AHRQ program promotes patient safety and liability reform

Medical liability reform efforts traditionally have focused on lowering the cost and increasing the availability of liability insurance for physicians. Caps on awards have been viewed as the key means of addressing these problems. Over the past several years, however, new strategies have emerged for pursuing medical liability reform. These efforts center on improving patient safety and reducing the number of lawsuits against physicians. Patient safety is of the utmost importance, and research shows that increased patient safety is associated with lower rates of liability litigation.¹

In June 2009, President Barack Obama addressed the American Medical Association on the subject of liability reform. The President acknowledged the medical community’s concerns, saying that many physicians “feel like they are constantly looking over their shoulders for fear of lawsuits.”² President Obama also emphasized the importance of patient safety and of creating an environment in which health care professionals could focus on delivering high-quality care, rather than on practicing “defensive” medicine. The President reiterated this message in a September 2009 address to Congress during which he announced that the U.S. Department of Health and Human Services (HHS) would allot $25 million through the Agency for Healthcare Research and Quality (AHRQ) to an initiative promoting patient safety and medical liability reform.

AHRQ action

In preparation for the new endeavor to promote patient safety and medical liability reform, HHS and AHRQ consulted a broad range of experts and stakeholders, reviewed existing evidence, and invited interested parties to submit innovative proposals. The result of these efforts was the launch of the Medical Liability Reform and Patient Safety Initiative. The goals of the initiative were to enhance patient safety, improve physician-patient communications, ensure fair and timely compensation to injured patients, reduce the number of frivolous lawsuits, and cut liability premiums (see Table 1).³

Table 1: Goals of medical liability reform and Patient Safety Initiative Grants³

Make patient safety first; reduce preventable injuries Foster better doctor-patient communications Ensure fair and timely compensation for injured patients Reduce number of frivolous lawsuits Reduce liability premiums

Demonstration grants valued at up to $3 million over three years were announced for the “implementation and evaluation of evidence-based patient safety and medical liability demonstrations.”⁴ One-year planning grants of up to $300,000 were established to fund plans and provide technical assistance for an evidence-based safety and liability demonstration.⁵

The AHRQ reviewed prior safety and liability efforts. Published in December 2009, this effectiveness review was intended to guide the initiative, inform applicants, and help the AHRQ evaluate grant proposals. Based on this analysis, the AHRQ concluded that there was a lack of evidence regarding the impact of liability reforms on patient safety and that the existing evidence suggested that medical errors tended to be infrequently and inaccurately reported.⁶

Grants and results

In evaluating applicants for the grants, AHRQ focused on three “areas of promise”: preventing harm through best practices, improving communication with patients, and promoting alternative methods of dispute resolution.⁴ Across these areas, the AHRQ awarded seven demonstration grants and 13 planning grants (see Table 2). The results of these initiatives have been very promising thus far, as the following examples illustrate:⁷

• Fairview Health Services in Minneapolis, MN, was awarded a demonstration grant to establish perinatal best practices across its 16 hospitals and to assess the impact on patient safety and liability activity.⁸ The program has resulted in a 74 percent reduction in preventable birth trauma to full-term newborns (preventing 30 cases over four years), 38 percent fewer preventable neonatal intensive care unit admissions of full-term babies, and a 12 percent reduction in preventable maternal complications (172 cases prevented over four years).

• Ascension Health system in St. Louis, MO, was awarded a grant to implement a “uniform, evidence-based obstetrics practice model,” with the expectation that eliminating variation in practice would enhance patient safety.⁸ As of February 2012, no liability cases or notices of intent for shoulder dystocia had been filed. Ascension historically would have experienced at least three incidents over the 20-month period since the program was established in July 2010. In addition, rates of reporting breaches in patient safety increased three-fold in that interim, but the severity of reported cases decreased. Finally, fewer birth traumas occurred in the five hospitals included in the initiative.

• The University of Illinois, Chicago (UIC), was awarded a demonstration grant to expand its Seven Pillars Program and to evaluate its impact on liability activity.⁹ The initiative has yielded an 80 percent reduction in time to settle full disclosure cases, a 70 percent reduction in litigation-related costs, and UIC reports that no meritless suits were filed for at least 18 months.⁷ The initiative saved payors, including Medicare and Medicaid, an estimated $3 million annually since 2006.⁷ In all, 20 more hospitals have joined the initiative, even though they received no funding to do so. Furthermore, the initiative seems to have significantly slowed the practice of defensive medicine, reducing the rate of growth in clinical lab orders by 24 percent and radiology orders by 18 percent.⁷

Table 2: Demonstration Grants Awarded (2010) by the Medical Liability Reform and Patient Safety Initiative⁴

Area of promise	Recipient	Proposal
Best practices and patient safety	Fairview Health Services, Minneapolis, MN	Establish perinatal best practices in 16 hospitals to assess the impact on patient safety and the level of malpractice activity
	Ascension Health system, St. Louis, MO	Create uniform, evidence-based obstetrics practice model; expect that eliminating variation in obstetrical practice improves patient safety
Improved provider-patient communication	University of Illinois at Chicago	Build on Seven Pillars Program; expand existing disclosure program and evaluate impact on malpractice activity
	University of Washington, Seattle	Develop statewide initiative involving communication training for health care workers; collaboration between hospitals and a malpractice insurer to improve adverse event analysis, disclosure, and compensation
	University of Texas Health Science Center, Houston	Establish disclosure and compensation model; identify and disseminate best practices for disclosure to improve patient safety; focus on incorporating patient and family input into root cause analysis
	Massachusetts State Department of Public Health, Boston	Engage clinicians, patients, malpractice insurers, and the state public health agency to ensure more timely resolution of medical errorsIdentify key areas contributing to ambulatory medical errors and malpractice in a group of Massachusetts primary care practicesPromote patient-centered communication
Alternative dispute resolution	New York State Unified Court System, New York	Protect obstetrical and/or surgery patients from injuries caused by providers’ mistakesReduce the cost of medical malpractice through an expanded and enhanced judge-directed negotiation program, coupled with a new hospital early disclosure and settlement model(See article describing the New York State AHRQ project)

Current status and future directions

Currently, planning grants are near completion and demonstration grants are beginning their third and final year. Grants are on target to accomplish their aims. James Bell Associates, Inc. and the RAND Corporation intend to release a comprehensive evaluation of the initiative later this year. This report will assess the effects of interventions on patient safety, patient-provider communication, liability premiums, the timeliness and fairness of compensation, and the number of lawsuits filed.

Table 3: Planning Grants Awarded (2010) by the Medical Liability Reform and Patient Safety Initiative⁵

Theme	Recipient	Initiative
Safe harbors and evidence-based practice guidelines	Office for Oregon Health Policy and Research, Portland	Set priorities for evidence-based practice guidelines. Create safe harbor legislative proposalConduct effectiveness analysis (if applicable)
Shared decision making	University of Washington, Seattle	Develop shared decision-making tools and processes for orthopaedic surgery patientsEmpower patients through knowledge
Quality of care monitoring	Washington State University, Pullman	Develop best practice medication risk-management systems that can be integrated into transitional careMaximize safety, quality, and cost-effectiveness while reducing medical liability
	North Carolina State/Department HHS, Raleigh	Establish near-miss reporting and improvement tracking system in primary careIncrease providers’ confidence and experience disclosing errors to patients
	Johns Hopkins University, Baltimore, MD	Monitor the quality of care at hospital dischargeIdentify safety concerns and notify leaders in real time
	Multicare Health System, Tacoma, WA	Plan for an integrated medical liability and patient safety programIdentify avoidable patient safety problemsProvide acknowledgement, apology, and standardized compensation
	Sanford Research, Sioux Falls, SD	Create infrastructure for a patient advocacy reporting systemCollect information on patients’ and families’ concernsIdentify individual physicians and system components at disproportionate risk for unsafe care and possible lawsuits
	Jackson Memorial Hospital, Miami, FL	Reduce patient suicidesConduct surveys and focus groups to determine how medical liability can be restructured
	Ohio State University, Columbus	Establish statewide pregnancy-associated mortality review systemRecommend interventions to reduce maternal mortality and disparities
Early disclosure and offers	University of Utah, Salt Lake City	Set policy and protocol for disclosure to patients and families
	Beth Israel Deaconess Medical Center, Boston, MA	Develop disclosure-and-offer patient safety initiative in MassachusettsCreate new medical liability system to improve trust, reduce fear, and improve patient safety
Improved communication following preventable injuries	Carilion Medical Center, Roanoke, VA	Foster improved teamwork and communication among providers and with patients
	Wishard Health Services, Indianapolis, IN	Collect, analyze, and evaluate data regarding claims management modelPromote open communication and identify risk-prone areas

Conclusion

These types of patient safety and liability reforms are so important. Poor clinical outcomes harm patients and physicians. Lawsuits cause pain and suffering for all parties involved, and physicians often describe themselves as “forever changed” by the experience. It is truly fair to say that when patient safety improves, everyone benefits: patients, clinicians, and the public.

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References

1. Greenberg MD, Haviland AM, Ashwood JS, Main R. Is better patient safety associated with less malpractice activity? 2010. RAND Corporation. Available at: www.rand.org/content/dam/rand/pubs/technical_reports/2010/RAND_TR824.pdf. Accessed January 8, 2013.
2. President Obama’s speech to American Medical Association. USA Today. 2009. Available at: http://usatoday30.usatoday.com/news/washington/2009-06-15-obama-speech-text_N.htm. Accessed January 8, 2013.
3. U.S. Department of Health and Human Services. Agency for Healthcare Research and Quality. Medical liability reform and patient safety: Demonstration and planning grants. 2012. Available at: www.ahrq.gov/qual/liability/. Accessed January 8, 2013.
4. U.S. Department of Health and Human Services. Agency for Healthcare Research and Quality. Medical liability reform and patient safety: Demonstration grants. 2010. Available at: www.ahrq.gov/qual/liability/demogrants.htm. Accessed January 8, 2013.
5. U.S. Department of Health and Human Services. Agency for Healthcare Research and Quality. Medical liability reform and patient safety: Planning grants. 2010. Available at: www.ahrq.gov/qual/liability/planninggrants.htm. Accessed January 8, 2013.
6. Hellinger F, Encinosa W. Review of reforms to our medical liability system. 2009. U.S. Department of Health and Human Services. Agency for Healthcare Research and Quality. Available at: www.ahrq.gov/qual/liability/reforms.htm. Accessed January 8, 2013.
7. AHRQ-funded medical liability and patient safety initiative shows promise for reducing patient harm, lawsuits, and costs. 2012. Available at: www.ahrq.gov/research/sep12/0912ra1.htm. Accessed January 8, 2013.
8. Medical Liability Reform and Patient Safety Initiative Progress Report. February 2012. Rockville, MD: Agency for Healthcare Research and Quality. Available at: www.ahrq.gov/qual/liability/medliabrep.htm. Accessed January 8, 2013.
9. McDonald TB, Helmchen LA, Smith KM, Centomani N, Gunderson A, Mayer D, Chamberlin WH. Responding to patient safety incidents: The “seven pillars.” Qual Saf Health Care. 2010;19(6):e11.