Abstract
Background
Methods
Findings
Conclusions
Introduction and Background
- •Promotes safe, high-quality maternity care consistent with best evidence, and minimizes avoidable harm;
- •Minimizes maternity professionals' liability-associated fear and disaffection;
- •Avoids incentives for defensive maternity practice;
- •Fosters access to high-value liability insurance policies for all maternity caregivers;
- •Responds appropriately when women and newborns sustain injury;
- •Assists families with responsibility for costly care of infants and women with long-term disabilities in a timely, efficient manner; and
- •Minimizes legal and administrative costs (Sakala et al., 2013a).
Methods
Results
Interventions | Aims | ||||||
---|---|---|---|---|---|---|---|
↑ Safe, High- Quality Care | ↓ Clinician Fear, Distress | ↓Defensive Practice, Practice Variation | ↑ Public Interest Liability Insurance | ↑ Appropriate Response to Injury | ↑ Help for Infants, Women With Disabilities | ↓ Legal and Administrative Costs | |
Prevention strategies | |||||||
Quality improvement | + | + | + | (+) | (+) | (−) | + |
Enterprise liability | (+) | (+) | (+) | (+) | (+) | ? | (+) |
Leverage of health insurance, accrediting, credentialing, etc. | (+) | (+) | (+) | (+) | (+) | (−) | (+) |
Shared decision making | (+) | (+) | (+) | (+) | (+) | (−) | (+) |
Aligning legal standard with best evidence | (+) | (+) | (+) | (+) | (−) | (−) | (+) |
Liability insurance coverage regulation | (+) | ? | ? | (+) | (−) | (−) | (−) |
Redress strategies | |||||||
Disclosure, empathy, apology | (+) | ? | ? | (+) | (+) | (+) | (+) |
Health courts | (+) | ? | ? | ? | (+) | (+) | (+) |
Administrative compensation systems | (−) | ? | ? | ? | + | + | + |
High-low agreements | (−) | (−) | (−) | (−) | (+) | (+) | (+) |
Prevention: Quality Improvement—A Health Care Reform
- •Over the first decade of its system-wide maternity care QI program, the nation's largest hospital system reduced its primary cesarean rate, improved maternity outcomes, reduced its obstetric malpractice claim rate by two thirds, and brought its cost of claims below costs for “accidents on hospital grounds” (Clark et al., 2011;Clark, 2009b;Clark et al., 2008).
- •In its 16 hospitals with maternity units, a health system evaluated its liability history and implemented patient safety programs. Over a 5-year period, birth trauma decreased from 5.0 to 0.2 per 1,000 births, birth-related occurrences that could lead to a claim decreased from 7.2 to 2.5 per 1,000 births, the average cost per claim decreased from $1 million to less than $500,000, and the number of new claims decreased by 48% (Simpson et al., 2009).
- •Reviewing liability claims, a health system identified maternity care as having the greatest potential for improving patient safety. After implementing a protocol-driven electronic system that monitors adherence to standards of care and provides real-time alerts, the four participating hospitals improved targeted quality measures by 25% and learned from near misses. Within 3 years, the system recouped costs of investing in and operating the system through reduced self-insurance funding. It experienced large declines in actual compared with expected frequency and severity of claims and a claim-free period of 15 months for the 2007 loss year (Smith and Berry, 2007).
- •In the seventh year of implementing a comprehensive patient safety program, a tertiary academic referral center achieved a 99.1% decrease in obstetric liability payouts relative to the average of the first 3 years. On average, in the 3 most recent years, the center saved over $25 million annually relative to average payouts in the initial four years. Sentinel events fell to zero in the 2 most recent years, with similarly favorable results for several severe adverse events, and a very favorable outlook for future payouts (Grunebaum et al., 2011).
- •A safety net tertiary care center implemented a multifaceted labor and birth safety program over 5 years. The number of claims that its insurance companies reserved for financing possible legal expenses declined about 20% annually. The center experienced no claims during the four most recent years, with about 2,400 births annually (Iverson and Heffner, 2011).
- •A risk insurance company and risk management foundation affiliated with a major university instituted a premium discount program for maternity providers who complete specific patient safety activities, and found that "early results show a drop in malpractice claims frequency and a downward trend in adverse outcomes" (McCarthy, 2007).
- •In a multivariable analysis, investigators found a strong correlation between changes in Patient Safety Indicator event counts and changes in the volume of claims against obstetrician-gynecologists at the county level in California from 2001 to 2005; Patient Safety Indicator event count changes accounted for about 30% of the variance in malpractice claims (Greenberg et al., 2010).
Strategy | Role in Maternity Care |
---|---|
Using national standardized safety measures, “Safe Practices” and “Serious Reportable Events,” to measure, report, and improve performance | National Quality Forum, 2010a , National Quality Forum, 2010b |
Using national standardized perinatal care quality measures and adverse event reporting systems to measure, report, and improve performance | Hibbard et al., 2003 ; Levinson, 2008 ; Main, 2009 ; National Quality Forum, 2012 |
Implementing payment reform to align incentives with quality | Center for Healthcare Quality ; Hyman and Silver, 2005 , Hyman and Silver, 2006 ; James and Savitz, 2011 ; Lantos, 2010 ; Rosenthal et al., 2009 |
Implementing maternity care quality improvement collaboratives or maternity-focused programs within broad-scope collaboratives | Childbirth Connection, 2012c ; Childbirth Connection. (2012c). Quality improvement toolkits. Available at: http://transform.childbirthconnection.org/resources/toolkits/. Main and Bingham, 2008 |
Implementing focused toolkits to improve practice | Childbirth Connection, 2012b Childbirth Connection. (2012b). Maternal and perinatal care quality collaboratives. Available at: http://transform.childbirthconnection.org/resources/collaboratives/. |
Implementing medication safety systems, including focus on common “high-alert” medications (synthetic oxytocin, narcotics/opioids, epidural or intrathecal medications) | Clark et al., 2009 ; Institute for Safe Medication Practices, 2008 ; Keohane and Bates, 2008 |
Reducing unwarranted overuse of interventions that are associated with sentinel events and serious maternal and newborn morbidity, including cesarean section and labor induction | Elkamil et al., 2011 ; Gilbert et al., 2010 ; Kramer et al., 2006 ; Marshall et al., 2011 ; Martinez-Biarge et al., 2012 ; Mercer et al., 2008 ; Murray et al., 2009 ; Silver, 2010 ; Silver et al., 2006 ; Vardo et al., 2011 |
Implementing shared decision making using high-quality, up-to-date decision aids | Dugas et al., 2012 ; Frosch et al., 2011 ; Say et al., 2011 ; Stacey et al., 2012 |
Developing systems for effective patient-centered informed consent processes, consistent with the predominant “patient” standard of informed consent and childbearing women's desire for information prior to consent | American College of Obstetricians and Gynecologists, 2005 ; Declercq et al., 2006 ; Matiasek and Wynia, 2008 ; National Quality Forum, 2005 ; Studdert et al., 2007 |
Harnessing potential of electronic health records to foster access to full and accurate documentation and data collection and to support appropriate care | Bernstein et al., 2005 ; Cusack, 2008 ; Eden et al., 2008 ; George and Bernstein, 2009 ; Haberman et al., 2009 ; Nielsen et al., 2000 ; Quinn et al., 2010 |
Building effective teams, improving interpersonal relationships and communication and strengthening collaborative practice | Hickson and Entman, 2008 ; Lyndon et al., 2012 ; Lyndon et al., 2011 ; Mann and Pratt, 2008 ; Merién et al., 2010 ; Nielsen and Mann, 2008 ; Pratt et al., 2007 ; Williams et al., 2010 |
Implementing high-reliability practice that aligns care with best evidence and reduces practice variation, including use of clinical decision support, protocols, explicit evidence-based guidelines, checklists, etc. | Clark et al., 2011 ; Clark et al., 2008 ; Clark et al., 2007 ; Fausett et al., 2011 ; Grobman et al., 2011 ; Hasley, 2011 ; Knox and Simpson, 2011 ; Pettker, 2011 |
Implementing quality of care peer review systems (e.g., American College of Obstetricians and Gynecologists Voluntary Review of Quality of Care) | Lichtmacher, 2008 ; Stumpf, 2007 |
Using laborists (maternity care hospitalists) for labor and birth care, which may foster retention of core knowledge and skills, high intrapartum competence, on-site provider presence throughout labor, appropriate use of interventions to control onset of or hasten labor, better maternal experience, better health professional satisfaction | Devoe, 2009 ; Gussman, .; Gussman, D. (n.d.) Hospitalists review essay. Available at: oblaborist.org/studies.php. Srinivas and Lorch, 2012 |
In education programs, renewed focus on teaching fundamentals of intrapartum care and common standardized terminology | Cohen and Schifrin, 2007 ; Devoe, 2009 |
Taking safety and emergency preparedness courses, including Advanced Life Support in Obstetrics, Managing Obstetrical Risk Efficiently, Managing Obstetric Emergencies and Trauma, and PRactical Obstetric MultiProfessional Training | Beasley et al., 2005 ; Childbirth Connection, 2012a ; Childbirth Connection. (2012a). Maternal and newborn care quality and safety courses. Available at: http://transform.childbirthconnection.org/resources/safetycourses/. Draycott et al., 2008 ; Grady et al., 2007 ; Milne and Lalonde, 2007 |
Using simulation to build skills, knowledge, and teamwork and to prepare for emergencies | Fisher et al., 2011 ; Gardner and Raemer, 2008 ; Gardner et al., 2008 ; Merién et al., 2010 |
Creating a plan for respectful management of serious adverse events, integrating into organization's culture of quality and safety, and implementing it as needed | Conway et al., 2011 |
Conducting analysis of adverse events and associated circumstances, and incorporating lessons into care systems | Boothman and Blackwell, 2010 ; Mulligan & Nechodom, 2008 ; Schifrin & Ater, 2006 ; Smetzer et al. 2010 |
Carrying out analyses of closed and open claims and circumstances associated with them, and incorporating lessons into care delivery systems | Angelini and Greenwald, 2005 ; Clark et al., 2008 ; Crawforth, 2002 ; Hickson et al., 1992 ; Jevitt et al., 2005 ; Kravitz et al., 1991 ; Richards and Thomasson, 1992 ; Ward, 1991 ; White et al., 2005 |
When patients are harmed during care processes, implementing national “Care of the Caregiver” standard, through just treatment, respect, understanding and compassion, supportive care, and transparency | Denham, 2010 ; National Quality Forum, 2010a |
Developing and implementing standards and measures for clinician behavior, and carrying out system-level programs to identify problem clinicians and address shortcomings | American College of Obstetricians and Gynecologists, 2007b ; Chervenak and McCullough, 2005 ; Leape and Fromson, 2006 ; Rosenstein, 2011 ; Simpson, 2007 |
Improving the accuracy, completeness, and timeliness of data in the National Practitioner Data Bank and the Healthcare Integrity and Protection Data Bank, and using them to identify unsafe caregivers | Sibelius and Wakefield, 2010 ; Sibelius, K., & Wakefield, M. K. (2010, February 12). Letter to governors. Available at: http://www.propublica.org/images/uploads/series/NPDB-HIPDB-Dear-Governor.pdf Weber and Ornstein, 2010 |
Comparing the effectiveness of change strategies and implementing the most effective approaches | Clark et al., 2010
Reduction in elective delivery at <39 weeks of gestation: Comparative effectiveness of 3 approaches to change and the impact on neonatal intensive care admission and stillbirth. American Journal of Obstetrics & Gynecology. 2010; 203: 449.e1-449.e6 |
Prevention: Enterprise Liability—A Tort Alternative Reform
- •Is consistent with the finding that about two-thirds of injuries owing to error involve individual and system factors, whereas about one third can be attributed solely to individuals (Mello et al., 2008);
- •Incents self-insured entities with premiums reflecting past claims experience to foster patient safety, versus limited experience rating with individual liability (Abraham and Weiler, 1994;Peters, 2008);
- •Gives liability responsibility to entities that have the benefit of system leaders, centralized planning, and resources for QI programs, which are more difficult for solo and group clinicians (Mello and Studdert, 2008;Peters, 2008;Sage, 2004);
- •Fosters health system coordination (Sage, 2005);
- •Reduces clinician discomfort, defensiveness, pressure to conceal errors, and stigma, fostering greater cooperation and potential to support injured parties and learn from errors (Peters, 2008;Sage et al., 1994);
- •Reduces health professional discontent by removing penalties such as threat to reputation, embarrassment, and—regardless of merit—reporting settlements to National Practitioner Data Bank and disclosing claims on applications for admitting privileges, board certification, and liability insurance (Peters, 2008);
- •Enables more equitable distribution of liability costs across specialties, sparing obstetrician-gynecologists and other high-risk specialists from disproportionate cost (Abraham and Weiler, 1994;Peters, 2008;Sage, 2004);
- •Shields health professionals from periodic liability insurance premium spikes (Peters, 2008);
- •Provides large risk pools to ensure that resources are available for large judgments (Abraham and Weiler, 1994);
- •Has potential to build in other strategies such as arbitration and no-fault payment (Sage, 2004), schedules for fair and predictable non-economic damages compensation (Abraham and Weiler, 1994), and disclosure and offer;
- •Reduces multi-defendant litigation costs by consolidating liability in a single corporate defendant (Abraham and Weiler, 1994;Peters, 2008); and
- •Has fostered safety in other industries (e.g., aviation and automobile;Peters, 2008) and is used to compensate workplace injury (Mello and Studdert, 2008).
Prevention: Leverage of Health Insurance, Accreditation, and Credentialing—A Health Insurance and Health Care Reform
Policymakers should link financial relief for the malpractice crisis to selected improvements in safety and accountability within the health care system, such as voluntary error reporting and analysis, better communication with patients and families, and pay-for-performance mechanisms. The most straightforward way to accomplish this is through health insurance, particularly the Medicare and Medicaid programs. (483–484)
Prevention: Shared Decision Making—A Health Care Reform
Ottawa Hospital Research Institute. (2011). Patient decision aids. Available at: http://decisionaid.ohri.ca.
Prevention: Align Legal Standards with Best Evidence—A Tort Alternative Reform
Prevention: Liability Insurance Coverage Regulation—A Liability Insurance Reform
Redress: Disclosure, Empathy, Apology—A Tort Alternative Reform
American Medical Association. (1994). Code of medical ethics: Opinion 8.12—Patient information. Available at: http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion812.shtml.
American Academy of Family Physicians. (2006). Disclosing unanticipated clinical outcomes: A resource guide for family physicians (position paper). Available at: http://www.aafp.org/online/en/home/policy/policies/c/clinicaloutcomes.html.
Redress: Health Courts—A Tort Alternative Reform
Redress: Administrative Compensation Systems—A Tort Alternative Reform
Redress: High-Low Agreements—A Tort Alternative Reform
Discussion
Agency for Healthcare Research and Quality. (2010). Medical liability reform and patient safety: Demonstration and planning grants. Rockville, MD: Author. Available at: http://www.ahrq.gov/qual/liability.
Acknowledgments
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