Data-Driven Risk Management for Advanced Practice Providers

Compared to physicians, advanced practice providers (APPs)—physician assistants, nurse practitioners, nurse anesthetists, and nurse midwifes—are infrequently named in medical professional liability lawsuits. An analysis of 7,170 Coverys malpractice claims closed between 2017 and 2021 shows that only 7% of claims involved APPs and 6% of the total indemnity paid involved cases in which an APP was the defendant. As APPs become more prevalent in the healthcare landscape, the risk of lawsuits is likely to grow.

Below are some notable trends:

• The APP workforce is growing. According to the U.S. Bureau of Labor Statistics (BLS), in 2021, there were 139,100 physician assistants and the occupation is expected to grow by 28% between 2021 and 2031. Additionally, the BLS says there are 300,000 nurse anesthetists, nurse midwives, and nurse practitioners, and these occupations are expected to grow by 40%. Projections from the New England Journal of Medicine show that nurse practitioners and physician assistants will account for 67.3% of healthcare practitioners added to the workforce between 2016 and 2030.
• Most physicians and patients will interact APPs. Even when APPs aren’t named in a lawsuit, they are likely to have been involved in the care provided.
• Most healthcare organizations employ APPs. The Association of American Medical Colleges says there could be a shortage of up to 124,000 physicians by 2034. This means healthcare organizations may have to rely on APPs more heavily in the future.

Following are insights from the Coverys closed malpractice claim data referenced above.

Most Claims Are Diagnosis-Related

Approximately one-third of all Coverys claims involving APPs are diagnosis-related, which is similar to the numbers for claims involving physicians. However, there are some variances depending on the type of APP involved.

• Certified nurse midwife claims often involve poor heart tones during labor.
• Certified registered nurse anesthetist claims often include a failure to monitor.
• Most claims involving NPs and PAs involve diagnostic error. Specifically, 80% of claims involving NPs and 78% of claims involving PAs allege diagnostic error.

Drilling Down Into Diagnostic Issues

The top diagnosis allegations in cases involving APPs include:

• Evaluation of the patient – 56%.
• Ordering diagnostics and lab tests – 23%.
• Referral management – 13%.
• Follow-up with the patient – 4%.
• Interpretation of tests – 4%.

Cancer and infection are the two most common missed diagnoses, followed by cardiac, vascular, orthopedic, and neurological conditions.

Claims Severity

Claims against APPs involve death or serious injury 44% of the time.

Not all claims result in a payment – this is true no matter if the claim involves physicians or APPs. However, APP claims are more likely to result in a payment, either through a settlement or a verdict. Of the APP claims that occurred over the past five years, 26% closed with an indemnity payment. This is slightly higher than the average for claims against other providers.

However, payments on APP claims tend to be lower. In 2021, for example, APP claim payments averaged $346,067, whereas claim payments for other providers averaged $424,097.

Top Locations for Diagnosis-Related Claims

It was most common for diagnosis-related claims involving APPs to occur in an office or clinical setting.

• 45% occurred in an office or clinic.
• 29% occurred in an emergency department or urgent care.
• 21% occurred in an inpatient room.

Top Risk Management Issues

To reduce claims and improve patient outcomes, you need to know the source of claims. By far, the top risk management issue in claims involving APPs is clinical judgment, accounting for 60% of all claims.
During patient assessment, clinical judgement issues include:

• A narrow diagnostic focus, possibly stemming from anchoring bias, confirmation bias, or wishful thinking bias.
• Test ordering.
• Failure to assess the patient’s condition adequately.

In the selection and management of therapy, they include:

• Failing to consider the patient’s family or personal history.
• Decisions regarding treatment that are suboptimal for the patient.

Other common issues include:

• Clinical system issues such as premature discharge, the failure to transfer a patient, a delay in admission, failure to manage follow-up care (such as testing) or to notify others about follow-up care needs.
• Electronic health record errors such as incorrect patient information due to a system conversion, a failure in the decision support software to provide an alert, or the sharing of passwords between staff.
• Communication issues often involve provider-to-provider communication but can also include communication gaps with patients or their families.

Managing APP Risks

Appropriate risk management strategies can help healthcare facilities reduce claims and improve patient care and outcomes. The growing importance of APPs underscores the need to implement risk management strategies that address their unique risks. Following are some recommendations:

• Hire appropriately. Screen and credential APPs just like other providers and develop a process for granting privileges. Make sure you spell out responsibilities and that supervising or collaborating physicians are willing and able to work with APPs. Know the law regarding APPs (including what they can do) and implement a clinical review process.
• Manage issues caused by staffing shortages. Staff shortages or emergencies do not create an exemption to scope of practice rules. It’s important to know what APPs are permitted to do under state law and to ensure compliance. Determine what the APP is qualified to do, develop a compliant emergency privileging checklist, make sure the APPs are comfortable with their tasks, and document informed consent throughout the process. Never place APPs in a position where they are pressured to operate outside of their scope of practice, even if your facility is short staffed.
• Implement written supervision or collaboration agreements. APPs may not always have the experience necessary to recognize the need for input or support. Avoid this issue – and the diagnostic errors that can result – by establishing clear expectations regarding supervision and collaboration with physicians. Create written agreements and ensure these comply with state law.
• Improve diagnostic accuracy. Improved diagnostic accuracy can go a long way toward preventing claims and improving outcomes. Develop and establish a tracking system for test results and referrals – don’t let critical results fall through the cracks. Document non-critical results and manage incidental findings. Communicating test results and follow-ups are also key.
• Reduce distractions to improve communication. A study published in the Annals of Emergency Medicine found that physicians were interrupted about once every 4.3 minutes. Interruptions are a common issue that can result in lost communication or miscommunication. Healthcare organizations can improve communication by:
  • Identifying and correcting workflows that create interruptions.
  • Creating no-interruption zones.
  • Communicating in patients’ rooms.
  • Empowering providers to speak up and delay interruptions as needed.
  • Training providers to use mental or visual bookmarks to help them remember where they were in a task.
  • Encouraging providers to use real-time communication (face to face, phone, or video) for urgent issues and using clear written communication that highlights key calls to action and avoids jargon.
• Don’t misrepresent. Patients may assume an APP is a doctor. To ensure the patient understands who is treating them, APPs should identify themselves as such and wear name badges that clearly identify their role and licensure. Some states have specific guidance regarding this.

As APPs continue to play an increasingly critical role in the healthcare system, these risk management strategies will become vital for avoiding diagnostic errors and other common claims.
 
This article was based in part on the Coverys presentation “Advanced Practice Providers: Using Claims Data to Manage Risk,” by Marlene Icenhower, BSN, JD, CPHRM.