In reviewing outcomes that are associated with the implementation of a series of labor and delivery patient safety efforts from 2004-2009, we requested data on the number of related professional liability claims that were reserved by our insurance companies that are established with the specific objective of financing risks that emanate from their parent group or groups. While we restructured the manner in which we give care, required training modules, and provided simulations to our providers, our legal risk continued to be monitored independently and in parallel. Retrospective review of the number of cases for which money was held in reserve for claims demonstrated a 20% decrease per year, which was adjusted for delivery volume, over this time period. We believe that the improved care that resulted from our safety projects has led to this decreased legal risk.
Patient care may be defined in terms of both patient safety and satisfaction. Specific outcome data, such as cesarean rates or specific complication rates, are not necessarily indicative of the quality of care and the patient’s perceptions. Aggregated data, such as the Adverse Outcome Index (AOI), are attempts to combine data for evaluation; these collective outcome measures are not yet proven measures and do not describe the patient’s hospital experience completely. Patient perceptions of poor care or communication can lead to claims or suits, despite medically acceptable outcomes.
As we implemented patient safety improvements, we noted a concomitant decrease in the number of reserved claims. Based on the cumulative experience reported here, we believe that the number of claims for which funds are reserved by a service’s professional liability insurer is another useful reflection of safety improvements and patient care.
Materials and methods
Boston Medical Center (BMC) is an urban safety net hospital that is the primary teaching hospital for Boston University School of Medicine. Although 80% of the obstetric patients are covered by government insurance or are uninsured, the hospital and medical school staff also use the facility. English is spoken by only 62% of the women who deliver at BMC; the center has regionally recognized programs for human immunodeficiency virus–infected and substance-abusing pregnant women. The annual delivery volume averages 2400.
The labor and delivery staff at BMC is comprised of nurses, midwives, obstetricians, family medicine physicians, and residents in obstetrics and gynecology and family and emergency medicine. Third- and fourth-year medical students typically are involved in patient care. The labor and delivery staff is “closed,” in that all providers are full-time employees of either the hospital or the faculty practice plan. BMC is self-insured through a captive insurance company (an insurance company that is established with the specific objective of financing risks that emanate from their parent group or groups) that was incorporated in 2002.
In 2004, we began a series of interventions (described in detail later) to improve patient safety and satisfaction on labor and delivery. We have collected cases with poor outcomes and patient complaints through a variety of sources. We have an active risk management group, which is contacted immediately when unexpected poor outcomes occur. There is an anonymous online reporting system that is available to all BMC employees to report patient safety concerns; these reports are followed up by the risk management group and our quality improvement committee. We have a “complications reporting section” on discharge summaries that flags cases for further review. Finally, we communicate with our patient advocates when patient concerns arise. All of the identified cases are reviewed by our obstetric quality-improvement committee and the risk management team. Obstetric cases with poor outcomes are evaluated by legal and medical experts within the insurance captive, independent of the providers, and the quality-improvement committee, because it is a common practice to reserve funds for cases that may require legal defense. Specifically, the risk management team reviews events with the insurance captive to decide which cases may result in a professional liability claim. When there is believed to be significant risk of a claim or suit, money is set in reserve for defense or settlement. Because the amount of money that is reserved is determined by the captive insurance company using regionally specific data, we believed that it would be more useful to measure the number of reserved claims rather than the amount of dollars that are held.
We conducted a retrospective observational study that compared the number of reserved claims per policy year, which was adjusted for the annual number of deliveries, over the 5 policy years from July 1, 2004, to June 30, 2009. Mantel-Haenszel statistics were used to evaluate the data on the 11,931 deliveries that were included in the analyses. Poisson regression analysis was performed. Because no specific identifiable patient information was used in this study, it was exempt from institutional review board approval.
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