At many hospitals and health systems, risk managers and claims managers rely on different safety data sets and generally keep their focus on distinct, different work streams.

But an effort to align the two departments at UMass Memorial Health Care in Worcester is yielding positive results, according to a study published in the Journal of Healthcare Risk Management.

“Traditionally claims managers and clinical risk managers have lived in totally separate worlds within our health care entities. Each role owns vast information and knowledge, which historically have not been shared and cross-pollinated,” says Dana Siegal R.N., Director of Patient Safety for CRICO Strategies and a co-author of the study.

The insights gleaned from claims files, which may include clinical records, depositions, expert analyses and court documents, can significantly augment the sources of information typically used by risk management staff: adverse event reports (mandatory, voluntary, near miss, etc.) and results from Root Cause Analyses and Failure Mode and Effects Analyses.

“Having been a medical malpractice defense attorney, I understand what’s happening on the claims side,” says Janell Forget, R.N., B.S.N., J.D., Senior Director of Risk Management at UMass Memorial Health Care, and a co-author of the study with Siegal and Tim Slowick, M.B.A., who is the Director of Claims Management at UMass Memorial.

Since assuming her leadership role in 2015, Forget has made it a priority to collaborate with her colleagues in claims management to reduce risk and improve patient safety. Forget says the hospital also has increased the number of risk managers and embedded them in departments where ongoing, daily involvement means they can develop relationships, become part of the team and avoid being perceived by other managers and clinicians as people who show up only when something bad happens.

National database provides additional perspective

UMass Memorial Health Care has its own captive malpractice insurer and manages its own claims but contracts with CRICO’s Comparative Benchmarking System (CBS), a large database of malpractice claims from across the country, for additional data and learning opportunities. CRICO Strategies is a division of the medical professional liability company that insures health care organizations and clinicians affiliated with the Harvard medical community, including Massachusetts General Hospital, Brigham and Women’s Hospital, Beth Israel Lahey Health and others.

Forget and Slowick combine claims data — from their own cases at the hospital and from the national CBS — as well as adverse event reporting and other information to monitor trends, learn about vulnerabilities, and direct improvement initiatives. They look for connections and clues in the data that indicate patterns and outliers.

In one example they provide, the hospital received a cluster of four claims for cases of testicular torsion in a short period of time.

Root cause analyses determined that lack of on-site ultrasound staffing contributed to a delayed diagnosis of torsion in each of these cases. Forget and Slowick also looked at past claims and several near-miss cases to confirm that the delays stemmed from a problem with timely access to imaging in the emergency department.

Using data in CRICO’s CBS, they were also able to see that UMass Memorial’s performance on testicular torsion cases did not meet a national benchmark. Armed with all of these data points, and the backing of UMass Memorial’s Chief Medical Officer, they were able to advocate successfully for full-time ultrasound staffing in the emergency department. UMass Memorial has not had a claim for a testicular torsion since.

Having access to good information and staff members who are skilled and comfortable in data analysis is important, but Forget and Slowick share a few other learnings from their work:

• A supportive organizational culture and the trust of their colleagues underlies the ability to use data effectively.
• By visibly working together, they model collaboration for others in their departments.
• Pre-hire screening for staff who will be good members of the larger claims-risk team is also important.
• When risk and claims managers collaborate, they can develop more compelling stories and business cases than when working separately.

Forget adds, “At our captive insurance company, where the CEO of the health system is a board member, we’re able to present data and concerns at a variety of meetings and informally, which makes it easier to mobilize support for our issues.”

The National Academy of Medicine (NAM), in a 2015 report on diagnostic safety, recommended that health care organizations work with insurers to improve patient safety. NAM mentions in particular large, national databases and analysis can add broad context that individual provider organizations cannot supply on their own.

CRICO’s Siegal points out that the process of coding — segmenting and labelling the claims data (including both legal and clinical information) so it can be searched, analyzed and used — is much faster than it used to be, in large part because so many records are now electronic. CRICO begins coding claims on receipt and completes the process as the case progresses. Siegal says, “Cases are eligible for analysis long before they close. People often think, ‘Oh, medical malpractice takes forever,’ but not really. The bulk of the learning from each case is right there for you, right up front.”

Siegal admires the culture of collaboration Forget and Slowick have developed at UMass Memorial and says she hopes this will be a growing trend.