Medical liability coverage for Texas physicians

ACCME commends TMLT CME for engaging with the environment

By Lesley Viner, MS

"The ACCME congratulates you and commends your organization for not only meeting ACCME's accreditation requirements, but for demonstrating that yours is a learning organization and a change agent for the physicians you serve. You have demonstrated an engagement with your environment in support of physician learning and change that is a part of a system for quality improvement."

Murray Kopelow, MD, MS, FRCPC
ACCME Chief Executive

In December 2009, TMLT received notification from the Accreditation Council of Continuing Medical Education (ACCME) that Accreditation with Commendation, the ACCME's highest level of recognition, was achieved. TMLT is the first professional medical liability carrier in Texas to achieve commendation status, and one of only 10% of all CME providers surveyed under the new criteria to be recognized in this way.

In order to award Accreditation with Commendation, the ACCME expects that CME providers "engage with the environment." This article will address TMLT's efforts to engage with the environment and meet ACCME's level three criteria (Criteria 16-22) for commendation.

ACCME's Criterion 16

The provider operates in a manner that integrates CME into the process for improving professional practice.

TMLT integrates CME into the process for improving professional practice by offering an innovative, practice-based CME activity. This activity is unique because it is a practice-specific intervention offering one-on-one learning.

Practice based CME activities are offered at no cost to TMLT policyholders and take place throughout Texas on a per-request basis. The practice-based CME activity is a part of the practice review process, which consists of:

• an examination by a risk manager of the physician's office premises for physical safety and concerns;
• a review of the practice's policies and procedures;
• an evaluation of medical record documentation for risk management strengths and weaknesses;
• a confidential, written summary of the findings and recommendations for the physician's review, with a request for a written plan of action addressing each recommendation.

In order to receive 1 CME credit, the physician must first complete a self-assessment survey to reflect and analyze aspects of his/her medical practice. The physician must then participate in a one-hour discussion with the risk manager regarding identified areas of potential liability, recommended risk management interventions, and other pertinent risk management issues. When the risk manager returns for a re-visit, physician implementation of the risk management recommendations made at the initial visit is assessed.

ACCME's Criterion 17

The provider utilizes non-education strategies to enhance change as an adjunct to its activities/educational interventions (e.g., reminders, patient feedback).

The following non-educational strategies are used as adjuncts to TMLT CME programs:

• telephone consultations (risk managers are available daily to respond to risk management inquiries);
• access to closed-claim studies;
• resources available (examples include: sample diagnostic review labels, sample physician-patient relationship termination letter, sample medical record release form);
• bimonthly newsletter, the Reporter;
• postcard reminders to schedule practice review/practice-based CME;
• postcard reminders to respond to review recommendations;
• premium discounts.

These strategies are additional resources physicians can use when implementing changes in their practice. They are connected to TMLT's CME programs, as they can enhance each type of risk management activity offered.

ACCME's Criterion 18

The provider identifies factors outside the provider's control that impact on patient outcomes.

There are factors outside of the CME program's control that have an impact on patient outcomes, such as legislative and regulatory changes. For example, in June of 2003 the Texas legislature passed one of the nation's most comprehensive medical liability reform bills. It included the following:

• a non-economic damage cap;
• protections for emergency care;
• allowing periodic payments for future damages; and
• implementing expert witness reforms to reduce litigation costs and the number of frivolous filings.

The liability reforms impacted TMLT's CME program by increasing physician awareness of liability issues and bringing topics like risk management, medical errors, and patient safety to the forefront. As a result, TMLT developed the following CME seminars to address physician concerns: Medical Errors, Mandatory Disclosure & You, Patient Safety: Closing the Door on Murphy's Law, You've Been Sued: Successfully Navigating the Litigation Process, and Avoiding the Courthouse: 10 Practice Pitfalls.

These legislative changes also produced regulatory changes in the form of increased physician oversight by the Texas Medical Board. In response to policyholders concerns, TMLT developed a seminar entitled You've Received a Letter from the Texas Medical Board: What's Next?

ACCME's Criterion 19

The provider implements educational strategies to remove, overcome or address barriers to physician change.

To remove, overcome, or address barriers to physician change, TMLT provides practical resources/materials to assist physicians with implementing changes in their medical practice. Below is a limited list of the sample materials/best practices offered to assist physicians with changes they may otherwise find difficult:

• medical practice policy and procedure manual
• telephone message pocket pad
• telephone decision guidelines
• medication flow sheet
• missed appointment letter
• informed refusal letter
• consent for office procedures
• medication refill policy
• termination of physician-patient relationship letter
• termination for non-payment letter

In addition, through closed-claim studies, TMLT can provide "real-life" examples to physicians regarding the importance of risk management practices. For example, if a physician does not see the importance of documenting after hours phone calls, TMLT can provide case examples that illustrate how failure to document these may have affected patient care and contributed to the filing of a lawsuit.

Other barriers the CME program strives to overcome are the lack of financial resources and time. By offering free CME options to physicians, the financial resource barrier is minimized. By offering a variety of CME opportunities (including enduring materials and on-line courses), the barrier for those physicians with time constraints or who live in remote locations is minimized.

ACCME's Criterion 20

The provider builds bridges with other stakeholders through collaboration and cooperation.

TMLT is engaged in collaborative relationships with other stakeholders, including the Texas Medical Association (TMA), the Texas Academy of Family Physicians (TAFP), the Texas Alliance for Patient Access (TAPA), and various state-wide county medical societies.

CME staff members meet quarterly with TMA's practice management team to discuss and identify educational trends/needs for Texas physicians. The following are reviewed: legislative and regulatory issues, program requests, CME activity evaluation summaries, and TMLT closed claims data/trends. In addition, TMLT receives regular program requests from TAFP for risk management seminars, and also provides programs for county medical societies throughout the state. In 2003, TMLT partnered with TMA and TAPA to lobby for medical liability reform in Texas.

ACCME's Criterion 21

The provider participates within an institutional or system framework for quality improvement.

The program's framework links the CME committee with the following quality improvement committees:

CME Advisory Committee
The purpose of the CME advisory committee is to review and revise TMLT's CME mission statement annually, make recommendations regarding program topics, evaluate the overall CME program, and provide suggestions on ways to improve. Members include physicians from the governing board, as well as risk management staff.

Risk Management/Underwriting/Claims Committee
The goal of this committee is to exchange information regarding newly identified risks, discuss risk alerts, identify internal claims trends, discuss closed claim coding questions, and evaluate underwriting practice reviews. Members include staff from the risk management, claims, and underwriting departments.

Risk Management Quality Improvement Committee
The purpose of the QI Committee is to facilitate an open forum for ideas among the risk management department staff, act as a starting point for progressive and creative thinking to improve risk management processes, and allow staff to voice issues/concerns along with possible solutions. Staff members of the risk management department serve on this committee.

ACCME's Criterion 22

The provider is positioned to influence the scope and content of activities/educational interventions.

The program's organizational practices influence the scope and content of activities through the following means:

Trends/topics for activities are identified through data/reports generated by TMLT's internal closed-claim coding process. TMLT submits coding data to the Physicians Insurers Association of America (PIAA), subsequently receiving compiled reports from PIAA with some of the following information for inclusion in CME programs:

• Trend Analysis of Claims by Close Year
• Comparative Payment Threshold Analysis
• Comparative Total Expense Payments by Specialty
• Comparative Payment Analysis by Close Year
• Expense Payment Analysis by Close Year
• Claims by Adjudication Status
• Claims by 5 Most Prevalent Medical Conditions
• Claims by 5 Most Prevalent Medical Misadventures
• Payments by Policy Limit and Severity of Injury
• Financial Analysis

Trends/topics for programs are also identified by running reports outlining the most frequently received risk management phone call topics. Topics tracked include:

• medical records
• informed consent
• staffing
• general office
• appointments
• telephone protocol
• fees, billing, collections
• termination of relationship
• patient complaints
• release of records
• follow up procedures
• HIV procedures
• equipment maintenance
• medication administration
• patient visits
• exams and treatment procedures
• diagnostic procedures
• surgical procedures
• office emergency
• infection control
• waste management
• peer review
• electronic medicine
• form/resource request
• HIPAA
• care of minors
• selling/closing a practice
• prescription issues

Trends are also identified for program content by tracking and analyzing the most frequently made recommendations during the practice review process. Below is a sample of recommendations:

• documentation of after- hours calls incomplete
• incomplete forms
• lack of patient education documentation
• medication samples not adequately documented
• lack of timely completion of progress note
• informed refusal not documented
• prescription pads accessible to patients

The initiatives described have enabled TMLT to achieve and enhance its CME mission, as well as continuously improve CME programs offered to physicians.