In a perfect world, pediatricians could practice quality medicine and never have to worry about being sued. It is often said that malpractice allegations are more likely to arise from bad outcomes than bad care. Breakdowns in communication between physician and patient can also lead to potential increased risk of legal action. Practicing quality care is no guarantee against malpractice claims. Effective risk management can reduce the likelihood of adverse events in practice settings and minimize the financial losses from those instances.
Risk management is a systematic process to help identify, evaluate and address problems that may injure patients, lead to malpractice claims, and cause financial loss to health care entities. Risk management is proactive with an aim to prevent future problems. One way to do that is to learn from past adverse events and mitigate that risk. Another useful approach is to proactively assess processes and patient contacts.
Effective risk prevention depends on the reliable recognition of risk exposure, determination of its causes, implementation of corrective actions, and continual monitoring of risk indicators to determine if risk exposure improves.
Because pediatric practice is so dynamic, the risk management cycle must be continuous and lead to appropriate readjustment and fine-tuning of the process. The full scope of risk management encompasses all organizational activity—operational and clinical—because liability may originate in either area. In developing a risk-management strategy, the practice must make certain that the program has sufficient scope to cover the risk, the risk reduction strategies are appropriate, and the program is documented in written policies and procedures.
The following characteristics unique to pediatrics make risk management more challenging in pediatric settings:
- Relative rarity of many pediatric illnesses
- Limited capacity for communication and cooperation in young children
- High levels of dependency on others (e.g., parental observation and assessment of problem)
- Changes in patient (e.g., weight, height, physiologic and developmental maturation)
- High-volume specialty (many patients, many visits, many telephone calls, and the emergence of telehealth care).
Risk Identification Methods
Effective risk management begins with a system for identifying the specific events likely to result in loss and the general clinical areas of risk exposure. The following are some common methods.
The easiest and most obvious way to identify risk is to assess what ordinary activities of pediatric practices result in lawsuits.
Patient/Family Complaints and Satisfaction Surveys
Reviewing patient/family complaints is a good way to detect cases involving communication failures or poor quality health care. Many organizations have formalized mechanisms for handling patient/family complaints. Often, descriptive statistics of patient/family complaints are generated routinely, such as monthly compilation of all complaints by type, clinical/administrative area, and involved staff. Creating a culture of exploration into the reason for the complaint can determine patterns with systems or specific providers than can be addressed. A focused review of complaints that suggest communication problems or poor quality can be a productive undertaking when looking for patterns that might increase risk. Occasional random patient/family satisfaction surveys can also reveal areas of risk (as well as practice strengths).
A review of billing disputes is another method of identifying risk and quality deficiencies. Patients often refuse to pay bills because they believe that the care received was substandard and therefore not deserving of payment. Some patients also make accusations of poor quality care simply to justify their refusal to pay for care. This compromises the cost-effectiveness of billing disputes as a risk identification tool. Consequently, detailed clinical review of all cases resulting in a billing dispute should probably be reserved for cases involving large sums of money or significant accusations of substandard quality.
Occurrence (Incident) Reporting
Rather than wait for a legal action, record request, complaint or billing dispute to initiate the process of risk identification, most practices ask staff to notify the managing partner of the practice should an untoward or unusual incident occur. Hospitals or larger practices have Risk Management Departments and skilled professionals who should be immediately contacted for guidance.
If you are a pediatrician in an independent practice, it would be prudent to notify your medical liability insurer who may open a file regarding the incident. Often a special form, commonly referred to as an incident report, patient safety report, or variance report, is provided for this purpose. The form indicates the minimum specific information that must be provided about the incident. Although the information contained in the report may be protected from legal discovery by state law, some institutions request that the reports of patient harm resulting from medical misdiagnoses, therapies, and procedures be reported verbally rather than in writing. If an incident report is filed, it should not be referenced in the medical record, or it might be deemed discoverable.
Random Medical Record Review
A common practice in the early years of risk management, random medical record reviews involved an unfocused peer review of randomly selected medical records as a quality assurance activity. Random medical record review is less commonly used today because the low yield of positive findings made it cost-inefficient. However, a program of random medical record reviews by physicians can be beneficial in educating them about the wide variety of practice styles and approaches present among the providers. Over time, this may lead to group consensus on the identification of less than optimal behavior or poor documentation. Some medical liability insurers offer onsite evaluations of practice for risk reduction purposes. These may include random chart reviews if requested by the practice. Frequently these evaluations result in concrete suggestions for improving risk management.
Because occurrence reporting can be unreliable, some practices identify groups of cases for screening review without depending upon reporting from staff. This risk identification method is called occurrence screening. These can be generic screening events that have been identified as areas of concern (e.g., unanticipated return visits for the same problem within a specified time period, emergency department encounters shortly after an office visit.). The mere occurrence of a generic event does not imply the presence of risk or a quality deficiency. Rather, the occurrence event indicator is meant to trigger a careful review to ascertain whether a quality problem or risk exists.
Closed Malpractice Claims
One of the best ways to identify potential risks is to review closed malpractice claims and articles on malpractice trends.
Pediatricians are not free from malpractice risks. In fact, 1 in 5 is sued once over the course of their career. Although pediatricians are not accused of malpractice as frequently as other specialists, when they are sued the stakes are high.
It is well worth your time and money to invest in the above risk management strategies to protect your office and your career from malpractice claims.
- Pediatricians and the Law in AAP News – Monthly articles on an array of medicolegal topics offering practical and timely risk management advice.
- National Conference and Exhibition – Onsite and on-demand educational programs on avoiding medical liability targeted specifically for pediatric primary care, medical subspecialists and surgical specialists.
- Trends in Pediatric Malpractice Claims 1987–2015: Results from the Periodic Survey of Fellows
American Academy of Pediatrics