Hospitalists & Medical Liability

by Michael Matray, editor of Medical Liability Monitor

Two decades since the term “hospitalist” was first coined in a 1996 New England Journal of Medicine article looking at the expanding role of general internists employed in the hospital setting, the more than 44,000 hospitalists nationwide are more critical to the success of the American hospital system than ever before. Because hospitalists have demonstrated the ability to decrease the length – and cost – of a patient’s hospital stay, improve overall safety and reduce the number of readmissions after discharge, their expertise is paramount as the healthcare delivery system moves from a volume- to a value-based reimbursement model.

As their presence became more prominent in the late 1990s and early 2000s, hospitalists affected fundamental change to the hospital healthcare system:

• Previously, primary care physicians in private practice attended to their patients in the hospital during daily rounds. If the patient’s primary care physician was not on the hospital grounds when a decision on care arose, the hospital’s clinical staff would call the primary care physician. Now, hospitalists are charged with the continuum of care during a patient’s hospital stay, not the primary care physician.

• Hospitalists took over many roles in the hospital setting, including quality assurance, patient risk management, the teaching of medical students/residents, protocol development, utilization-review activities and patient satisfaction improvement.

• The length and cost of a patient’s stay in the hospital decreased when under the supervision of a hospitalist, and the quality of care and patient satisfaction increased.

The positive effect that hospitalists had on quality and efficiency in the hospital system dovetailed with the emerging realities of managed care, which emphasizes coordination and efficiency as a means to contain overall cost. As such, the number of hospitalists grew from less than 1,000 in the 1990s to more than 30,000 nationwide – with a presence in more than half of all hospitals – by the end of the 2000s. The Bureau of Labor Statistics estimates this sector to grow by 15 percent during the next decade.

With the explosive increase in the number of hospitalists in practice, there has to be a correlating increase in the number of medical professional liability claims against the specialty. Because the hospitalist phenomenon is relatively new, there has been little data available on how the specialty’s medical liability claims benchmark against other specialists and general internists.

Medical professional liability insurer The Doctors Company (TDC) – the nation’s largest physician-owned insurer of physician medical liability – recently analyzed the claims data of its insured hospitalists to publish its “Hospitalist Closed Claim Study: An Expert Analysis of Medical Malpractice Allegations.” The study analyzed 464 claims against hospitalists insured by TDC between 2007 and 2014. More than 2,100 hospitalists were insured by TDC during this period.

According to the TDC study, 78 percent of all claims against hospitalists fell into one of the three allegations: failure to, delay in or wrong diagnosis accounted for 36 percent of all claims against hospitalists; improper management of treatment accounted for 31 percent of all claims against hospitalists; and medication-related error accounted for 11 percent of claims against hospitalists.

Authors of the TDC hospitalist study drilled down on the factors contributing to patient harm, and the most common factors underlying a claim against a hospitalist included: patient assessment issues contributed to patient injury in 35 percent of cases; communication among providers contributed to patient injury in 23 percent of claims; selection and management of therapy contributed to patient injury in 16 percent of claims; communication between patient or family and provider contributed to patient injury in 12 percent of claims; failure to obtain a consult or referral contributed to patient injury in 12 percent of claims; and patient noncompliance factors contributed to patient injury in 12 percent of claims.

Due to the nature of their role in the healthcare delivery system, hospitalists treat patients with a higher acuity and greater complexity without the benefit of an established patient-physician relationship. This bore out when benchmarking hospitalist patient injury severity against all other physician specialties. According to the TDC hospitalist study, 72 percent of claims against hospitalists fell within the high-severity (permanent significant, permanent major, permanent grave or death) range of injury, while only 34 percent of claims against all physicians fell within the high-severity range.

Upon reviewing the claims against hospitalists, TDC created a list of risk mitigation strategies that can help hospitalists avoid the issues outlined in its study. These include building a rapport with nursing staff so that they are more likely turn to the hospitalist should any questions arise, provide advanced warning to the next shift’s hospitalist team for patients who have confusing presentations or deteriorating conditions, review all documentation to be aware of all consultation reports and any subtle changes in the patient’s condition that nurses have noted, among others.

To download a copy of TDC’s “Hospitalist Closed Claim Study,” click here.