The same risk management initiatives that head off medical malpractice also can enhance clinical practices, improve patient outcomes and reduce expenses of care, according to a new report based on
10 years of tracking such efforts.
The report concludes that these initiatives work best when they combine clinical monitoring procedures with focused collection and analysis of performance data. The results are then plowed back into the education of caregivers and the process of care.
That collection of data can determine how well the risk management initiative is working. But just as important, it also can uncover emerging risks that otherwise might not be countered until adverse outcomes begin to show up, according to the report from MMI Cos., a Deerfield, Ill.-based risk management and malpractice insurance firm.
For example, data collected from the company's participating hospitals have detected a recent increase in the premature-birth rate and neonatal death rate at healthcare organizations with "Level I" services for newborns, the most basic level.
That may indicate a trend toward avoiding top-of-the-line "Level III" facilities at tertiary hospitals for cost reasons-a trend that's backfiring, according to the report.
Statistical confirmation. The primary goal of the risk modification process is a lower incidence of malpractice claims. The report issued by MMI recorded reductions in losses for what it said are three of the most costly and visible areas of healthcare liability: perinatal, anesthesia and emergency services.
About 400 client organizations were included in the analysis of risk modification programs in those three areas dating back to 1985. Results were compiled using a three-year rolling average between 1989 and 1994.
According to the report, liability losses were reduced during that period by 16% for perinatal services, 31% for anesthesia services and 9% for emergency services.
Those results were "statistical confirmation that the extent of participation in a program of educational, consultative and informational risk modification activities is significantly associated with a decrease in the number of liability claims," said G. Eric Knox, M.D., MMI's medical director.
Along the way, 110 organizations that continuously participated between 1990 and 1994 were reviewed to determine the outcomes accomplished over time, said Dorothy Berry, assistant vice president of healthcare information services for MMI's risk management resources division.
The review showed reduction in some of the key adverse outcomes associated with perinatal and anesthesia services.
The rate of anesthesia-related deaths and cardiac arrests in operating and recovery rooms declined 40% to 5.8 per 10,000 anesthetics administered in 1993, compared with 9.9 in 1986.
There also was a 30% reduction in the rate of low assessment scores for infants five minutes after birth. The assessments, called Apgar scores, measure a handful of vital signs and are a key indicator of breathing difficulty, the report said.
Low scores indicate an infant was under stress during labor and delivery and may not have gotten enough oxygen, said Pamela Lockowitz, senior vice president of healthcare consulting services for the risk management division.
Ounce of prevention. The campaign to reduce neonatal liability losses and improve outcomes hinged on early assessment of problems, Lockowitz said. Pivotal to that assessment was the introduction of fetal monitoring as soon as the mother-to-be walked in the door to the delivery area.
For liability purposes, it established a baseline condition including problems that existed before the hospital got involved, Lockowitz said. For clinical purposes, it raised awareness and got clinicians involved earlier to head off more serious problems.
MMI found that healthcare organizations likely were monitoring the mother right away but weren't monitoring the fetus. By 1993, according to the report, virtually all participating organizations were doing a "fetal well-being assessment" as one of their first responses to a woman in labor. However, according to the National Center for Health Statistics, less than 80% of facilities nationwide did such an assessment in 1993.
In anesthesia services, the 40% reduction in complications paralleled the widespread introduction of monitoring technologies in the operating room, including continuous pulse oximetry-a way to assess blood oxygen levels-and a carbon-dioxide monitor that confirms whether a tube is correctly threaded into a patient's trachea.
The report said low levels of oxygen and improper tube placement can cause oxygen deficit, central nervous system damage, heart attack or death.
Danger signals. The company's program for anesthesia management was revised in 1993 to cover anesthesia wherever it's administered, recognizing that surgery is moving to outpatient sites and often involves sedation for minimally invasive procedures in which patients are conscious.
It found that the same monitoring practices used effectively in operating rooms weren't being carried over to other settings.
Healthcare organizations were 10 times as likely not to continuously monitor blood-oxygen levels of inpatients elsewhere in the hospital. The rate at which monitoring was not provided in outpatient and ambulatory settings also was much higher than in the operating room (See chart).
The report said the trend was an early indicator that proven risk management practices weren't being followed in a growing new sector of surgery and anesthesia.
Another alarming trend turned up in neonatal care, in which the premature birth rate in Level I institutions shot up in 1994 after remaining relatively constant for nearly a decade. A rise in the neonatal death rate accompanied that upturn (See chart).
The report said it was too early to tell whether these increases signaled the beginning of a trend or were onetime events, but it added that "the potential for increased liability must be recognized and managed."
If the trend was brought on by market forces inhibiting transfer of women in labor to a more fully equipped Level III facility, the move may be costing more in the long run, the report said.
According to figures it cited from the Perinatal Consulting Group, the average cost of a normal birth in a tertiary facility was $762 in 1993. The cost was $1,198 if a normal newborn was transferred to the tertiary facility after birth.
A premature infant's care in the tertiary setting was $50,000. But the bill for transferred premature infants was higher at $54,000.
The disparity was bigger for infants with birth asphyxia, or breathing difficulty. It cost $22,000 to care for such infants born at the facility, but $42,000 for those transferred after being born somewhere else.
Besides costing more for remedial care, the surge in premature-infant care at lower-level facilities also risks bigger losses in court, Berry said. "When things go wrong in obstetrics, they go very wrong," she said.
MMI recommends that high-risk babies not only should be cared for at a Level III tertiary facility but that it's better to transport the mother before the birth than to transport the baby afterward, Lockowitz said.