UMass Memorial Healthcare is the largest healthcare system in central Massachusetts, comprised of three hospitals across four campuses and seven office-based community practices. We had the opportunity to hear from Janell Forget, AVP Risk Management and Timothy Slowick, Director PL/GL Claim Management at UMass Memorial Health Care in October at Virtual Connections 2020 –– North America edition.
This engaging presentation shed light on how medical malpractice data can help healthcare organizations better analyze their litigation practices, trend financial outcomes and identify clinical services that can be improved. In this article, you’ll learn about the organization’s efforts to link their risk and claim teams and how this process provides valuable takeaways to improve patient safety.
Claims and Risk Departments: Journey to Collaboration
Prior to 2015, collaboration between UMass Memorial Healthcare’s risk and claims department occurred on an ad hoc basis. Risk management departments at all locations were using a separate reporting structure, had separate goals and reported up to a variety of different entities. While each site had unique areas of excellence, there was little collaboration between them. And while these sites had a positive relationship with the organization's claims team, there was an overall fear of reporting which resulted in a delay of adverse event reporting. Claims spent designated time with the organization’s risk management sites twice a year, but this infrequency made it difficult to develop rapport and effectively examine and provide feedback on processes at each site.
The organization’s focus in 2015 was to drive system-wide collaboration between the risk and claims departments. These efforts started with aligning the risk and already system-wide claims teams. One of Janell‘s first steps involved equipping risk managers with system level responsibilities. For example, if a safety event occurred in the radiology department, the risk manager assigned to that department would be responsible for taking the necessary steps to investigate that specific event, regardless of where the event occurs across the health system. UMass’ next step was to identify, based on their safety event data provided by RLDatix, where safety events were occurring and how to tailor their internal education to better support these areas.
To further the link between the organization’s risk and claims departments, the organization created monthly meetings between claims and risk to review new claims and lawsuits, review new regulatory matters, discuss observation “focus” files and discuss current issues under investigation.
The Impact of System-Wide Collaboration
As a result, UMass has observed an increase in day-to-day interactions between the risk and claims staff. Risk managers now submit Potentially Compensable Events (PCE) into the claims database, allowing them to have a better understanding of the organization's claims process and assessment severity.
Timothy highlighted UMass’ incredible results from their reorganization of departments and robust collaboration between claims and risk. On a quarterly basis, the claims department looks at their “Known Percentage,” which encompasses the new claims and lawsuits that are filed and what percentage the organization knew about the claim prior to it being filed. Visibility into known claims and lawsuits has allowed the organization to positively impact their insurance program performance and they have seen a general trend upwards for their known percentage. Results for the second and third quarter of 2020 indicate that UMass has had a 100% known percentage of claims and lawsuits.
UMass’ risk management department helps the organization limit its financial exposure with early investigation of potential claims before they become a claim or lawsuit, helping inform relevant personnel with the information they need to intervene earlier to reduce liability and premiums. Utilizing key data within various reports such as the organization’s average indemnity payment, closed without payment percentage, average allocated loss adjustment expense and average initial reserve, the organization can now analyze and share data to identify risk factors and implement corrective actions. Additionally, Risk management’s involvement in apology disclosure has also helped limit UMass’ claims, lawsuits and legal expenses.
Targeted Education at UMass Memorial Health
The presentation highlighted the organization’s improved education efforts around PCE, claim and lawsuit experience for a specific department. UMass takes data from these categories and trends it with data from their safety event reports. Based on the results, the risk management department can then formulate specific education for those departments which includes case studies that speak to the issues staff are encountering.
Annual Grand Round sessions serve as another way to create meaningful and engaging education experiences at UMass. The organization selects a topic at the beginning of the year and the session is then open for all departments to attend. These education opportunities have been pivotal in building strong relationships between the risk management department and frontline staff which has resulted in an increase in engagement with education initiatives and greater visibility for the claims department. In some organizations, risk management is viewed as a team that is only present when there are problems occurring on the frontlines. Since the realignment of UMass’ risk department, the risk team now works with the claims department earlier in the process and is viewed as a resource to staff, a key group of people staff can go to with questions or concerns.
Case Study Overview: An Obstetrics/Gynecology Process Improvement Strategy
The power of UMass’ medical malpractice data and robust training is most evident in a case study outlined in Janell and Timothy’s presentation, covering the organization’s obstetrics and gynecology department. In 2012, the organization noted that the OBGYN department’s claim and suit data was an outlier. Part of UMass’ process improvement strategy involved obtaining funding through the organization’s risk management grant program to target initiatives within the OB department.
Upon review, the organization identified key issues underlying the claims in this area. These issues were broken down into four major categories:
Communication and Teamwork
Failure to Recognize/Assess/EFM
Hand offs and oversight
Based on these findings, UMass created targeted education to address and improve each of these issues–– below you will find information on a few of the key education initiatives that UMass has implemented as a result of the review.
To improve communication efforts within the department, UMass implemented Team STEPPS, a standardized communication and teamwork model developed by Agency for Healthcare Research and Quality (ARHQ). To further support communication, family practice/obstetrical simulation sessions were developed based on data and information provided by the claims and risk management departments.
UMass introduced the program GNOSISS, an online learning platform, to address staff members’ shortcomings when recognizing and assessing EFMs. These trainings include content on intro to fetal heart monitoring, fetal assessment monitoring and more. All new providers at the organization must take the EFM module and residents must complete the EFM on an annual basis.
Mislabeled specimens were an issue that the organization faced without having an electronic medical record system that could provide barcoding or double check verification. Prior to implementing EPIC, UMass utilized a scanning system called Lattice, a bar code labeling system for laboratory testing and blood administration. With the EPIC Rover system, the organization can now barcode for specimens at the bedside in the presence of a patient. This helps reduce the risk of specimens being put in an incorrect location.
The underlying issues around lack of hand-offs and oversight stemmed from a lack of structure and process resulting in inconsistent practice of formal handoffs between UMass’ Family Practice and the OB department. This occurred when patients required more specialized care during labor. To help reduce these occurrences, the organization created simulation scenarios focusing on proper hand offs during emergent cases. EPIC’s secure chat was also utilized for real time conversation between frontline staff about patients. On an education front, chain of command policy education was integrated into the organization’s simulation training for both physicians and nurses.
Following these steps and initiatives that were put in place in 2012, the organizations saw no OB claims or lawsuits between 2013 and 2015, 2019 and no cases have been reported in 2020. Cases reported in 2016 and 2017 were identified as a different type of case in that the obstetrical exposure was relative to patients who were coming in for a labor check. In response, UMass instituted new, tailored education around this issue.
The Future of Claims and Risk Collaboration
The claims and risk teams at UMass are continuing to look for ways to build upon their safety efforts by utilizing claims, coding, events and national trends data. Janell and Timothy concluded their presentation with what they feel are the underlying critical elements that support a successful claims and risk management program including:
The ability to access claims data within RLDatix to compare your data on a wide scale to get a true measure of where you stand
Development and maintenance of trusting relationships between risk managers and clinical staff
Ongoing rapid cycle review of data to effectively target and focus on specific initiatives
At least an annual review of data to develop key topics for general education
Through consistent collaboration, utilization of claims data and comprehensive education, the risk and claims teams at UMass Memorial Healthcare have had the unique opportunity to develop initiatives, rooted in data, that ultimately support patient safety and improved care.
Interested in learning more from Virtual Connections 2020? Check out our recap of Beaumont Health’s presentation on their journey to effective policy management!