CRICO Strategies Publishes New Benchmarking Report
On February 12, 2019, CRICO Strategies, a division of Harvard’s Risk Management Foundation (see footnote below), released its annual benchmarking report entitled, “Medical Malpractice in America – a 10-Year Assessment with Insights.” The Report analyzes 124,000 medical professional liability cases from 2007 to 2016, representing 30% of the total MPL claims in the nation.
As your professional liability carrier, MIEC is determined to bring insight and actionable data to our members to improve patient safety and reduce both the number and cost of medical professional liability (MPL) claims. CRICO Strategies’ output is one of the most definitive sources available for MPL claims data. MIEC was one of the first MPL carriers to partner with and submit data to CRICO, because we recognize that actionable data demands the biggest possible pool to develop insights.
We all realize that, as we expand the data pool, the insights become potentially less valuable for any one specialty. However, over time, if organizations like ours participate in adding to the data pool, trends for specialties can and do emerge (see the report’s discussion on OB/GYN claims frequency). These trends and patterns help MIEC determine our course of action to achieve our shared goals of improved patient safety and fewer and less expensive claims in the future.
Andy Firth, MIEC President
Key Findings of the Assessment:
- Over the 10 years of the study, frequency of total MPL claims decreased by 27%, from 5.1 claims to 3.7 claims per 100 physicians. This change was reflected across many segments of health care delivery.
- OB/Gyn (whose frequency historically has been higher than other specialties) experienced a 44% decrease in cases filed against clinicians, 10.8 cases per 100 physicians to 5.1 claims.
- Medical (nonsurgical) specialties experienced a modest decline of 29% in case frequency.
- Surgical specialties experienced a 23% decline.
- The cost to manage cases (with or without indemnity payment) steadily increased and outpaced the rate of inflation.
- Expenses for cases closed with no indemnity payment grew at the greatest rate. Expenses increased at an average rate of 4.7% annually, outpacing cases with indemnity payment under $1 million (1.4% growth) and cases over $1 million (1.3% growth). (Page 7)
- Average indemnity payments for all cases increased modestly (3.3% annually), just above CPI and just below the rate of medical inflation.
- Cases with payments of over $1 million experienced greater increases; indemnity payments in $1-3 million cases increased by 4.4%, and payments in $3-11 million cases increased by 7.9%. (Page 9)
- The number of cases with $1 million+ in indemnity payments grew at an annual rate of 4.4%.
- 72% of surgery-related cases involved medium or low-severity injuries.
- 63% of cases alleging a diagnostic error involved high-severity injuries (significant permanent injury or greater).
- High-severity injury cases were 41% more likely to result in an indemnity payment.
- Permanent severe injury cases resulted in average indemnity payments almost twice the average payment for cases involving deaths. (Page 10)
- CRICO Strategies divided cases into three categories: surgical, medical, and diagnosis-related. Surgical cases accounted for 28% of all analyzed claims, followed by medical cases at 24%, and diagnosis-related claims at 21%.
- Diagnosis-related claims were associated with the highest average indemnity payment of all three categories ($472,000) and the highest percentage of claims closed with payment (35%). (Page 13)
- Surgery-related cases dominated case volume and total losses, despite having the lowest average indemnity payment ($351,000).
- A rise in the number of surgical procedures and obstetric deliveries seems to point to an increased case rate. CRICO Strategies analysts surmised that the increase in the per patient case rate could indicate greater risks in larger capacity settings, and are “possibly a result of a more complex patient mix.” (Page 16)
Surgery cases per 10,000 procedures Ob/Gyn cases per 10,000 births
Surgeries per year Case Rate Births per year Case Rate <10,000 1.5 <1,000 3.5 10K -20K 2.9 1K-2K 6.8 20,000+ 4.2 2,000+ 9.5
- One of CRICO Strategies’ greatest contributions to the MPL conversation is the organization’s focus on the building of a taxonomy that captures and classifies critical factors that trigger litigation and/or impact outcome.
- CRICO Strategies’ contributing factors identify vulnerabilities in several categories. Three main overarching classifications that significantly impacted the 124,000 claims in the 10-year Assessment are: clinical judgment, technical skill issues, and breakdowns in communication.
- Drilling down further in clinical judgment, insufficient patient assessment (e.g., inadequate history and physical) was present in 35% of ambulatory care cases, 38% of inpatient care cases, and 65% of emergency department cases. Selection and management of therapy (e.g., failure to order proper tests, improper medication, inappropriate procedures) was a factor in 20%, 29% and 21% of ambulatory, inpatient, and emergency department cases, respectively.
- Improper technical performance impacted 36% of ambulatory care and 39% of inpatient care
- Poor communication with patients and their families (e.g., inadequate consent) was a contributing factor in 22% of ambulatory care, 15% of inpatient, and 15% of emergency department cases. Communication issues between providers impacted 11% of ambulatory, 18% of inpatient and 19% of emergency department claims.
Diagnostic Process of Care (POC):
- CRICO Strategies has divided the Diagnostic Process of Care into 12 steps and three phases: Phase 1) Initial Diagnostic Assessment; Phase 2) Testing and Results Processing; and, Phase 3) Follow up and Coordination. (Page 20)
- Mapping the Contributing Factors (outlined above) to the 12-step POC, 91% of the cases were identified with breakdowns within one, two or more of the three phases; 68% of the cases had a misstep in patient assessment.
- The majority of the 6,700 ambulatory diagnostic cases involved errors in two or all three of the POC phases.
- “Clinician overreliance on cognitive and intuitive skills can narrow the diagnostic focus, obscuring contrary signals, inhibit test or consult orders, and limit their ability to interrupt a cascade of missed opportunities.” (Page 21)
Allegation type: Failure or delay in diagnosis
Phase 1: Initial diagnostic assessment
68% of cases; 79% of losses
Phase 2: Tests and results
32% of cases; 38% of losses
Phase 3: Follow up and coordination
54% of cases; 61% of losses
Breakdown in phases and odds of case closing with payment
Breakdown in one phase: 4.32
Breakdown in two phases: 7.26
Breakdown in three phases: 9.33
High severity injury jumps from 1.99 to 5.13
PSRM Efforts to Address Error and Injury
The report draws the reader’s attention to several patient safety and quality improvement initiatives that have contributed to fewer MPL cases including:
- Training to improve team communication during labor and delivery;
- Multidisciplinary education on fetal heart rate tracings;
- Efforts to “close the loop” for test results and referrals may be gaining traction;
- Surgical initiatives that focus on a more holistic pre-op assessment, patient-centered informed consent, simulation-based drills, timeouts, debriefs, and teamwork training;
- Strategies to expedite claim resolution (e.g., communication and resolution programs);
- Root cause analysis of high-severity claims; and,
- Widespread attention to the mitigation of diagnostic error claims.
Click here to obtain a obtain a copy of the full report from CRICO Strategies.
A link to the recorded webinar discussing the report’s findings can be found here.
Footnote: Founded more than 40 years ago, the CRICO insurance program insures all of the Harvard medical institutions and their affiliates, providing coverage to 26 hospitals, 13,500 physicians, more than 300 other health care organizations, and in excess of 100,000 other clinicians and employees. In 1979, The Risk Management Foundation of the Harvard Medical Institutions Incorporated (RMF) was established to, among other things, implement a data-driven approach to reducing medical error through clinical analysis of malpractice claims.
National partnerships allow analytic insights to be shared across the country through the CRICO Strategies division of RMF. By partnering with captive and commercial insurers across the country, Strategies created a national Comparative Benchmarking Database (CBS) for shared learning. CBS now represents approximately one-third of all U.S. MPL claims, including those of CRICO’s Harvard affiliated members, as well as MPL data from Strategies partners across the country. This extensive database allows for individual and competitive analysis based upon a common coding taxonomy. As a result, health care leaders can identify vulnerabilities and mitigate risks through targeted patient safety initiatives. Leveraging this clinical analysis, learnings related to medical error inform patient safety initiatives, helping to transform mishap into opportunity.