By Jock Hoffman, CRICO
It is a rare discussion among patient safety experts when someone in the room (physician, lawyer, CEO) doesn’t interject, “Let me tell you what happened the last time my mother saw her doctor.”
No matter what our role is in working to perfect patient safety, reduce adverse events, and prevent malpractice claims, we often also get to see systemic imperfections from the patient or family member’s perspective. Indeed, those anecdotes often help build the narratives we use to frame improvement efforts.
One such improvement effort is better coordinated care delivery systems. A recent New York Times article predicted that, by 2020, accountable care organizations (ACOs) and similar care consortiums will have replaced the U.S. health insurance industry. While that’s speculation, providers do need to ramp up their ability to explain new health care delivery models to the patient populations they will be managing. In doing so, those “my mother” patient-perspective narratives become even more poignant for participating physicians.
A key requirement for ACOs and similar entities is more fully engaging patients in their health-related decisions. Exactly how to achieve patient engagement is still a bit murky, but the essential component is enabling patients to conduct well-informed discussions with a coordinated team of providers about their health, care options, and medical decisions. The expected consequence is that patients who appreciate the more focused and synchronized approach to their care will make informed decisions that benefit both themselves and the overall population. An additional benefit is that a more engaged patient population serves as another layer of patient safety protection.
Of course, a patient’s motivation to be engaged in her care can be counterbalanced by skepticism if she doesn’t perceive a direct benefit. Friends, family and the popular media may influence an attitude that patient engagement is just a new tactic for advising everyone to diet and exercise more often. And, even without any external influence, change may engender frustration or distrust for some patients.
For example, decisions regarding what tests are ordered, what consults or referrals are proffered, and what treatment or medications are recommended, may be challenged. Increased access to medical records may introduce unfamiliar terms or information displays that trigger requests for clarification. How you answer your patients’ questions will be a key aspect of their attitudes toward engagement and a healthy physician-patient relationship.
CRICO, and other organizations are working to identify best practices for aligning patient engagement with patient safety. The better that physicians, and the organizations they’re affiliated with, are informed about risks and enabled by proven solutions, the better equipped you’ll be to help “my mother” become an engaged patient.
Additional Material
Original Source, Strategies for Patient Safety
By Jock Hoffman, CRICO
A recently published study measuring the scope of care in an ambulatory practice (Harvard Vanguard Medical Associates) notes that a typical (full-time) general practitioner annually manages more than 1,100 different diagnoses, medications, lab tests, referrals, imaging studies and procedures; some do many more than that. That is both a testament to the complexity of primary care and a yardstick for the risk inherent in a profession that combines so many variables.
Malpractice claims and suits alleging a diagnostic error in a (non-ED) outpatient setting account for 67 percent of all CRICO cases based on care rendered since 2002. Roughly half of those involve cancer, but more than 50 different types; an additional 50 non-cancer diagnoses make up the other half. For 75 diagnosis-related cases involving Emergency Department patients from the same time period, more than 30 different final diagnoses were listed. Clearly, patient safety cannot focus too narrowly on particular case types but, rather, needs to address the potential pitfalls in the diagnostic process for all patients, especially outpatients.
There is, however, value in applying to a broader set of circumstances, generalizable lessons drawn from a subset of high-severity claims, particularly those alleging a failure to diagnose breast, colorectal, or prostate cancer.
Self-detected symptoms
Whether or not you can detect what the patient has indicated (e.g., breast lump, bloody stool, abdominal pain) he or she expects to be followed to conclusion. Leaving a self-detected complaint unresolved (in the patient's mind) may foster distrust. A subsequent diagnosis may be considered "missed" by a patient who believes he or she wasn't taken seriously from the beginning.
Patient risk factors
An insufficient or outdated history (personal and family) can inhibit risk-stratified screening—and timely referrals for high-risk counseling. Patients may need to be prompted and guided through the process of providing an informative history.
Test results
Following an ordered diagnostic test through to a conclusion requires both the ordering physician and other clinicians involved in the process to confirm that it was conducted, and that the results were interpreted, communicated to all pertinent parties, and discussed with the patient. Unconfirmed assumptions put both patient and providers at risk.
Follow-up
A follow-up plan has to become a follow-up action. Documentation, especially when shared with the patient and family members, helps, but only if it is structured with alerts to missed appointments or milestones.
Referrals
A referral treated as a one-way engagement exposes you and your patients to diagnostic delays if anything alters the intended course of events. Make sure to coordinate a closed-loop communication process with clinical colleagues, and clarify for the patient the roles of each of his or her providers.
Managing expectations
Any doubts you have that you will be able to translate a patient's complaint or symptoms or test results into a concrete diagnosis need to be balanced against the patient's expectations. Sharing the limits of the diagnostic process with a patient may help maintain his or her trust during a period of anxiety, and ultimately protect you against an allegation of substandard practice.
Given the vast amount of information patients expect their physicians to learn, retain, and appropriately apply, those physicians who complement their routines and memory with decision support tools are likely to make fewer missteps along the diagnostic path.
Additional Material
Original Source, Strategies for Patient Safety
By Jock Hoffman, CRICO
Health care constantly intersects with challenging decisions, perhaps none more unsettling than the choice between waiting, or acting on an ambiguous presentation. If the patient is not physically present (e.g., on the phone or emailing), then the provider has even fewer cues to guide that decision. When the remote communication of history, symptoms, and status involves third parties (parent, interpreter, answering service, etc.) the risks associated with making a “wait” or “don’t wait” decision increase significantly. Such situations are even further complicated if the patient (or spouse or parent) is hesitant to leave home for the doctor’s office or the nearest emergency room barring a sense of urgency. Physicians and nurses who routinely have remote care encounters are encouraged to review this case study from a recent CRICO malpractice claim.
Malpractice case studies present an important opportunity for providers to learn by exploring what went right, what went wrong, and what could have been done differently. Although these cases often represent negative and emotionally charged circumstances, positive learning can emerge from examining them. Staff from CRICO’s Patient Safety Department continually select and develop case studies (of closed claims or lawsuits) that offer teaching opportunities. More than 75 such case studies are available on the CRICO web site. Clinician facilitators who choose to incorporate abstracts from malpractice claims into their clinical presentations may want to read the suggestions offered in 10 Tips for Presenting Closed Claims Abstracts for Grand Rounds.
Additional Material
Original Source, Strategies for Patient Safety
By Jock Hoffman, CRICO
For virtually every physician-patient interaction, your patient’s past is prologue to today’s encounter and tomorrow’s care plan. But coordination of care—even over a brief office visit or hospital stay—is as much of a patient safety challenge as is making a proper diagnosis or carrying out a successful treatment. The path of care from the initial complaint to completion of treatment is far from seamless. Indeed, it is full of cracks—opportunities for losing, misdirecting, or misunderstanding critical information—that pose serious risks for the patient and his or her multiple health care providers.
Coordination of care risks can derive from patients you see often for chronic care and for those who you’ve never met (e.g., a patient new to your panel being seen in the ED). Most malpractice cases involving poorly coordinated care are those alleging a missed or delayed diagnosis, commonly due to a mismanaged test result, referral, or hand-off. For 522 cases filed against CRICO insureds from January 2005 to October 2010 with care coordination issues, the following three contributing factors were prominent:
- Mismanagement of test results
(234 cases*/average incurred loss=$1M)
- Mismanagement of referral
(230 cases/average incurred loss=$852K)
- Mismanagement of hand-off or sign-out
(255 cases/average incurred loss=$888K)
Those categories comprise myriad communication and documentation factors that prevent multiple caregivers from having a complete picture of the patient’s status and subsequent care needs. Relying solely on memory—yours or the patient’s—is ill-advised; systems that fail to keep everyone (including future providers) well-informed about past care and future responsibilities are equally inadequate.
At the broad level, CRICO is working with its insured organizations to enhance closed-loop communication of test results and referrals, and improve team communication at key transitions for providers (e.g., hand-offs) and patients (e.g., discharge). For individual physicians and nurses, CRICO and its clinical experts have developed answers to a series of Frequently Asked Questions that address many coordination of care issues.
A quick review might help you and your co-providers keep crucial patient information from slipping between the cracks.
*A single malpractice case may involve more than one factor
Additional Material
Original Source, Strategies for Patient Safety
