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By RICHARD H. KENNISON, president and general manager of PeerPoint Medical Education Institute, and JO TOWNSON, risk management specialist/continuing medical education at NORCAL Mutual Insurance Company.

Educational programs aimed at reducing liability risk exposure have been incorporated within healthcare for quite some time. For many years, through their hospital risk management departments and medical liability insurance carriers, doctors have enjoyed access to speakers and written materials that present cautionary tales and provide helpful tips regarding communication, follow up and documentation practices that could, theoretically, help them practice better medicine and endure fewer lawsuits.

--Verified implementation of risk management and patient safety-oriented "best practices" or quality metrics; for example, implementation of policies, procedures and forms that standardize care and increase the defensibility of that care in the event of a lawsuit.

--Reduced prevalence of medical errors.

--Reduced claims frequency (i.e. number of suits alleged).

--Reduced claims severity (i.e. indemnity paid).

--Increased patient satisfaction.

Some medical professional liability insurers, such as NORCAL Mutual Insurance Company based in San Francisco, have been creating and implementing successful PI CME programs for a few years.

After a thorough analysis of the company's own claims experience, NORCAL implemented an education-based PI initiative called the "Risk Management Self-Assessment Modules," consisting of three online user-directed modules that guide insureds through a structured process designed to engage the policyholder in reducing their risk exposure through a combination of behavioral and system-based changes.

This PI initiative was designed to accomplish multiple objectives includingcreating an opportunity for physicians to 1) assess their personal risk exposure pertaining to a variety of high risk areas;2) develop a manageable action plan geared at reducing their risk in these areas; and 3) evaluate how well the action plan improved their approach to these risk areas. Participation in the modules earns policyholders 20 AMA PRA Category 1 Credits and, for those who qualify, results in a sizable insurance premium discount.

While available to all policyholders to participate by choice, the educational modules were deployed through company mandatory processes to be utilized by policyholders who demonstrated the highest risk exposure to the company due to high claims frequency and/or severity.

When used in conjunction with these mandatory risk management processes, the education includes hands-on proctoring by risk management staff members, who are trained to assist policyholders in implementing action plans. The self-assessment modules and mandatory risk management processes are an ongoing PI initiative, but early results indicate great success in reducing or eliminating risk exposure and repeat claims for the policyholders who have participated.

Similarly, PeerPoint Medical Education Institute recently concluded a successful initiative that focused on increasing the improving care components associated with the recognition and diagnosis of the causes behind joint pain in the primary care practice setting, another medical professional liability risk issue.

Specifically, PeerPoint looked at: 1) improving the diagnostic skills associated with joint pain; 2) improving the flow of patients through the office; 3) decreasing the time to a definitive diagnosis associated with joint pain; 4) improving the referral process for patients with troublesome joint pain and; 5) improving the selection process for primary and secondary interventions to treat joint pain.

The program was open to primary care physicians and their physician extenders for a period of 15 months. The target audience was reached through direct marketing campaigns and through membership channels with the partners on the initiative.

Approximately 10,000 unique users visited the Web site and over 3,500 took part in some component of the program. Due to attrition, 78 providers completed the PI component of the initiative. These 78 providers submitted data on approximately 1,100 patients during this component, which allowed PeerPoint to achieve statistical significance in many of their predetermined performance measures.

The themes that hit some level of statistical significance were: 1) improving the diagnostic skill for joint pain; 2) decreasing the time to a definitive diagnosis associated with joint pain; and 3) improving the referral process for patients with troublesome joint pain. The theme that focused on improving the flow of patients through the office resulted in an overall self-reported efficiency increase of 23 percent for all groups.

IMPROVEMENT INITIATIVES

The two examples outlined above illustrate that education-based performance improvement may be a risk management strategy worth considering in a variety of healthcare settings. This type of educational intervention represents a new approach in marrying risk management with performance improvement and continuing medical education with the expressed purpose of changing high-risk behaviors and inadequate systems and achieving measurable results.

In order to work, education-based risk management performance improvement initiatives must specifically target high-risk areas in healthcare delivery. These areas are identified through many sources; for example, the root cause analyses of medical errors when they occur and, in the event of litigation, the in-depth review of closed claims files. These records illuminate problematic provider behaviors and inadequate systems that, if mitigated, can reduce the likelihood of future claims or reduce their severity when they do occur.

The following is a list of helpful hints when considering the implementation of an education-based performance improvement initiative:

1. Determine the greatest area(s) of need for your organization.These programs can be used to reduce risk exposure through a variety of mechanisms (e.g. via quality improvement metrics or through frequency and severity of claims)

2. Find partners with common goals. Maybe another industry member is facing the same concerns and is willing to collaborate to produce the initiative.Finding a CME company with extensive PI CME experience may be beneficial.

3. Determine how your target audience will react to an initiative. Some physician groups may be more interested in participating than others.It has to be touted as bringing value without being an administrative burden to busy practitioners.

4. Try to determine performance metrics that have interest to internal stakeholders. Due to the nature of these programs, multiple departments may be asking the same questions that you are. Take this into consideration when looking for partners.

In conclusion, as technology, quality improvement process and education advance, there are new opportunities available to risk managers that may not have been available just a few years ago. Educationally based performance improvement initiatives have been proven effective and assist in meeting common goals and objectives of multiple groups of stakeholders.

November 1, 2009

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