Risk Insurance

Grant award program partnerships with your professional liability insurance carrier: An innovative approach to loss prevention and improved patient safety By Phillip M. Cox II, Esq., Jan Rebstock, RHIT, LHRM, CPHRM, Randall C. Jenkins, Esq., Marvin A. Dewar, MD, JD, and Laura Gruber, MBA, MHS

The financial success of a malpractice insurance program is directly influenced by how effectively the covered providers respond to risk. This article describes a University Self-Insurance Program partnership to provide small grants to providers who have the expertise and passion for a specific risk reduction activity that is cost effective and measurable and has a high probability of improving patient care and reducing claims or lawsuits. Implementation of this small grant concept can be tailored to become operational in virtually any setting from an independent medical practice to a multistate healthcare system. I N TR O D U C TI O N Grant awards for risk management, loss prevention, and patient safety initiatives often involve substantial federal grant opportunities or nonprofit foundation award programs. While both federal and nonprofit programs such as those developed by the Agency for Healthcare, Research and Quality (AHRQ1), National Institutes of Health (NIH2), and the Robert Wood Johnson Foundation make available important funding for healthcare provider–driven projects focused around national priorities, there is also a role for small-scale funded grants that take advantage of unique local opportunities to focus on internal needs and objectives that may also meet national or international safety objectives. Indeed, relatively modest grant awards that leverage the energy and interests of local healthcare providers to solve issues of immediate local importance can produce an immediate and direct impact that greatly exceeds the resources provided.3 Emerging as a trend in small-scale grant funding, a number of such programs are now being sponsored and/or administered by medical malpractice insurance providers.4,5 From a business perspective, funding and administering healthcare grants makes practical sense for malpractice carriers. The financial success of a malpractice insurer is directly influenced by how effectively the insured providers respond to risks. The specific focus of the various insurance carrier grant programs vary according to needs and objectives. This article describes a

© 2014 American Society for Healthcare Risk Management of the American Hospital Association Published online in Wiley Online Library (wileyonlinelibrary.com) • DOI: 10.1002/jhrm.21133 34

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university self-insurance program partnership to provide small grants to insured providers who have the expertise and passion for a specific risk reduction activity that is cost effective and measurable and has a high probability of improving patient care and reducing claims or lawsuits.

opposed to investing in a large multi-initiative project that could span years.

A N I N N O VATI V E PA RTN E R S HI P

The SIP recognized a mutual philosophy and shared sense This innovative program pairs the College of Medicine of purpose in targeting patient safety and loss prevenOffice of Continuing Education with the University of tion initiatives that also had a high probability of reducFlorida Health Science Center Self-Insurance Program ing claims by empowering providers to impact care and (SIP) to create the W. Martin Smith Interdisciplinary mitigate loss. In 2011, the SIP established a partnership Patient Quality and Safety Awards Program (Smith with the UF CME office to fund, promote, and develop Awards). The SIP provides professional liability insurance the Smith Awards program, named after the foundto the 6 colleges of the University of Florida Health ing director of the University of Florida Self-Insurance Science Center,6 to other state medical schools in Program, who had a 40-plus-year career commitment to Florida, including Florida State University, University patient safety and claims reduction. of Central Florida, Florida International University, and Florida Atlantic Univeristy (as well as its two The partnership finances several achievement-focused proaffiliate teaching hospitals).7 The jects with modest awards over a quanUniversity of Florida Continuing tified period.9 Consequently, 7 or 8 small grants are awarded semiannually Medical Education (UF CME) office (January and July) in amounts up to provides education programs and $25 000, with project completion not professional development for the The grant process to exceed 18 months. The grant profaculty of the University of Florida cess is competitive, with approximateCollege of Medicine. In recent is competitive, with ly 3 applications submitted for every years, the Accreditation Council grant awarded. The addition of the for Continuing Medical Education approximately 3 SIP as a grant partner with UF CME (ACCME) has emphasized the applications submitted for means the awards program now has importance of aligning continuing the specific goal of sponsoring projects educational efforts with both national every grant awarded. that dovetail with claims reduction, and local quality improvement and loss prevention, and strategic patient patient safety initiatives. The UF safety initiatives. Submissions that CME office strongly supports that focus on measurable patient safety trend and initiated a competitive improvements that have the likelihood small grant initiative to provide of reducing future claims have a higher probability of resources to faculty who developed time-limited and receiving funding. discrete projects likely to successfully address a specific clinical quality or patient safety issue of importance to the enterprise. Partnering with the already existing CME P R O GR A M P R O C E S S E S A N D PAR AM ET ER S Clinical Quality Awards program allowed the SIP to expand an ongoing, proven program by adding resources In addition to increased funding and a greater focus on and direction and provide an incentive to a number of its loss prevention and claims reduction, the SIP and UF clients to reduce claims, improve patient safety through CME accomplished further refinements of the grant measurable loss prevention research effects, and advance process by developing a tracking system for each award the delivery of care. cycle and a more robust process that delineates clear expectations of award recipients and accountability measures that are conducive to project success. BACKG ROU N D The first collaborative Smith Awards were awarded in 2012, adopting the guiding philosophy of the original CME program, which was that individuals who have conceived innovative projects with achievable goals are empowered to succeed with funding to implement their ideas. Participant enthusiasm and personal buy-in would fuel the success of feasible projects more effectively than a systemwide project mandated from the top down (as identified in a study by McClelland8). The program’s thesis is that providing resources to several small, focused projects over a specified time period would result in multiple simultaneous improvements as DOI: 10.1002/jhrm

The initial tasks were to develop enhanced project requirements and a standardized grant application (Exhibit 1). To become a recipient of a Smith Awards grant, projects must meet the following criteria: • The project’s objective must improve clinical education or implement a clinical process improvement that can directly advance patient safety and minimize the opportunity for claims and litigation. • The project must have a detailed implementation plan and a method for evaluating the impact of the process and/or educational improvement effort.

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Exhibit 1: Grant Application Information

Section I: PROJECT TITLE:

Section II PROJECT DESCRIPTION

PRINCIPAL INVESTIGATOR INFORMATION: Name/Title: Department: Professional Mailing Address: Phone Numbers: Office: Cell: Professional Email Address: NOTE TO PRINCIPAL INVESTIGATORS: Please attach CV (no more than 5 pages please) Other Team Member(s) Biographical Information: Name/Title: Department: Section III BUDGET REQUEST Total Amount Requested: Anticipated Project Duration: Budget Category: Amount Requested Personnel Regular salary Other Personnel Services (OPS) Consultants Benefits Total Operating Expenses Office supplies Computer supplies Travel (in-state) Travel (out-of-state) Office equipment Printing Postage/mailing Food Miscellaneous Total Total Expenses BUDGET JUSTIFICATION: Describe each major budget category according to its direct relationship to achieving the project goals. 36

Project Overview (1-page maximum) Describe how the project promotes a patient safety and clinical quality goal as described in the program description materials. (1-page maximum) Describe how staff and faculty will work together to accomplish project goals. (1-page maximum) Describe the project methodology and timeline. (5-page maximum) Describe how you will measure project success. (1-page maximum) Describe your plans for presenting, publishing or disseminating the project results locally and beyond. (one-half-page maximum) References (one-half-page maximum)

Section IV Signatures: Please place a date signed by each signature Principal Investigator Co-Investigator(s)

Acknowledged: Department Chair Or Hospital Leader Department Administrator

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Exhibit 2: Quarterly Progress Report

• Institutional Review Board (IRB) approval must be obtained prior to initiating the project and receiving funds unless it meets the definition of a Continuous Quality Improvement project.10 • A continuing educational program must be developed from the project with a copy of any published material resulting from the project provided to the Smith Awards program. • Funding requests for personnel to support new full-time employment positions or ongoing expenses extending beyond the grant period are not approved. Monies requested for equipment that would be more appropriately submitted through the regular capital budget process are not approved for grant purposes. • Travel expense requests are confined to attending conferences for the purpose of poster or lecture presentations on completed project results and capped at $5 000.11 DOI: 10.1002/jhrm

Quarterly progress reports (Exhibit 2) are required from all approved projects. A final project report (Exhibit 3) containing detailed impact evaluations is due at the end of the grant. Web page links for the Smith Awards grants are now on both the Florida Board of Governors Self-Insurance Programs website12 and the UF Health CME website13 to promote the availability of the grants and make it easy for applicants to access grant-related information. A grant review committee made up of members from the SIP, UF Health Administrators, providers, and UF CME reviews and evaluates applications and selects the grant awardees. The committee uses a scoring evaluation form (Exhibit 4) to evaluate the submission in a fair and equitable manner. Recipients of project grants are recognized at a ceremony where they give a short synopsis of their projects and

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Exhibit 3: Final Progress Report

stated objectives. Previous grant awardees who are at the midpoint of their project are also asked to do a brief presentation to update the grant committee on their progress and to serve as an example for the new grant winners.

P ROGRAM IMPAC T Since the initial Smith Awards in January 2012, the partnership between the UF CME office and the SIP has resulted in over $438 000 awarded to fund 22 grants that address a wide variety of improvement initiatives (Exhibit 5). As of this writing, the initial grant recipients have not completed their 18-month cycle. Consequently, anticipated return-on-investment analyses and evaluations on 38

the impact of the process and/or educational improvement efforts are still pending. However, early feedback on funded projects has been encouraging. One example is the Second Victim Staff Program grant awarded in 2012. The proposal seeks to increase the awareness of the needs of healthcare providers who are involved in an adverse patient event or unanticipated outcome, and who now feel they have failed the patient, are secondguessing their clinical skills, and are even contemplating a career change (as identified by Scott14). The objective was to develop a second victim support committee that would select and educate peer support responders in crisis intervention, team briefing, and mentoring. Once the initial responders were in place, there was a facilitywide rollout and promotion of a 24/7 support number to call when needed. Research cited in the project found that “second victim” healthcare providers undergo

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Exhibit 4: W. Martin Smith Interdisciplinary Patient Quality & Safety Awards Evaluation Sheet

Grant Proposal #’s

1

2

3

4

5

6

7

8

9

10

Comments:

Means criteria Met X Means criteria Not Met (>50% of subcategory criteria is considered met)

1. Topic Relevance: a. addresses a National, State, or local patient safety/clinical process improvement initiative or goal b. proposed project has high probability of preventing/reducing adverse events and claims

2. Methodology : a. Designed to directly improve patient safety, clinical processes and/or delivery of care b. approach is interdisciplinary and involves appropriate team members c. methodology describes the goals d. proposal includes project steps and a timeline for each part of the process e.does not exceed 18 months in duration

3. Outcome Measures : a. proposal describes how project success will be objectively measured and achievements sustained

4. Educational Activities : a. proposal includes a plan to complete a CME approved study presentation to include resultant findings and improvement process changes b. project is expected to result in publication, poster presentation or other scholarly activity

5. Budget Evaluation: a. Total fund request does not exceed $25,000 b. Requests for limited FTE support funding is confined to the grant period c. Equipment funding request is not to offset what should be a capital budget expense d. proposed travel budget expenses do not exceed $5,000

Overall Grade: A- meets all 5 criteria; B- meets 4 of 5 criteria; C- meets 3 of 5 criteria; D- meets 2 of 5 criteria; F- meets 1 or less criteria

predictable recovery stages that include “enduring the inquisition”15 and coping with high levels of anxiety over institutional investigation, licensure actions, and litigation. Knowing how devastating it can be for providers involved in an adverse event from working with them as witnesses and defendants in lawsuits and practitioner license investigations, Smith Awards committee members recognized that a second victim program could provide vital peer support counseling. The project principal investigator, Virginia Pesata, ARNP, reports that, to date, 40 healthcare providers have been trained to provide peer support, with the objective of responding to anyone who calls or otherwise requests help within 24 hours.16 Pesata relates that “We are on track to be able to provide support and perspective to providers who’ve been shaken by the effects of an undesired outcome. It doesn’t take a lot of time, but talking to a peer about what happened does so much for these folks. We want to give them appropriate resource referrals and let them know they are not alone.” DOI: 10.1002/jhrm

C H A LLE N GE S The next step in the evolution of the Smith Awards is to develop a meaningful mechanism for analyzing return-oninvestment based on project results reported by awardees. Traditional monetary-based performance measures used to evaluate the efficiency of investment or to compare the efficiency of multiple investments do not always translate precisely in a social investment context.17,18 The leadership of the Smith Awards seeks measurable ways of assessing economic value for each award winner as well as measure the perception and experience of interested parties and identify quantifiable gauges of what has changed as a result of the grant awards.

C O N C E P T A P P LI C ATI O N S While this award program was developed within an academic medical center, variations of this small grant concept could easily be applied and accomplished in (continued on page 41)

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Exhibit 5: The following is a current list of projects funded through the Smith Awards as of July, 2013

Project Title

Awards Amounts

Improving Patient and Family Centered Care: A Family Partner for the Inpatient Unit at Shands Hospital for Children at the University of Florida

$23 050

Developing a Second Victim Staff Pilot Program for the Consequences of Unanticipated Clinical Events

$24 381

Implementation of a Hospital Based Discharge Intervention to Improve Heart Failure Readmissions

$24 540

Implementation of a Prospective Quality Assessment Program for the UF-Shands Breast Cancer Program

$27 318

Prehospital Sepsis Recognition

$24 974

Venous Air Embolism (VAE): A Widespread and Likely Fatal Complication and the Development of a Multidisciplinary Simulation Model for the Education of the Physiology, Detection and Management of VAE.

$25 000

Management of the Traumatic Brain Injury Patient in Acute Care

$15 000

Impact of Structured Support Group on Quality of Life & Disease Course in Teenagers with Inflammatory Bowel Disease

$11 069

Implementation of a Protocol, for Early Identification & Management of Sepsis, Severe Sepsis/Septic Shock Patients—An Institution Wide Multidisciplinary Collaborative

$25 000

Improving Physician/Patient Communication with AIDET (Acknowledge, Introduce, Duration, Explanation, Thanks)

$5 131

Medication Error by Hospitalized Patients and Analysis of Patient Satisfaction Using a Daily Medication list

$10 700

Best Fed Beginnings: A First Step

$15 000

The Effect of a Pain Management Protocol on Postoperative Neurosurgical Pain

$24 200

Impact of Collaborative Care Services for High-Risk Patients After Discharge From a Large Urban Academic Medical Center

$11 113

Building Infrastructure to Develop and Promote a Culture of Safety: A Pilot Program for General Surgery Patients

$24 975

Pressure Ulcers: Crisis of Prevention

$24 100

Implementation of Obstetric Emergency Simulation Drills

$20 000

Communication Intervention to Improve Patient Experience During a Genetic Counseling Visit: Pre-visit Pilot Project

$18 900

Reducing Errors in Radiation Treatment through the Implementation of Electronic Safety Checklists within the University of Florida Department of Radiation Oncology

$18 500

Can Program Development Improve the Quality of Care for Patients with Breast Cancer?

$24 859

Expectation Management and Medical Information (EMMI) Patient Education Implementation

$18 500

Patient Comprehension of Discharge Medication Regimen Post Percutaneous Coronary Intervention

$22 500

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(continued from page 39) other facility settings. Medical malpractice insurance companies welcome value-based proposals to improve patient safety through targeted system improvements. The partnership described in this article is currently being evaluated for implementation by diverse insurance carrier and healthcare provider combinations. With minor alterations, grant partnerships can become operational in virtually any setting from an independent medical practice to a multistate healthcare system.

SUMMARY A partnership between a professional liability carrier and covered healthcare providers and facilities to jointly invest in patient safety and claims-focused initiatives is a trend that adds a new dimension to the term loss prevention. The Smith Awards model, with its strong localized partnerships with interested stakeholders, is one that can be modified to fit a variety of settings. In addition, collaboration among groups with similar goals and objectives, such as what occurred between the University of Florida Self-Insurance Program and Continuing Medical Education Office, provides an opportunity for a resulting synergy that leverages available resources toward the shared goal of improving safety and reducing claims. Most important, the program promises to be a winwin for all stakeholders: the patients, who benefit from improvements in the delivery of care; the insureds, who enjoy higher patient satisfaction, fewer adverse events, and lower premiums for sustained loss prevention improvements; and the insurers, who realize a reduction in claims and improved loss results.

RE FE REN C ES 1. AHRQ has funded approximately 851 patient safety grants over the past ten years. http://gold .ahrq.gov/projectsearch/grant_search_result.jsp ?SORT=YEAR&&PORT=C. AHRQ’s recent “Advances in Patient Safety Through Simulation Research” grant program would support project budgets of up to $350 000 in total cost per year. 2. http://grants.nih.gov/grants/guide/pa-files/PAR-11 -024.html. 3. Grant awards of less than $25 000 over a 1- to 2-year period. 4. Through its foundation, the Doctor’s Company focus grant monies on funding medical meetings and conferences with a primary focus on patient safety. http:// www.tdcfoundation.com/index.htm. DOI: 10.1002/jhrm

5. Ohio Hospital Association Insurance Solutions, Inc., a malpractice carrier funded by the Ohio Hospital Association, focuses its grant awards on projects that improve upon or implement new clinical patient safety policies or processes. McClelland DC, Winton DG. http://www.ohanet.org/news-article/ohais-grant -funding-available-for-patient-safety-risk-managementprograms/13547/. Accessed December 23, 2013. 6. University of Florida Health Science Center consists of the College of Medicine, the College of Nursing, the College of Pharmacy, the College of Dentistry, the College of Public Health and Health Professions, and the College of Veterinary Medicine. 7. SIPs exist for the following institutions: University of Florida, University of South Florida, Florida State University, University of Central Florida, Florida Atlantic University, Florida International University, UF Health Shands Hospital, and UF Health Jacksonville. 8. McClelland DC, Winter DG. Motivating Economic Achievement. New York, NY: Free Press, 1969. Researcher David C. McClelland, PhD, studied the achievement motive of individuals at Harvard University for over 20 years. Dr. McClelland’s findings on achievement motivation suggested that achievement-oriented people tend to follow what has been dubbed “the overload principal,” whereby they set moderately difficult but potentially achievable goals, which maximizes their ability to master the challenge they are working on. However, McClelland also recognized that because reaching the goals is difficult, in order to succeed, people do far better when undertaking activities they care about. 9. The partnership has allowed the program to double the level of funding and increase the number of award recipients to 18 awardees in 2011–2012. 10. Following the initial grant awards in January 2012, it became apparent that more assistance was needed to minimize delays in the IRB process. Several of the awardees had no previous experience navigating the IRB process, which can be extremely daunting and frustrating to those unfamiliar with it. As a result, one of the IRB directors volunteered to be the point of contact for Smith Awards recipients who need guidance and assistance. This IRB representative attends the award sessions in January and July to discuss the process in general and to set up individual meetings with all who request one. Additionally, because projects could not be initiated nor funds released without first obtaining IRB approval, quarterly progress report due dates begin after receiving IRB approval. 11. Several of the initial budget requests for travel included significant amounts for conference

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attendance, so this was an area that required further clarification resulting in restricting funds to attend conference for presenting lectures or poster presentations on results of completed grant projects. The amount of the request was also capped at $5 000. 12. Florida Board of Governors Self-Insurance Programs website. http://www.flbog.sip.ufl.edu/. Accessed December 23, 2013. 13. University of Florida Health. W. Martin Smith Interdisciplinary Patient Quality and Safety Awards Program. http://www.cme.ufl.edu/clinical-quality -awards. Accessed December 23, 2013. 14. Scott SD, Hirschinger LE, Cox KR, McCoig M, Hall LW. The natural history of recovery for the healthcare provider “second victim” after adverse patient events. Qual Saf Health Care. 2009;18:325-350; doi:10.1136/ qshc.2009.032870. 15. Scott S, Miller V. Have a heart: caring for our own. ASHRM Webinar; 2012. 16. A preintervention survey was prepared and data from the survey were collected from over 270 nurses, physicians, therapists, pharmacists and social workers. The results of the survey were reviewed and used to create the peer responder training. 17. Arvidson M, Lyon F, McKay S, Moro D. The ambitions and challenges of SROI. TSRC Working Paper 49; 2010. 18. Millar R, Hall K. Social return on investment (SROI) and performance measurement. Pub Mgt Rev. 2013;15(6):923–941. doi:10.1080/14719037.2012. 698857.

ABOUT TH E AU TH ORS Phillip M. Cox II, Esq., is the associate director of patient safety research and education for the Florida Board of Governors Self-Insurance Programs and an adjunct assistant

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professor with the University of Florida College of Public Health and Health Professions. He earned his law degree from Indiana University–Bloomington School of Law and is a member of the Florida Bar. His practice specialty is medical malpractice, patient safety law, and other medical-legal issues. Jan Rebstock, RHIT, LHRM, CPHRM, is a coordinator of patient safety research and education for the Florida Board of Governors Self-Insurance Programs. Responsibilities include risk management consultant to program participants, online educational program development, coordination of the W. Martin Smith Interdisciplinary Patient Quality and Safety Awards program, and is creator and editor of the program’s quarterly publication, Risk Rx. She is a graduate of Alfred State College in New York and the University of Florida. Her healthcare career spans 35 years, and she has served as a director of Health Information Management, director of quality, health facility evaluator for Florida’s Agency for Health Care Administration, and hospital risk manager. Randall C. Jenkins, Esq., is the President, UF Healthcare Education Insurance company, and Director of the UF, FIU, UCF, and FAU Self-Insurance Programs. He is also a clinical associate professor of Health Care Law and Ethics, University of Florida College of Public Health and Health Professions, and adjunct professor at the UF Levin College of Law. Mr. Jenkins, a licensed member of the Florida Bar Association, focuses his practice areas to medical malpractice litigation, insurance litigation, and related healthcare medical-legal issues. Marvin A. Dewar, MD, JD, is the Senior Associate Dean and Chief Executive Officer of University of Florida Physicians at the University of Florida College of Medicine. Dr. Dewar completed his medical degree at the University of South Florida College of Medicine and his JD from the University of Florida College of Law and is a member of the Florida Bar. Laura Gruber, MBA, MHS, is the senior director of Administration, Strategy, and Education for the University of Florida Physicians and is responsible for administrative activities for the University of Florida Physicians as well as the Continuing Medical Education unit of the University of Florida College of Medicine. She earned her Bachelor of Science in Business Administration, Master of Business Administration, and Master of Health Science degrees from the University of Florida.

JOURNAL OF HEALTHCARE RISK MANAGEMENT • VOLUME 33, NUMBER 3

DOI: 10.1002/jhrm

Grant award program partnerships with your professional liability insurance carrier: an innovative approach to loss prevention and improved patient safety.

The financial success of a malpractice insurance program is directly influenced by how effectively the covered providers respond to risk. This article...
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