Successful Recoveries: The Colorado 3Rs Experience

1. Successful Recoveries: The Colorado 3Rs Experience 2nd Annual Ellison-Pierce Symposium “Positioning Your ORs For The Future” Jerome M. Buckley, MD Former CEO/COB COPIC

2. In your opinion, which is most effective in preventing medical malpractice lawsuits? • Competence • Compassion 0/0

3. How comfortable are you with your malpractice insurance coverage? • Very comfortable • Moderately comfortable • Somewhat comfortable • Not comfortable at all 0/0

4. Today’s Discussions • Real Issue is Patient Safety • COPIC’s 3Rs Program • What it is & Purpose • Why needed & Goals • How it works (Process) • 3Rs Results and Evaluation • Why 3Rs is part of any successful recovery • Perspective of book “Internal Bleeding” by Wachter & Shojania

5. Internal Bleeding(Book by: Robert M. Wachter, MD and Kaveh G. Shojania, MD) • Part 1: The System • Accountability of all stakeholders • Part 2: The (10) Errors of OUR Ways • Legibility • Medication errors • Drug interactions • Wrong side surgery • Leaving things behind • Hand-offs and fumbles • Code Blue/ DNR • Advanced Directives • Communication Issues • Chest pain dilemma All OR Issues

6. Internal Bleeding(Book by: Robert M. Wachter, MD and Kaveh G. Shojania, MD) • Part 3: The Consequences • Medical Liability with/without malpractice • Part 4: The Cures • What doesn’t work (punitive approach) • Proper perspective (mortals in complex systems) • Systems thinking and Proper Culture • Patients • But what if unanticipated event? • What can youdo? (successful recovery)

7. Planned Event- Questionable Informed Consent 4

8. Unanticipated Event andAdverse Outcome 5

9. COPIC’s 3Rs ProgramAn Awareness and Action ProgramA path to a successful recovery • Recognize unanticipated event • Respondsoon after event • Resolveissues related to unanticipated event • Conceived and designed by: • K. Mason Howard, MDFounding Chairman of COPIC • Thomas F. Tucker, M.A.A.A., C.P.C.U.COPIC’s original insurance consultant and consulting actuary

10. COPIC’s 3Rs Program-- What is it? • A Risk ManagementEarly Intervention Program • 3Rs is a non-fault based risk management program designed to: • Meet the patient’s immediate and near term needs • Preserve the patient/physician relationship • Prevent unanticipated medical outcomes from entering the ineffective, inefficient and adversarial legal system • 3Rs is a learning program based on Communication

11. Why a 3Rs Program? • Traditional claims resolution system broken • Ineffective, costly, untimely, and inefficient • Those negligently injured not usually ones properly compensated • Only $1 out of every $3 goes to patient • Expensive: average claim range is $29,000 - $300,000 • Takes 2-7 years to resolve • Adversarial • Patient/Physician relationship is shattered • Not what patients or physicians desire or deserve!

12. Why 3Rs?Some Physicians Get Sued and Others Do Not – Why? • Physicians too often only learn in school/ residency/fellowship to be: • Competent - has all the knowledge • Capable – has all the skill sets -- This was all that was expected/required • Being the best“2C” physician does not always protect you from unanticipated events • Physician then needsotherattributes

13. Why Some Physicians Get Sued and Others Do Not • A “7 C” Physician is Competent and Capable, plus -- • Communicator (effective/patient) • Concerned (truly) • Caring (definitely) • Compassionate (palpably) • Committed (completely) • Value of being a superb “5C” physician =rarely gets sued

14. Why a 3Rs Program? • To preserve and protect the patient/physician relationship • To meet the needs of the patient -- when an unanticipated event occurs • Must have “7C” physicians who • Recognizethe depth and breadth of patient needs • Respond in timely, effective and continual manner to patient and family • Resolve all the consequences of the event as best they can as perceived by the patient

15. COPIC’s 3RsReimbursement Guidelines • Documented related out-of-pocket medical expenses • Reimbursement up to $25,000 • Loss of time from participation in normal activities • Reimbursement up to $100/day or $5,000 maximum • Remember—Patient signs no release and retains the right to sue • 3Rs reimbursed-dollars not reportable to • NPDB since no written demand • CBME since no written release

16. COPIC’s 3Rs ProgramPhysician Expectations • Physician must be enrolled in the 3Rs Program • Reviews material and signs agreement • Attends “enrollment seminar” • Occurs with first unanticipated event • Encouraged to do communication training (may become required) • Mandatory Early Reporting of unanticipated event (Cornerstone) • Could be potential barrier for some states and some companies (but can be overcome)

17. 3RsExclusion Criteria • Written demand for money (NPDB) • Attorney involvement • Death • CBME complaint • Any concerns about substandard care • Referred directly to Claims • If indemnity paid, brought to attentionof CBME and reported to NPDB

18. 3Rs Process • Incident called in to COPIC Risk Management • Risk Management review • Does not meet 3Rs criteria—forward to Claims for incident review • Meets 3Rs criteria --Physician and 3Rs Administrator agree to proceed • Compassionate expressions of Concerned Caring (possible apology) • Explanation of Program (Communicate) • Being there for the patient (Commitment)

19. Evaluation of 3Rs Program10/01/00-12/31/05 (Inception to Date) • Results and associated costs • Patient and physician participantssubjective evaluation summaries and comments • Essence of the actuarial analysis of claims and potential savings • Benefits and Focus Group Findings • Similar Programs

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21. Traditional Claim Resolution 20032005 • Closed Claims/Suits 643 584 • Suits only 237 338 • Average Severity $88,056 $77,936 • Cases closed withno indemnity 505 485 • Average amount paid $29,097$27,980 • Cases closed withindemnity paid 138 99 • Average amount paid $303,326 $258,799 • Cases closed with indemnityand costs greater than $1M $13,758,785 $14,761,538 (7 cases) (6 cases) • 3Rs Average Paid Incident$6,094$5,224

22. After An Incident Is ResolvedFeedback from Subjective Evaluations • Patient and physician complete questionnaire • Physician/Patient relationships almost always still intact • Patient’s evaluations all favorableexcept patient’s perception of most physician’s communication skills not favorable • Physician’s false perception of their own communication skills

23. Actuarial Analysis(Based on Pure Premium Comparisons) • Parameters chosen for objective analysis of potential savings • Number of claims (frequency) • Total dollar cost (of either ALAE, Indemnity or both) • Pure Premium • Equals total $ of cost divided by # of physicians’ exposures • Excludes operational/reinsurance cost

25. 3Rs Program Benefits • Addresses the needs ofthis patient • Information • Emotional support • Financial assistance • Early return to function • Protecting and preserving the patient/physician relationship • Takes nothing from the patient • This patient retains the right to pursue a claim—no signed release • This patient may pursue a complaint to the CBME

26. 3Rs Program Additional Benefits • 3Rs Protecting the Public • Learn from this patient to protect the next patient • Risk Management takes the lessons to other physicians • Entire quality bar raised for all patients • Their doctor took lessons learned, improved the quality of their practice, and became a better 7C physician

27. Unanticipated Events from thePatient’s Perspective • Focus group results from interviews of patients from 3Rs programBy Christine Duclos, PhD. of UCHSC Family Practice Department * • Worries, confusion, frustrations, and anger • Traumas—physical, emotional, financial • Needs—vary immensely by patient and event • Unappreciated, especially the financial • How needs must be individually addressed *International Journal for Quality in Health Care, 2005: pp 1-8

28. 3Rs - Patient Perspective • UCHSC Study • Perceptions reaffirmed • Importance of Concerned Caring/Apology • Make me “whole” again • Value the physician/patient relationship • Patients assured their problem will improve care for the next patient • Learning the importance of eliminating immediate financial concerns

29. Lessons Learned from Patients Financial Confusion No Information or Help Poor Communication ANGER Frustration LegalConsult Financial Trauma Build-up Break In Relationship Social Pressure Emotional Physical 26

30. Other “Similar” Programs • Disclosure programs only: • New Minnesota Hospital disclosure legislation • Minnesota Hospitals – mandatory full reporting disclosure program-27 parameters • Some hospitals have added a “Sorry Works!” approach • http://www.sorryworks.net • Connecticut and New Jersey to follow • Disclosure with only error-driven payment program • Veterans Hospital in Lexington KY(late 1990s) -- as of 2005 now the rule • University of Michigan Medical Center Hospital (2003 – 2005) • Halved the number of pending lawsuits • Reduced litigation costs by $2M annually • The National Medical Error Disclosure and Compensation Act of 2005 • (S-1784, S. Clinton and R. Obama)

31. 3Rs Program Now has 5 Goals • Recognize, Respond andResolve allconsequences of an unanticipated eventin the most timely manner • Improve and preserve the physician patient communication and relationship • Make this patient whole (immediate and near-term needs) • Understanding (communication) • Emotionally (concern/empathy, prevent in future, be there for you) • Physically (do whatever is necessary medically—consults, etc.) • Financially (reimburse for out-of-pocket expenses and lost time)

32. 3Rs Program 5 Goals(cont’d) • Learn and prevent—practice safer, more high quality medicine for next patient • Leave as many $ as possible in the health care delivery system to deliver health care Achieving the first 3 goals with any unanticipated event “will go a long way to” a successful recovery

33. Thank You! Any Questions?