October 19, 2021By Lance Baily

Dr. Schaffer Explains How Healthcare Simulation Can Reduce Medical Malpractice Claims

Does healthcare simulation training help to reduce malpractice rates across obstetrics and gynecology? A team of five medical professionals sought to find an answer to this question through their original research entitled “Association of Simulation Training With Rates of Medical Malpractice Claims Among Obstetrician–Gynecologists”, published in the Journal of Obstetrics and Gynecology. Specifically, the data compare rates before and after participation in clinical simulation training, while maintaining a focus on team training during a high-acuity clinical case. While previously HealthySimulation.com covered this research in our article Significant Reduction in Malpractice Claims After Medical Simulation Training, this article goes further with an exclusive interview with  study’s lead author, Dr. Adam Schaffer, MD, MPH, Assistant Professor of Medicine at Brigham and Women’s Hospital at Harvard, to better understand the research and what it means for our industry’s future.

HealthySimulation.com: Where did the idea for this malpractice simulation research stem from?

Dr. Schaffer: One of the challenges in evaluating medical simulation programs is how to measure their efficacy. As described in a paper by Cox and colleagues (Cox T, Seymour N, Stefanidis D. Moving the Needle: Simulation’s Impact on Patient Outcomes. Surg Clin North Am. 2015 Aug;95(4):827-38. doi: 10.1016/j.suc.2015.03.005. Epub 2015 Apr 22. PMID: 26210974), many efforts to evaluate simulation programs examine whether the participant felt that the training was valuable or believes that their skills have improved due to the simulation training. However, a more compelling outcome to look at in assessing whether simulation programs are working is whether they result in improved patient care.

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Since malpractice claims generally arise from actual adverse clinical events, looking at malpractice claims as an outcome in assessing simulation training allows us to get at the affect simulation is having on actual patient care. In addition, CRICO—the malpractice insurer involved in the study, who is the malpractice insurer for the Harvard-affiliated medical institutions—offers a premium reduction program to incentivize participation in simulation training by clinicians. We also wanted to look at whether the simulation training was having a salutary effect on malpractice claims rates.

HealthySimulation.com: In your experience, how have malpractice rates across obstetrics and gynecology impacted the healthcare industry?

Dr. Schaffer: As is true for almost all medical specialties, the overall trend in obstetrics and gynecology is that malpractice claims rates have been decreasing. That said, compared to other specialties, obstetrics and gynecology have high malpractice claims rates and the average amount paid on malpractice claims. (Reference: CRICO’s report Medical Malpractice in America) Thus, obstetrics and gynecology make sense as a specialty on which we want to focus our efforts to enhance patient safety and reduce malpractice claims rates.

HealthySimulation.com: What was your reaction to the study’s results/conclusions?

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Dr. Schaffer: I was pleased to see that participation in simulation training was associated with a decrease in medical malpractice claims rates. Very few patient safety programs have been associated with a decrease in malpractice claims rates, and so it was really encouraging that our data suggested that simulation training was able to “move the needle,” with a significant decrease in malpractice claims rates occurring after participation in simulation training.

HealthySimulation.com: How does healthcare simulation training have the ability to influence rates of malpractice?

Dr. Schaffer: When we look at the data about the factors underlying the adverse events that occur within obstetrics and gynecology, which have the potential to become malpractice claims, many of them revolve around ineffective communication and teamwork. For example, in a report from the Joint Commission about the root causes underlying sentinel events in obstetrics, the most common issue was communication problems, which were present in 72% of cases.

The next most common issue was deficiencies in the organizational culture, including an inability to work as a team and a dysfunctional hierarchy, which were present in 55% of cases. These are the types of skills that the simulation training we studied was designed to enhance. Moreover, the simulation training occurs in a clinical context—a patient suddenly becoming very sick—in which it is especially important that everyone communicates effectively and works together as a team. An important caveat is that, given the retrospective design of our study, we were able to show an association between simulation training and a subsequent reduction in malpractice claims rates, but we could not prove causation.

HealthySimulation.com: Why do you and the other authors recommend that wider use of clinical simulation training within obstetrics and gynecology be considered?

Dr. Schaffer: We have data showing that the skills that the simulation training we studied was designed to develop, such as teamwork and communication, are important factors contributing to adverse events, and so enhancing these skills is important to improving patient safety. Many of the simulation sessions involved relatively rare high-acuity clinical scenarios, making it especially important that one gain experience in these situations in a setting, such as simulation, in which one can learn from one’s mistakes without any negative impact on an actual patient. There has been an increasing recognition within obstetrics and gynecology of the importance of simulation training, with the majority of ob-gyn residency programs now reporting that they offer simulation-based training.

There is a video depicting simulation of the sort we studied. Encapsulating why we need simulation training, there is a moment in the middle of the video in which someone shouts “Who’s running this code?” Ensuring that there is a functional team hierarchy so that you always know who’s running the code, is one of the reasons we need simulation training.

HealthySimulation.com: After the conclusion of this study, is there any related research you plan to pursue next?

Dr. Schaffer: One of the particularly valuable attributes of the malpractice data we have is that it includes the specific contributing factors underlying the adverse event giving rise to the malpractice claim, which is determined based on a manual review of the cases by trained nurse coders. One possible next step is to use these contributing factors to examine whether we are seeing a decrease in the malpractice claims involving the specific skills domains that simulation training is designed to enhance. There is also the potential to use the information obtained from looking at these contributing factors to inform the design of future simulation programs.

Malpractice Claim Rates Research Background

Together, the authors performed a retrospective analysis comparing the claim rates before and after clinical simulation training among 292 obstetrician-gynecologists, all of whom were insured by the same malpractice insurer, who attended one or more clinical simulation training sessions from 2002 to 2019. According to the research, the insurer provided malpractice claims data involving study physicians, along with durations of coverage, which the authors used to calculate claim rates, expressed as claims per 100 physician coverage years.

Related Article: Significant Reduction in Malpractice Claims After Medical Simulation Training

Then, the authors used three different time periods in their presimulation and postsimulation training claim rates comparisons: the entire study period, two years presimulation and postsimulation training, and 1-year presimulation and postsimulation training. Secondary outcomes included indemnity payment amounts, percent of claims paid, and injury severity.

From their research, the authors found that, compared with presimulation training, malpractice claim rates were significantly lower postsimulation training for the full study period (11.2 vs 5.7 claims per 100 physician coverage years; P<.001). They were also significantly lower during the two-year presimulation and postsimulation training (9.2 vs 5.4 claims per 100 physician coverage years; P=.043).

Also according to the research, for the one-year presimulation and postsimulation training comparison, the decrease in claim rates was nonsignificant (8.8 vs 5.3 claims per 100 physician coverage years; P=.162). Further, attending more than one clinical simulation session was associated with a greater reduction in claim rates. Postsimulation claim rates for physicians who attended one, two, or three or more simulation sessions were 6.3, 2.1, and 1.3 claims per 100 physician coverage years, respectively (P<.001).

Compared with presimulation training, there was no significant difference in the median or mean indemnity paid percent of claims on which an indemnity payment was made, or median severity of injury after clinical simulation training. Ultimately, the authors used all of this information to deduce that there was a significant reduction in malpractice claim rates after simulation training. They recommend that wider use of clinical simulation training within obstetrics and gynecology be considered.

Read the Full Clinical Simulation Research Article

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