Reducing medical malpractice in ambulatory care represents a priority area that has been relatively neglected in the face of more dramatic and costly inpatient errors. Given shifts in care, increasing stresses on office practices, growing evidence of unreliable office processes, and recent experience of our malpractice insurance carriers, neither complacency nor resignation to the problems of ensuring safe patient-centered office care can be justified. Working with the two leading malpractice insurers in Massachusetts, we have assembled a consortium to improve patient safety and decrease malpractice risk in ambulatory practice-the Proactive Reduction in Outpatient Malpractice: Improving Safety, Efficiency and Satisfaction (PROMISES) project. We would work with leading quality improvement and safety experts to employ state-of-the art approaches and tools to achieve breakthrough changes in sixteen demonstration practices. The project has the following three specific aims:
AIM 1. Apply evidence from malpractice claims to identify key failure modes contributing to ambulatory medical errors and malpractice suits in order to redesign systems and care processes to prevent, minimize, and mitigate such errors in a group of Massachusetts primary care practices. We will target problem-prone processes in 3 areas of identified risk: 1) medication management, 2) test ordering and results management 3) follow-up and referral management AIM 2. Transform communication culture, processes and outcomes in demonstration practices to become more patient and family-centered, particularly around proactively seeking out, hearing, handling, and learning from patients'safety experiences, concerns and complaints.
AIM 3. In conjunction with key Massachusetts policy leaders, liability insurers, clinical, academic, quality improvement and consumer organizations, we will evaluate and disseminate the lessons learned and share successful intervention tools and strategies statewide with a broader audience of practices, practitioners, payers, and policy makers. The intervention would be designed as a randomized control trial comparing 16 demonstration practices with 16 control practices, each with 2-5 primary care providers recruited by the malpractice insurers. We will measure the effects of the improvement efforts using rigorous quantitative and qualitative data from staff interviews, patient surveys and chart review. We will then spread the successful tools, improvements, and lessons statewide.

Public Health Relevance

Previous studies found that malpractice was common, but malpractice suits failed to illuminate the seven of every eight cases where preventable harm occurred. We propose to focus on outpatient practice where most health care is delivered and where the majority of malpractice claims now originate. Legal advocates and medical professionals agree that a more productive focus would be to reduce errors from occurring in the first place. Employing a public health approach, we propose to more effectively engage clinicians, patients, malpractice insurers, and the state public health agency to ensure more timely mitigation of medical errors that occur in outpatient practices, and enhance communication around all aspects of care, particularly in problematic cases.

National Institute of Health (NIH)
Agency for Healthcare Research and Quality (AHRQ)
Research Demonstration and Dissemination Projects (R18)
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Special Emphasis Panel (ZHS1-HSR-F (02))
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Battles, James
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Massachusetts State Department of Pub Health
United States
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Schiff, Gordon D; Reyes Nieva, Harry; Griswold, Paula et al. (2017) Randomized Trial of Reducing Ambulatory Malpractice and Safety Risk: Results of the Massachusetts PROMISES Project. Med Care 55:797-805
Kerrissey, Michaela; Satterstrom, Patricia; Leydon, Nicholas et al. (2017) Integrating: A managerial practice that enables implementation in fragmented health care environments. Health Care Manage Rev 42:213-225
Schiff, Gordon D; Reyes Nieva, Harry; Griswold, Paula et al. (2016) Addressing Ambulatory Safety and Malpractice: The Massachusetts PROMISES Project. Health Serv Res 51 Suppl 3:2634-2641
Singer, Sara J; Reyes Nieva, Harry; Brede, Namara et al. (2015) Evaluating ambulatory practice safety: the PROMISES project administrators and practice staff surveys. Med Care 53:141-52
Schiff, Gordon D; Biondolillo, Madeleine (2014) We have strict statutes and most biting laws--reply. JAMA Intern Med 174:1202-3
Schiff, Gordon D; Puopolo, Ann Louise; Huben-Kearney, Anne et al. (2013) Primary care closed claims experience of Massachusetts malpractice insurers. JAMA Intern Med 173:2063-8