a common language and taxonomy, providinga robust body of evidence regarding specific areas ofvulnerability within a practice, institution, or group of institutions.Using the claims database, CRICO/RMF staff canshow, for example, that a hospital’s obstetrics department hasa relatively high rate of shoulder dystocia claims that involvedcommunication gaps between residents and attending physicians.On a more global level, the organization can identifythe locations within clinical processes where gaps are mostlikely, stating, for example, that across the Harvard system61% of the dollar losses associated with outpatient diagnosisrelatedclaims involved problems with the ordering of diagnostictests.The organizational leaders at CRICO/RMF also recognizethat each Harvard-affiliated institution has a unique cultureand that the most effective approach for implementing sustainablepatient safety interventions will vary from one institutionto another. When working with hospital administratorsand providers to encourage the adoption and spread of patientsafety practices, CRICO/RMF staff tries to remain cognizant ofthe existing culture. According to Kenneth Sands, MD, seniorvice president of health care quality at Beth Israel DeaconessMedical Center in Boston, CRICO/RMF staff provides “customizedinitiatives, which create uniquely valuable offeringsbecause they’re not ‘cookie cutter.’”Clients of RMF Strategies also have benefited from theCRICO/RMF approach of “leading with the data.” Larry Smith,vice president of risk management of MedStar Health, a healthsystem and captive insurer in the Maryland-D.C. area, says hisorganization created an obstetrics risk reduction task force,provided task force members with data that had been collectedand analyzed using the claims management software developedby RMF Strategies, and let the group determine potential solutions.“In the last eight years, this obstetrics program has beenone of the most visible patient safety-risk reduction initiativesacross the system. The obstetricians are envied by many of thephysicians elsewhere in the hospital system because they havecome together as a collective group, have a system-wide identityas a group, and have become patient safety experts in theirown right...It has transformed the way our obstetrics departmentlooks at patient safety.” Smith says that patient outcomes,such as cesarean section rates and APGAR scores haveimproved due to the risk reduction program. In addition, sincethe intervention, the obstetrics-related claims rate remainslower than anticipated based on previous experience.Figure 1. Breast Cancer Cases 1987–2008CRICO/RMF staff crafts a variety of risk reduction toolsbased on needs identified through claims data to help providersidentify and mitigate gaps in care processes that increase the riskof an error. For example, data analysts at CRICO/RMF identifiedan increase in claims related to failure to diagnose in the ambulatorysetting. One area of specific need that emerged was breastcancer diagnosis. CRICO/RMF staff worked with clinical expertsto develop decision support tools for the diagnosis of breast cancer.One tool, the Breast Care Management Algorithm, is used toremind providers of potential pitfalls in diagnosis, such as failureto create a system for tracking ordered tests and outside referralsto ensure notification of test results and referral outcomes. Workon the algorithm began in the early 1990s, when CRICO-insuredprimary care providers expressed concern over the frequency ofmalpractice claims alleging a failure to diagnose breast cancer.The first iteration was published in 1995; the document has beenrevised four times, culminating in the most recent (2009) edition.(View the algorithm at http://www.rmf.harvard.edu/files/documents/cricormf_bca.pdf.)Figure 2: Rate of Anesthesia Cases Before and After Initiation of Simulation Training22Patient Safety & Quality Healthcare ■ November/December 2009 www.psqh.com

ADVANCING PATIENT SAFETYing has reduced obstetric claims makes sense,“The obstetrician who finished training 30years ago is probably not up on facing shoulderdystocia or complicated deliveries,because of the emerging technology and thefact that they just haven’t had to face these situationsvery often at all. For any low-frequencyevent, simulation is very, very useful.”The simulation training also has beeneffectively applied at community hospitals.Mitchell S. Rein, MD, chief medical officerand senior vice president of medical affairs atNorth Shore Medical Center in Salem, Massachusetts,notes that the program was“Hugely successful. We’re still applying someof the lessons that we learned from the initiativeto other areas such as the operatingrooms and our hospitalist program. Obstetricsis a multidisciplinary effort, and the simulationand teamwork training lends itself toimproving a variety of the human factors in healthcare.”According to one survey, the majority of participants of thesimulation program reported having experienced a criticalclinical event since taking the course and that aspects of teamworkhad either significantly or somewhat improved due to thetraining (Gardner, 2008). Additionally, 90% stated they hadresponded better to critical events, and 87% reported that theycommunicated more effectively during the most significantcritical event that occurred since taking the course.The obstetrics team training premium discount programoffers a savings of 10% for each insured physician or nursemidwife. Over the five years of the program’s existence,CRICO/RMF has refunded more than $5 million back to participatingpractices and hospitals.SIX TIPS FOR SUCCESSFUL PATIENT SAFETY INITIATIVES1. Develop relationships with individuals at various levels of the departmentor organization of focus.2. Get to know your clinicians: What are the pain points for each subgroupof providers?3. Never underestimate the power of culture: Assess the degree to whichyour organization has a patient safety culture. If it needs a boost,mobilize respected clinical experts within your organization to championnew initiatives and to encourage hesitant providers to join them.4. Collect and analyze data so you can provide detailed information thatis actionable.5. Convene the right group of individuals, present them with relevantdata, and let them identify gaps and brainstorm solutions on theirown.6. Support resulting patient safety efforts with incentives; remember thatmany important incentives are nonfinancial, such as academicadvancement and work-life considerations.ConclusionPatient safety is a top priority to many constituents and organizationstoday. The CRICO/RMF strategy for promotingpatient safety initiatives in its owner hospitals is to build keyrelationships with leaders and providers, present detailed,actionable data, and provide financial incentives, with the endgoal of shifting providers toward practices that reduce the riskof error. Premium incentive programs based on simulationtraining are examples of a specific tool that CRICO/RMF leadershave successfully utilized to promote patient safety at Harvard-affiliatedorganizations. Leaders of healthcare organizationsand patient safety champions can apply similarapproaches for implementing patient safety initiatives at theirorganizations. ❙PSQHTranslating the CRICO/RMF Strategy toHealthcare OrganizationsDespite the disadvantage of having weaker leverage points forshifting practice patterns than entities that control salaries andcredentialing, CRICO/RMF staff has engaged providers in successfulpatient safety initiatives. The strategies that CRICO/RMFleaders used to create and sustain these initiatives can also beapplied by healthcare executives and patient safety champions toplan, implement, and sustain patient safety efforts. The overallstrategy used by CRICO/RMF leaders and staff is to “lead withthe data.”Their goal is to collect and present consistent, accurate,actionable data that are sufficiently detailed to inspire behaviorchange and action supportive of patient safety. Presenting thedata to individuals capable of the changes needed to improvepatient safety requires the development of relationships at alllevels of the organization. Finally, use of incentives often is necessaryfor capturing the attention of busy clinicians and encouragingthem to prioritize time, energy, and thought for a newpatient-related activity. (See sidebar for six specific tips forpatient safety initiatives.)Diane Shannon specializes in writing about performanceimprovement, patient safety, and quality in healthcare. As apracticing internist, she saw gaps in care processes that prompted herto pursue public health training to gain a broader perspective onsolutions. A full-time freelance writer for the last decade, she uses herclinical experience and writing skills to draw attention to deficienciesin the healthcare system and to highlight innovative programs forchange. She can be reached at dshannon@mdwriter.com.REFERENCESGardner R., Walzer T.B., Simon R., & Raemer D.B. (2008) Obstetricsimulation as a risk control strategy: course design andevaluation. Simulation in Healthcare, 3(2),119-127.Institute of Medicine. Committee on Quality of Health Care inAmerica. (2000). To err is human; Building a safer health caresystem. L. T. Kohn, J. M.Corrigan, & M. S. Donaldson (Eds.).Washington, DC: National Academy Press.National Quality Forum. Safe Practices for BetterHealthcare–2009 Update: A Consensus Report. Washington,DC: National Quality Forum; 2009.26Patient Safety & Quality Healthcare ■ November/December 2009 www.psqh.com