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Background: High reliability in health care requires a balance between intentionally designed systems and individual professional accountability. One element of accountability includes a process for addressing clinicians whose practices are associated with a disproportionate share of patient complaints. This study aimed to evaluate the impact of the Patient Advocacy Reporting System (PARS), a tiered intervention model to reduce patient complaints about clinicians., Methods: A retrospective cohort study was conducted involving a southeastern U.S. orthopaedic group practice. The study assessed the implementation of the PARS program and subsequent malpractice claims from 2004 to 2020., Results: The implementation of PARS was associated with an 83% reduction in malpractice claims cost per high-risk clinician after intervention (p = 0.05; Wilcoxon rank sum test). The overall practice group experienced an 87% reduction in mean annual claims cost per clinician (p = 0.007; segmented regression). The successful adoption required essential elements such as PARS champions, peer messengers, an Office of Patient Affairs, and a clear statement of practice values and professionalism expectations at the time of onboarding., Conclusions: The PARS program was successfully adopted within a surgical specialty group as a part of ongoing risk prevention and management efforts. The period following PARS was associated with a retrospectively measured reduction in malpractice claim costs. The PARS program can be effectively implemented in a large, single-specialty orthopaedic practice setting and, although not necessarily causal, was, in our case, associated with a period of reduced malpractice claim costs., Clinical Relevance: We have learned in previous research that there are clear links between professionalism and patient outcomes (e.g., surgical complications), but agree that the focus here on medical malpractice is not directly clinical., Competing Interests: Disclosure: No external funding was received for this study. The Article Processing Charge for open access publication was funded by the Center for Patient and Professional Advocacy at Vanderbilt University Medical Center. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/H981 )., (Copyright © 2024 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated. All rights reserved.)

Introduction: Unsolicited patient complaints (UPCs) serve as a powerful predictor of increased risk of malpractice claims, and reductions in UPCs, through targeted physician interventions, lower incidence of lawsuits and decrease cost of risk management. We analyzed UPCs, verified by trained counselors in patient relations, to determine the malpractice risk of plastic surgeons, compared to dermatologists, all surgeons, and all physicians, from a national patient complaint registry., Methods: We examined the patient complaint profiles and risk scores of 31,077 physicians (3935 surgeons, 338 plastic and reconstructive surgeons, and 519 dermatologists), who participated in the Patient Advocacy Reporting System, a national registry of UPCs. Patient complaint data were collected from 70 community and academic hospitals across 29 states, from 2009 to 2012. In addition to determining the specific complaint mix for plastic surgery compared to all physicians, each physician was assigned a patient complaint risk score, based on a proprietary weighted-sum algorithm, with a score higher than 70, indicative of high risk for malpractice claims. Patient complaint profiles and risk scores were compared between all groups, using Wilcoxon rank and χ analysis. P values less than 0.05 were assigned statistical significance., Results: Over this 4-year period, the majority of plastic surgeons (50.8%) did not generate any patient complaints, but those who did received an average of 9.8 complaints from 4.8 patients. The percentage of physicians at high risk for malpractice claims, based upon the Patient Advocacy Reporting System index score of patient complaints, was as follows: all physicians, 2.0%; all surgeons, 4.1%; plastic and reconstructive surgeons, 2.4%; dermatologists, 1.4%. Physicians (from 2012 only) who were identified by their sponsoring institutions as "reconstructive" plastic surgeons (n = 41) were 5 times as likely to have a high risk score, compared to physicians who were identified as "plastic" surgeons (n = 233), and were more likely to practice within an academic health care system that had a level 1 trauma center and a plastic surgery residency program. The overall mix of patient complaints from plastic and reconstructive surgeons was nearly the same as the national cohort of all physicians: care and treatment, 49%; communication, 19%; accessibility and availability, 14%; money or payment issues, 9%; and concern for patient/family, 9%., Conclusions: "Reconstructive" plastic surgeons are at increased risk for UPCs, compared to most physicians, especially dermatologists. Because UPCs are a robust proxy for malpractice risk, targeted interventions to decrease patient complaints may improve patient satisfaction and reduce malpractice claims and risk management activity. Monitoring UPCs may permit early identification of high-risk surgeons before malpractice claims accumulate.

Malpractice risk bedevils obstetricians. Suits can be a nuisance or emotionally and financially devastating. In this chapter, we ask simple questions and provide empiric data to demonstrate that interpersonal factors trigger suits. A supportive relationship between the obstetrician, team members, and the patient can reduce the chance of being sued after an unexpected event. Collaboration between physician colleagues and others to promote teamwork reduces error and increases patient satisfaction. Physicians who disrupt the emotional ecosystem increase liability for themselves and team members. A method of identifying physicians at increased risk and a strategy for intervening to reverse the pattern is described.

Objective: To study the association between physicians' complaint records and their risk management experiences in a regional healthcare center., Data Sources: Patient complaints about physicians in a large border state medical center's hospital and outpatient clinics were recorded and coded. The study period was from January 2001 through December 2003. These records were linked to the counterpart physicians' data covered by the institutions' risk management plan through June 2004., Study Design and Data Collection: All physicians at the institution who had contact with patients during the study period were identified as surgeons or non-surgeons. Complaints for these physicians were recorded by the institution's Office of Patient Relations (OPR) and independently coded using a standardized protocol to characterize the nature of the problem and to uniquely identify the person complained about. The complaint records were then linked to the risk management files (RMFs) for the defined physician cohort. In addition, these data were supplemented with clinical service values (RVUs) which were available for 338 members (76%) of the 445 member cohort., Principal Findings: Both patient complaints and risk management events were higher for surgeons than for non-surgeons. This was true for the number of RMFs, those involving expenditures, and for lawsuits. Logistic regression was used to assess the effects of complaint counts, practice type and volume of clinical activity. All were statistically significant in predicting the number of RMF openings, RMF openings with expenditures and lawsuits. Predictive concordance was 75% or greater for each of the three risk management outcomes., Conclusions: Expressions of patient dissatisfaction and practice type are significantly related to risk management experiences in a regional medical center. Associations of risk management experiences with volume of clinical activity (RVUs) for surgeons in the regional medical center environment were not as strong as those found in a similar study reported from an academic medical center.

Context: A small number of physicians experience a disproportionate share of malpractice claims and expenses. If malpractice risk is related in large measure to factors such as patient dissatisfaction with interpersonal behaviors, care and treatment, and access, it might be possible to monitor physicians' risk of being sued., Objective: To examine the association between physicians' patient complaint records and their risk management experiences., Design, Setting, and Participants: Retrospective longitudinal cohort study of 645 general and specialist physicians in a large US medical group between January 1992 and March 1998, accounting for 2546 physician-years of care., Main Outcome Measures: Computerized records of all unsolicited patient complaints were recorded by the medical center's patient affairs office, coded to characterize the nature of the problem and alleged offender, and compared with each physician's risk management records for the same period., Results: Both patient complaints and risk management events were higher for surgeons than nonsurgeons. Specifically, 137 (32%) of the 426 nonsurgeons had at least 1 risk management file compared with nearly two thirds (137 [63%] of 219) of all surgeons (chi2(1)= 54.7, P<.001). Both complaint and risk management data were positively correlated with physicians' volume of clinical activity. Logistic regression revealed that risk management file openings, file openings with expenditures, and lawsuits were significantly related to total numbers of patient complaints, even when data were adjusted for clinical activity. Predictive concordance of specialty group, complaint count, clinical activity, and sex for risk management file openings was 84%; file openings with expenditures, 83%; lawsuits, 81%; and multiple lawsuits, 87%., Conclusions: Unsolicited patient complaints captured and recorded by a medical group are positively associated with physicians' risk management experiences.

Objective: To determine whether Florida's implementation of a no-fault system for birth-related neurologic injuries reduced lawsuits and total spending associated with such injuries, and whether no-fault was more efficient than tort in distributing compensation., Methods: We compared claims and payments before and after implementation of a no-fault system in 1989. Data came from the Department of Insurance's medical malpractice closed claim files and no-fault records. Descriptive statistics were compiled for tort claims before 1989 and for tort and no-fault claims for 1989-1991. We developed two projection approaches to estimate claims and payments after 1989, with and without no-fault. We assessed the program's performance on the basis of comparisons of actual and projected values for 1989-1991., Results: The number of tort claims for permanent labor-delivery injury and death fell 16-32%. However, when no-fault claims were added to tort claims, total claims frequency rose by 11-38%. Annually, an estimated 479 children suffered birth-related injuries; however, only 13 were compensated under no-fault. Total combined payments to patients and all lawyers did not decrease, but of the total, a much larger portion went to patients. Compensation of patients after plaintiff lawyers' fees rose 4% or 44%, depending on the projection method used. Less than 3% of total payments went to lawyers under no-fault versus 39% under tort., Conclusion: Some claimants with birth-related injuries were winners, taking home a larger percentage of their awards than their tort counterparts. Lawyers clearly lost under no-fault. Because of the narrow statutory definition, many children with birth-related neurologic injuries did not qualify for coverage.

Objective: To examine the relationship between prior physician malpractice experience and patients' satisfaction with care., Design: Women were interviewed using a questionnaire that contained structured and open-ended questions., Participants: Mothers of all stillborn infants, infant deaths, and a random sampling of viable infants drawn from 1987 Florida Vital Statistics were sorted into four groups based on the malpractice claims experience of their obstetricians between 1983 and 1986. Interviews were completed with 963 of 1536 women, most by telephone, 53 by in-person interview., Main Outcome Measures: Mothers' responses to closed-ended and open-ended questions about their perceptions of the care they received during their pregnancy, labor, and delivery., Results: Even though none of the women actually filed a claim, a consistent pattern of differences emerged when comparing women's perceptions of care received. Patients seeing physicians with the most frequent numbers of claims but without high payments were significantly more likely to complain that they felt rushed, never received explanations for tests, and were ignored. In response to the open-ended question, "What part of your care were you least satisfied with?" women seeing physicians in the High Frequency malpractice risk group offered twice as many complaints as those seeing physicians who had never been sued. Problems with physician-patient communication were the most commonly offered complaints., Conclusion: Physicians who have been sued frequently are more often the objects of complaints about the interpersonal care they provide even by their patients who do not sue.

Objective: To determine the relationship between prior malpractice claims experience and the quality of clinical obstetric care., Design: Historical cohort study of obstetricians, classified by their prior malpractice claims experience, with blinded review of medical records from their practices 5 to 10 years later., Setting: Florida obstetricians who lost, settled, or defended malpractice claims between 1977 and 1983 and who were still practicing obstetrics in 1987., Main Outcome Measures: Objective and subjective assessment of quality of clinical care of patients attended by obstetricians with different histories of malpractice claims., Results: No differences were found in any of the objective or subjective measures of the quality of clinical care provided to patients of obstetricians who were classified into one of four groups according to their prior claims history., Conclusions: No relationship was found between prior malpractice claims experience and the technical quality of practice by Florida obstetricians. Strategies that attempt to identify physicians at risk for future clinical errors by using data on prior malpractice claims (such as the National Practitioner Data Bank) may be misjudging the likelihood that substandard clinical care will be provided by physicians with prior claims.

Objective: To identify self-reported reasons that prompt families to file malpractice claims following perinatal injuries., Design: Families were interviewed by telephone using a questionnaire that contained structured and open-ended questions., Participants: Mothers of infants who had experienced permanent injuries or deaths and had closed malpractice claims in Florida between 1986 and August 1989 were interviewed. Questionnaires were completed by 127 (35%) of a total of 368 such families., Outcome Measures: Reasons prompting families to file and families' descriptions of medical events, advice from acquaintances, and the quality of physician-family communication., Results: Families volunteered numerous reasons for filing: advised by knowledgeable acquaintances (33% of respondents), recognized cover-up (24%), needed money (24%), recognized that their child would have no future (23%), needed information (20%), and decided to seek revenge or protect others from harm (19%). Over one third of all families indicated that they were told by medical personnel prior to filing that the care provided had caused their children's injuries. Families expressed dissatisfaction with physician-patient communication. Families believed that physicians would not listen (13% of sample), would not talk openly (32%), attempted to mislead them (48%), or did not warn about long-term neurodevelopmental problems (70%)., Conclusion: Families give many reasons for filing a claim. Obtaining money may not be the only goal for some families who file suit.