advanced practice providers: enhancing their roles ... · © 2016 mmic/umia. all rights reserved...

© 2016 MMIC/UMIA. All rights reserved

Advisory Notice

This presentation has been abridged from a variety of

sources and is intended for informational and advisory

purposes only for MMIC/UMIA policyholders.

MMIC/UMIA does not undertake to establish any

standards of medical practice. This presentation is

provided as guidance relating to risk management and

claim prevention. Specific legal advice should be

obtained from a qualified attorney, when necessary.


Learning objectives

• List the professional liability risks involved in

employing advanced practice providers (APPs).

• Name the most common contributing factors in

professional liability cases involving APPs.

• Implement strategies to mitigate risk and enhance

patient safety.


Introduction

Lessons Learned



• 55-year-old man was examined by PA

• Complained of shortness of breath, fatigue

and lower extremity swelling

• History of asthma, high cholesterol,

hypertension and diabetes


• PA noted high BP, elevated blood sugar

and abnormal CXR

• Diagnosis: acute heart failure and

unstable diabetes

• Changed: heart, diabetes and

hypertension meds

• Added a diuretic

• Ordered baseline labs and a follow-up visit


• One week later, reexamined by same PA

• Somewhat improved, but still short of

breath

• No lab results present in medical record

• Repeat CXR showed improvement

• Diagnosis: pulmonary-related

• PA discontinued diuretic and ordered

asthma medication


• Two days later, the man collapsed at home

• Ambulance called; CPR initiated

• Coded in ED; ventricular arrhythmia

• Died in ED due to ischemic heart disease


• Family filed a malpractice claim

• Alleged PA failed to timely diagnose

and treat cardiac condition

• Experts were critical

• Case closed with payment


What you’ll learn about APPs

PART ONEEmployment trends

PART TWOProfessional liability risk

PART THREEReducing risk


APP employment trends


© 2016 MMIC. All rights reserved

APP employment today

Clinics Employing APPsMGMA Survey, 2014

35% have NPs

30% have PAs

Source: http://www.forbes.com/sites/brucejapsen/2015/07/15/nurse-practitioners-

physician-assistants-more-in-demand-than-most-doctors/#772bcd5d3610

100 Best Jobs of 2016US News & World Report

PAs rank 5th

NPs rank 6th


Emerging employment trends

2015 2022

Bureau of Labor Statistics

Projected growth by 2022

PAs 38%

NPs 34%


Emerging employment trends

All occupations 11%

Physicians/Surgeons 14%

All healthcare jobs 19%

2015 2022

Bureau of Labor Statistics

Projected growth by 2022

PAs 38%

NPs 34%


PA specialty areas

Source: AAPA PAs in Healthcare Annual Survey 2013

38%

26%

18%

15%

11%

3%

2%

1.5%

General Medicine

Surgery

Other

Internal Medicine

Emergency Medicine

Pediatrics

OB/Gyn

Occupational Medicine


• Regulated by state medical or PA boards

• Cannot practice independently

• Rural clinic designation

• Written agreement outlines scope

of practice

PA practice


NP specialty areas

Source: AANP NP Facts July 2015

55%

19%

8%

5%

5%

4%

3%

1%

1%

Family Medicine

Adult Medicine

Acute Care

Pediatrics

Women's Health

Psych/Mental Health

Gerontology

Oncology

Neonatology


• Governed by state nursing boards

• Many states allow independent practice

– No physician supervision required

• Some states have reduced or

restricted practice

– Collaborative practice agreement

– Delegation and supervision required

NP practice


State practice models for NPs

(as of Nov. 2015)

Full practice

Reduced practice

Restricted practice


Emerging trends for APPs

Increased

employment

in clinics and

hospitals

Increased

involvement in

pre- and

post-op care

Increased

management

of patients

in LTC


Perfect storm and perfect opportunity

Insured population

Population with chronic conditions

Demand for access

Demand for efficiency

Physician shortage

Mandate to reduce costs


8.0% 7.7% 7.9% 8.6% 8.0%

0%

5%

10%

15%

20%

2010 2011 2012 2013 2014

MMIC claims involving APPS

NPs PAs Total

MMIC APP claims per year

MMIC N=186 (APP) of 2,340 PL cases asserted 2010-2014

7.9% average

APPs and Professional Liability Risk



Elements of a malpractice claim

• Duty

• Breach of duty

• Existence of an injury

• Injury caused by breach of duty

Professional

Negligence

Failure to meet thestandard of care


Theories of potential liability

Direct

liability Vicarious

liability

Vicarious

liability

Negligent

credentialing

Negligent

credentialing

Negligent

supervision

Negligent

supervision

APP


• Physician employer

• Facility employer

• Locum tenens

Employment model may affect risk


Digging deeper, seeing farther

Analysis of our coded claims:

• Identifies signals of vulnerability

• Identifies opportunities to improve safety

• Catalyzes change for optimal risk reduction

Since 2013, MMIC has partnered with

Harvard-based CRICO Strategies for

data analytics

• Risk intelligence tool

• Comparative benchmarking data

Comparative Benchmarking System (CBS)300,000+ claims

Represents ~30% of National Practitioner Data Bank

400+ hospitals, 165k+ physicians, 8k+ cases per year

Membership

Copyrighted by and used with permission of The Risk

Management Foundation of the Harvard Medical

Institutions, Inc., all rights reserved.


Unique on the surface

Adverse event


… common

factors below

Common underlying

themes

• Initial misinterpretation

of scan

• Lack of communication

among providers

• Failure to respond

to repeated symptoms

• Diagnostic focus

too narrow

• Lack of patient assessment

Adverse event


Top allegations – all vs. APPs

MMIC N=2,340 PL cases asserted 2010–2014

0%

5%

10%

15%

20%

25%

30%

35%

40%

All Cases

All Cases Total Incurred


Top allegations – all vs. APPs

0%

5%

10%

15%

20%

25%

30%

35%

40%

Cases involving APPs

NPs PAs Total Incurred

MMIC N=186 PL cases asserted 2010-2014 involving APPsMMIC N=2,340 PL cases asserted 2010–2014

0%

5%

10%

15%

20%

25%

30%

35%

40%

All Cases

All Cases Total Incurred


35%

24%

18%

10%

6%

0%

5%

10%

15%

20%

25%

30%

35%

40%

Diagnosis-

related

Medical

Treatment

Surgical

Treatment

Medication-

related

Safety &

Security

NPs PAs

Top major allegation categories involving APPs

MMIC N=186 PL cases, asserted 1/1/2010–12/31/2014

NPs

43% PAs

57%

APP Cases


APP cases: settings and responsible services

0%

5%

10%

15%

20%

25%

30%

Responsible Services

NPs PAs

MMIC N=186 Asserted 2010-2014

Settings

ED

17%

Outpatient

51%

Inpatient

32%


Contributing factors

Factors * % APP % MMIC

Clinical judgment 74% 59%

Technical skill 32% 47%

Communication 31% 30%

Behavior-related 22% 30%

Administrative 21% 20%

Clinical environment 11% 6%

Supervision 7% 2%

Contributing factors are

those underlying issues

“under the iceberg”

from which we extract

common themes.

MMIC N=186 PL cases asserted 2010-2014

*A case will often have multiple factors identified.

= statistically significant (p < 0.05)


Clinical judgment








Supervision 7% 2% 74%of APP cases involve issues with

clinical judgmentMMIC N=186 PL cases asserted 2010-2014











Supervision 7% 2%

Clinical judgmentClinical judgment factors* % APP

Patient assessment issues 72%

Selection/mgmt. of therapy 30%

Failure/delay in obtaining

consult/referral14%

Occur early in the

diagnostic processMMIC N=186 PL cases asserted 2010-2014




Patient assessment issues* % NPs % PAs

Failure/delay

in ordering

diagnostic tests

14% 31%








Supervision 7% 2%

Clinical judgmentClinical judgment factors* % APP

Patient assessment issues 72%

Selection/mgmt. of therapy 30%

Failure/delay in obtaining

consult/referral14%

Occur early in the

diagnostic processMMIC N=186 PL cases asserted 2010-2014











Supervision 7% 2%

Technical skill

Less about

technical skill

factors












Supervision 7% 2%

Technical skill

Technical performance % cases*

Known risk of procedure 60%

Poor technique 18%












Supervision 7% 2%

Communication












Supervision 7% 2%

CommunicationCommunication % NPs % PAs

With patient and family 7% 11%

With other providers 10% 7%





Communication % NPs % PAs

With patient and family 7% 11%

With other providers 10% 7%








Supervision 7% 2%

Communication

With other providers - especially

• Regarding patient condition

• Failure to read record












Supervision 7% 2%

Behavior-related












Supervision 7% 2%

Behavior-related

Behavior-related % cases*

Patient factors 20%

Provider factors 2%












Supervision 7% 2%

Administrative












Supervision 7% 2%

Administrative

Administrative % cases*

Staff issues 10%

Policy issues 8%

Ethical 3%












Supervision 7% 2%

Clinical environment












Supervision 7% 2%



Workflow/workload

- Weekend/nightshift/holiday

- Busy-ness factors












Supervision 7% 2%

Supervision












Supervision 7% 2%

Supervision

Supervision factors

Supervision – nursing, staff, other

Signing off without review of or

participation in care.





Team-related vulnerabilities

Clinical judgment

Too much responsibility

No clinical guidelines,

care protocols, or

clinical decision support

Lack of mentoring

and collaboration

opportunities

Communication

Hierarchical,

unsafe culture

Lack of teamwork

skills and tools

Lack of empathy training

Lack of patient

engagement

Administrative

Inadequate physician

oversight due to lack of

role clarity

Lack of mentoring/

collaboration

opportunities

Lack of policies and

procedures


Reducing risk



Reducing risk: focus on three

Policy and

oversight

1Culture and

experience

2Tools and

training

3


Implement an

APP policy• Roles and responsibilities

• Identification of team

• Scope of practice and

delegation

• State regulations

• Prescribing authority

• Supervision and oversight

• Consultation

triggers/parameters

1 policy and

oversight



1 policy and

oversight

Evaluate

credentials and

competency

• Verify licensure, credentials

and prior experience

• Conduct background

investigation and reference

checks

• Assess competency

• Use skills checklists

• Provide orientation



1 policy and

oversight

Ensure oversight • Medical record review

• Consultation

triggers/parameters

• Case reviews

• Patient complaint reviews

• Mentoring relationships

• Metrics to evaluate

performance



Promote a safe

and collaborative

culture

• Encourage error reporting

• Give honest feedback

• Encourage and honor

requests for assistance

• Assess patient safety

culture

culture and

experience2



culture and

experience2

Make provider

well-being a priority

• Include it in your

mission statement

• Measure well-being

• Provide education

and tools

• Encourage self-care

• Promote resiliency tools



culture and

experience2

Enhance

communication

among members of

the health care team

• Critical language policy

• Communication tools

(e.g., SBAR, handoff tools)

• Communication triggers

• Teamwork training

• Huddles

• Clinic/department/

facility meetings



Provide education

and training

• Team-based care

• Clinical topics

• Effective communication

• Reducing risk

• Empathy training

tools and training3



tools and training3

Use clinical

and diagnostic

decision support and

other HIT tools

• Patient care protocols

• Clinical guidelines and

order sets

• Diagnostic decision

support (e.g., Isabel)

• Test management and

follow-up care tracking

• Patient population

management

• Medication management



tools and training3

Enhance

communication

skills for

patient interactions

• Health literacy tools

• Communication triggers

• Shared decision-making

model to enhance

engagement

• Apology and

communication process

• Empathetics

• Pulse 360



Closing thoughts

Making a difference



Resources

Nurse Practitioners

• American Association of Nurse Practitioners http://www.aanp.org

• American Association of Nurse Practitioners State Practice Environment map http://www.aanp.org/legislation-regulation/state-legislation-regulation/state-practice-environment

• Barton Associates NP Scope of Practice Law Guide http://www.bartonassociates.com/nurse-practitioners/nurse-practitioner-scope-of-practice-laws

Physician Assistants

• American Academy of Physician Assistants - https://www.aapa.org

• National Commission on Certification of Physician Assistants State Licensing Boards links http://www.nccpa.net/StateBoards

• Barton Associates PA Scope of Practice Law Guide http://www.bartonassociates.com/nurse-practitioners/physician-assistant-scope-of-practicelaws/?utm_medium=social&utm_campaign=PA+Wheel&utm_source=Facebook

http://www.aanp.org/

http://www.aanp.org/legislation-regulation/state-legislation-regulation/state-practice-environment

http://www.bartonassociates.com/nurse-practitioners/nurse-practitioner-scope-of-practice-laws/

https://www.aapa.org/

http://www.nccpa.net/StateBoards

http://www.bartonassociates.com/nurse-practitioners/physician-assistant-scope-of-practice-laws/?utm_medium=social&utm_campaign=PA+Wheel&utm_source=Facebook

advanced practice providers: enhancing their roles ... · © 2016 mmic/umia. all rights reserved...

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