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Arbaje et al J Patient Saf • Volume 00, Number 00, Month 2015
risk factors, such as care processes within a hospital, which con- that achieved 75% or more interreviewer agreement and deemed
tribute to suboptimal care transitions.23,24 This suggests that there likely to involve a suboptimal care transition were selected for full
is a gap in our approach for how to improve transitions. review of the litigation record and associated documents (medical
Medical malpractice claims are a potentially rich source of records, patient complaint documents, risk management files, and
information about suboptimal care transitions. Malpractice claims incident event documents from patient safety reporting systems).
related to suboptimal care transitions represent egregious mishaps Closed malpractice claims were analyzed for patients
and/or marked patient dissatisfaction, and claims can provide im- 18 years and older, hospitalized and discharged from 4 hospital
portant information regarding underlying system-level risk fac- sites affiliated with an academic medical center (n = 230). Two
tors. Many claims involve sentinel events, from which the health of the 4 hospitals were teaching hospitals. One hospital had ap-
system can learn about how to improve health care quality and re- proximately 1000 licensed beds, and the other 3 had between
duce future risk of liability—an opportunity to “make medical er- 200 and 400 licensed beds each. All claims were opened between
rors into medical treasures.”25 Malpractice claims analyses have January 1, 2000, and December 31, 2009, and included an adverse
made important contributions to patient safety in other areas of event that occurred after discharge from the hospital. To protect
health care,26–30 and claims analyses offer strengths for evaluating confidentiality and privilege, claims were redacted of sensitive
the quality of care transitions: (1) claims integrate documentation or identifying information before analysis (e.g., financial informa-
from both formal legal inquiries and confidential internal investi- tion, details of legal strategy).
gations, and claims can provide detailed descriptions of care, in- A qualitative approach was used to extract a broad set of risk
cluding information that is not always available in medical factors related to a suboptimal care transition from the malpractice
records26,27,30; (2) claims are likely to have information regarding data. We defined risk factor to be any attribute or characteristic at
an entire episode of care that spans across care settings and time. the patient or system level that was present in our review of cases
Combining malpractice claims with clinical documentation and that could potentially increase the likelihood of a suboptimal
and reports of adverse events can inform the development of a care transition (i.e., care that was not safe and/or did not meet the
conceptual model to guide the development of new care transi- patient's or informal caregiver's expectations). First, 3 investiga-
tions planning tools. New tools are needed because current tools tors (A.I.A., E.M.K., and R.T.B.) reviewed a subsample of cases
to measure and improve care transition quality31–33 are incomplete to develop a preliminary coding template based on concepts
and do not typically provide real-time feedback. Thus, the objec- emerging from the review.34 The coding template was reviewed
tives of this study were to (1) evaluate safety risks during care tran- by the entire multidisciplinary research team and refined for use
sitions that have led to malpractice claims and (2) use the claims to in subsequent case reviews. Resulting coding changes were ap-
help develop care transitions planning tools and to pilot test their plied retroactively to all previously coded cases. All of the cases
ability to evaluate care transitions from the hospital to home. were reviewed independently by at least 2 investigators, and differ-
ences were reconciled by consensus. The qualitative research soft-
METHODS ware, ATLAS.ti, was used to facilitate data analysis (ATLAS.ti
Scientific Software Development, Berlin, Germany).
Overview
We undertook a multistep process to achieve the stated objec- Development of Care Transitions Planning Tools
tives. First, we conducted a content analysis of malpractice claims Through Focus Group Ratings of Elements of
and used the results to inform the development of a conceptual Conceptual Model
model of safety risks during care transitions associated with mal- Risk factors within the conceptual model were rated and pri-
practice claims. Then, we conducted structured focus groups in oritized for inclusion in the tools through a series of 2 structured
which participants rated elements of the conceptual model and focus groups with key stakeholders. The care transitions planning
used the results to create 2 care transitions planning tools—one Tool Development Group (TDG) consisted of inpatient physi-
to be used by patients/caregivers and one for frontline care pro- cians, ambulatory physicians, patient safety officers, and senior
viders. Finally, we conducted initial feasibility testing of the tools. health system executives in safety and quality. The steps com-
This study was approved by a Johns Hopkins School of Medicine pleted by TDG members were as follows: (1) conducted a series
Institutional Review Board. of facilitated discussions to prioritize the conceptual domains in
terms of importance to improving patient safety during care
Content Analysis of Malpractice Claims transitions and reducing risk for litigation associated with hos-
Related to Care Transitions pital discharge processes; (2) proposed a list of candidate mea-
We developed a process to extract and analyze malpractice sures for monitoring the quality of care transitions planning; and
(3) narrowed the list of proposed measures and assembled them
claims related to care transitions. Summaries of closed malprac-
tice claim files for the past 10 years involving patients 18 years into 2 brief survey instruments that served as care transitions
and older were obtained from the institution's malpractice insur- planning tools, one intended for use with frontline inpatient
ance carrier (MCIC Vermont). A multidisciplinary research team care providers and another intended for patients and their
of patient safety experts, health services researchers, primary care families/caregivers at hospital discharge (see online supplement,
and hospital-based providers, and administrative leaders devel- http://links.lww.com/JPS/A32).
oped a case definition that was used by 9 expert reviewers to re-
view these claims for relevance to care transitions. A transition- Feasibility Testing of Care Transitions
of-care event was defined as follows: (1) an event occurring after Planning Tool
discharge from an acute care facility in our health system and Feasibility testing of the tools was conducted on 53 patient
(2) an event clearly involving the suboptimal transfer of equip- discharges from an inpatient general medical nursing unit during
ment (dentures, hearing aids, glasses, prosthetics, assistive de- a 2-week period. To test the feasibility of applying the tools in op-
vices, and others), knowable information (diagnoses, test results, erational settings, we recruited staff from a 17-bed inpatient gen-
complications), or components of the management plan at the eral medical patient care unit at one of the hospital sites, which
time of discharge (aftercare, monitoring, follow-up). The claims was already engaged in process improvement efforts to improve
Copyright © 2016 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
J Patient Saf • Volume 00, Number 00, Month 2015 Improving Transitions by Learning from Lawsuits
care transitions at the time of discharge. This unit was chosen be- purpose of these tools is to be used as both (1) an intervention
cause of the presence of institutional champions and strong staff to raise awareness of care transition planning issues in real time
awareness of the importance of improving care transition quality. (as the patient is being discharged) and (2) a measure for monitor-
This allowed for frank feedback that facilitated feasibility testing. ing the quality of care transition planning. Copies of both instru-
Each morning, except for weekends and holidays, physi- ments are included in the Appendix (Supplemental Digital Content,
cians, nurses, social workers, and other hospital staff on this unit http://links.lww.com/JPS/A36).
participated in a 90-minute “multidisciplinary rounds,” (MDRs)
led by the unit's nurse case manager and attended by the unit's so- Feasibility Testing of Care Transitions
cial worker, utilization nurse, pharmacist, dietician, physical and Planning Tools
occupational therapists, and each patient's nurse and hospitalist Feasibility testing yielded several insights. Hospital case
physician. The purposes of this meeting were to (1) review each managers who administered the provider tool reported that the in-
patient's care plan daily, (2) promote early discharge planning, struments were easy to use and did not affect the flow of multidis-
and (3) identify and address issues that might arise after hospital ciplinary rounds. However, case managers noted that it was
discharge. Typically, unit staff spent less than 5 minutes discussing important to actively seek responses from all participants, as some
each patient. later reported that members of the multidisciplinary team did not
To identify potential barriers to administering the tools, pro- raise certain issues out of concern it would delay rounding. Pro-
ject investigators attended MDRs to observe hospital workers viders also expressed concern about identifying and documenting
using the frontline provider tool and separately interviewed dis- problems on the anticipated discharge day, as many issues they
charged patients and their caregivers to obtain responses to the pa- identified (e.g., chronic substance abuse or absence of social sup-
tient tool independent of those obtained by unit nurses. The port at home) were problems that they were unable to address di-
investigators observed MDR workflow and patient-nurse interac- rectly. If the care team had concerns about patients' readiness for
tions for usability concerns related to the tools and recorded inde- discharge (e.g., patient needing additional tests, consultations, or
pendent responses to the provider and patient tools. Differences education before discharge), the team at times did not know dur-
between responses recorded by hospital unit staff and those re- ing morning rounds if the issue had been addressed. The use of
corded by project investigators were compiled and discussed with the tool prompted team members to communicate about these is-
the unit case manager afterward. sues before discharge and act upon unresolved issues.
The frontline provider tool was administered for each patient Patients who received the patient tool reported that the instru-
who was planned for discharge during the hospital unit's MDR ment was acceptable in terms of length and response burden. The
(n = 19). The provider tool was integrated into the MDR workflow primary concern identified during feasibility testing of the tools is
by enlisting the unit case manager to verbally administer the tool that patients and their caregivers often were still waiting for infor-
to the all MDR attendees as a group whenever a patient was iden- mation (e.g., about postdischarge appointments or about test re-
tified as planned-for-discharge that day. The unit case manager sults) at the time they encountered the tool. When they did have
recorded the responses of the group as a whole. Unit nurses admin- the information, patients specifically reported that the care plan
istered and completed the patient tool at the time of discharge when seemed appropriate.
they provided patient/family education (n = 53). Data were col-
lected on paper and later submitted to the project investigators.
DISCUSSION
RESULTS We used malpractice claims to guide the development of care
transitions planning tools. The pair of tools captured the experi-
Content Analysis of Malpractice Claims ences of health care providers, patients, and families, to identify
Related to Care Transitions which patients are at risk for safety problems after they leave the
hospital. The purpose of these tools was to be used as both
The content analysis of claims yielded 33 risk factors to sub- (1) an intervention to raise awareness of care transition planning
optimal care transitions corresponding to domains of the hospital issues in real time (as the patient is being discharged) and (2) as
work system, care transitions processes, and outcomes of care. a measure for monitoring the quality of care transition planning.
Table 1 represents a list of these factors and their definitions. Implementation of these instruments in an initial pilot study
For each litigation claim, we reviewed the associated medical re- yielded lessons about feasibility and further modifications.
cords, patient complaint documents, risk management files, and The results of this study were important because they led to a
incident event reporting documents from patient safety reporting novel approach to combine claims data and clinical data for use
systems. The factors in Table 1 from the claims analysis repre- in patient safety analyses and to the development of new tools to
sented a distinct set of factors related to suboptimal care transi- aid in hospital discharge. There were several important lessons
tions, revealing little overlap across the different reporting learned from this study. First, in analyzing the claims, we found
methods (litigation claims, patient relations reports, and patient little overlap among litigation claims, patient relations reports,
safety reporting systems). and patient safety reporting systems. This suggests that the exam-
ination of claims helped to identify a unique set of risk factors for
Care Transitions Planning Tool Through Focus suboptimal care transitions. Second, these risk factors corresponded
Group Ratings of Elements to not only patient-specific clinical factors but also factors related to
With the use a series of 3 structured rating exercises, the the hospital work system, care transitions processes, and outcomes
TDG converted the risk factors into 2 care transitions planning of care. This suggests, as others have,23,24 that broader targets po-
tools. The frontline provider tool is an 8-item instrument designed tentially can be helpful in care transitions planning. Broader tar-
for administration during hospital multidisciplinary discharge gets identified in this work include identifying the following
rounds before hospital discharge. It is intended to identify con- situations: patients whose expectations have not been met; pa-
cerns of frontline, inpatient care providers. The patient tool is a tients who required additional interventions by others (family,
4-item instrument intended for administration to patients and their friends, network) to meet their needs; patients experiencing an ad-
families/caregivers immediately before hospital discharge. The verse event; patients with unsuccessful attempts to access health
Copyright © 2016 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Arbaje et al J Patient Saf • Volume 00, Number 00, Month 2015
TABLE 1. Risk Factors to Suboptimal Care Transitions and Definitions Resulting From Qualitative Analysis
care in the organization; or providers experiencing difficulty coor- soliciting feedback from patients and informal caregivers as well
dinating or communicating about care plans. These broader as “sending” and “receiving” health care providers before, during,
targets highlight the importance of providing feedback to and and after the care transition. Third, the collection of real-time
Copyright © 2016 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
J Patient Saf • Volume 00, Number 00, Month 2015 Improving Transitions by Learning from Lawsuits
information using our care transitions planning tools identified implement action plans and build “recovery scenarios”23 to ad-
potential suboptimal care during transitions at a point well before dress challenges identified by the tools.
a claim might be filed. Feasibility testing of these tools yielded Third, the care transitions planning tools provide information
several insights that will shape further development of the care from multiple perspectives. A consensus document by the U.S. Na-
transitions planning tools. tional Transitions of Care Coalition47 outlines 3 perspectives from
Our study had some limitations. Claim files represent highly which information needs to be obtained to fully address optimal care
selected cases from which it can be difficult to generalize. They coordination and transitions: (1) patient/family, (2) health care profes-
may also be subject to hindsight bias and other biases.35 However, sional, and (3) health care system.31 The tools complement existing
claims file analysis also has some strengths relative to other measures examining care transitions and incorporate the 3 perspec-
methods, most prominently its ability to detect latent errors as well tives outlined by U.S. National Transitions of Care Coalition. Next
as including information from several different perspectives.36 steps for this effort will be to revise the tools and administration pro-
Given the high rates of rehospitalizations and postdischarge ad- cedures based on lessons learned from feasibility testing, retesting
verse events that have been reported previously, our examination the revised tools, and further dissemination of these instruments
of malpractice claims and associated documents likely under- as part of efforts to improve care transitions planning processes.
estimated the prevalence of care transitions issues in our organiza- Finally, lower-than-expected case identification in malprac-
tion. One reason for this may be that certain kinds of failures, such tice claims and limited overlap between claims documents and
as suboptimal care transitions, are reported through mechanisms those from patient relations, patient safety, and risk management
other than the legal system. Moreover, many suboptimal care tran- sources suggest the need to not rely on one source of information
sitions are likely not reported at all because robust mechanisms for and instead combine multiple sources of event reporting when
reporting are often not in place after discharge, a time when many studying suboptimal care transitions. The process developed for
care transition deficiencies are detected. This suggests that using this study may be applied to any of these nonstructured records.
hospital documentation systems to comprehensively examine sub-
optimal care transitions will require combining and integrating CONCLUSIONS
multiple sources of event reporting. The processes developed for Care transitions represent a point of heightened risk in the care
this project may also be used to examine other kinds of nonstruc- of patients and an opportunity to prevent harm. Strategies to iden-
tured administrative documents, such as patient complaints. tify increased risks of suboptimal care during transitions may
Suboptimal care transitions represent a broad concept in health complement efforts to reduce readmissions, lower health care costs,
care delivery. Many patients and providers may not identify sub- and decrease patient adverse events. The conceptual model devel-
optimal care during transitions as readily as they might identify oped in this study can be used to complement other approaches to
other suboptimal outcomes that arise in care delivery, such as characterize and monitor systems failures during care transitions
postprocedure wound infections, for example. Moreover, some at hospital discharge. This study confirmed observations that noted
risk factors identified in our study may seem more obviously re- a need for practical measures for monitoring care transitions pro-
lated to care transitions than others, yet the common theme is that cesses within health care organizations. The care transitions plan-
the risk factors were identified in care transitions-related claims ning tools developed during this project promise to add to the
and can contribute to patient harm. In other words, although the limited number of tools currently available to health care leaders.
presence of an individual risk factor in isolation may not necessar- Evaluating and synthesizing concerns drawn from malpractice
ily lead to a malpractice claim, several risk factors taken together claims provided insights that enrich our understanding of subopti-
could lead to harm and a subsequent claim. It is also important mal care transitions and the development of care transitions plan-
to note that the underrecognition of suboptimal care transitions ning tools. Pilot testing of the tools suggests that they would be
may also stem in part from a lack of a standardized classification feasible for use with minor adjustment. The malpractice data ap-
system for malpractice claims. Malpractice insurers and health care proach can be used to complement other approaches to character-
organizations can further modify the criteria used in this study to ize systems failures threatening patient safety.
identify claims related to suboptimal care transitions for quality im-
provement purposes. ACKNOWLEDGMENTS
Potential Usefulness of the Care Transitions The authors acknowledge the contributions of Lauree
Planning Tools Barreca and Margaret Garrett, senior counsel for Johns Hopkins
Medicine; Michelle Goldfarb, former director, Loss Prevention &
There are several areas of potential usefulness for the care Patient Safety, MCIC Vermont, for providing this study with access
transitions planning tools developed in this study. First, the pau- to the litigation documents used in this study; Renee Demski, se-
city of practical measures for monitoring suboptimal care transi- nior director, Quality Improvement, The Johns Hopkins Hospital
tions processes poses a barrier to effectively addressing safety and Johns Hopkins Health System; Margaret Neely, case manager
risks during care transitions. The care transitions planning tools at Johns Hopkins Hospital; and Modupe Savage, nurse manager
developed by this project add to the few tools available to clinical at Johns Hopkins Hospital for their support with the implementa-
teams, hospital executives, and other health care leaders.23,37 tion and feasibility testing of the patient and provider tools.
Second, the tools could be used to provide real-time feedback
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