Key Learnings from Risk Management Practice Reviews

Over the last few weeks, we visited several practices to conduct risk reviews. These visits afforded us and the practitioners an opportunity to learn and share medico-legal risk knowledge. These are the key learnings from these visits:

Typical Case Report

We received a letter of demand and a request for records from Ms X submitted by her lawyer accusing Dr Y of negligence. Amongst documents received was a consent by Ms X that her patient records can be accessed by the insurers and lawyers, and she will also report Dr Y to the Health Professions Council of South Africa (HPCSA).

The allegations were as follows:

• Dr Y performed a procedure on Ms X without fully informing her of the reasons why
• Dr Y failed to give Ms X antibiotics, as a result, she developed wound sepsis that required several further procedures and a prolonged stay in hospital, including in ICU
• Dr Y instructed her receptionist to call Ms X and convey blood test results
• Dr Y was not always present during Ms X’s stay in hospital and she did not even bother to follow up after she was discharged from hospital, yet Dr Y billed for the full stay even for the mistakes made by her

Ms X wants the following:

• An apology from Dr Y
• Monetary compensation for pain and suffering
• For Dr Y to be suspended from practice

Key Lessons

Contacting the doctor for risk management practice review visit:

Receiving the letter from the insurer generates untold anxiety from the doctor. The following are some of the questions from the doctor:

• “Am I in trouble?”
• “Am I a risky Doctor?”
• “Is this an underhanded way of cancelling my policy?”
• “This is just giving me sleepless nights.”  

We realised how stressful the letter is for the doctor, and where possible, we call the doctor prior to sending the letter and provide context to the visit or we call and discuss with the doctor before the visit. We realised that most doctors who have been in practice for decades, have never received a visit from their previous insurer/s. When they receive a risk letter, it was almost a guaranteed way that their cover will be terminated.  

Review of patient records:

When we visited Dr Y, we discussed at length Ms X’s claim and requested to review her records. The records are reviewed against the HPCSA guideline. We learnt that not all practitioners are aware of the HPCSA guideline pertaining to keeping patient records. The two important lessons have been (a) duration for the retention of health records and (b) recording of material non-clinical notes. In the case of Ms X, material facts were recorded. The notes stated clearly that the risks, benefits and possible complications were discussed before the procedure was undertaken, and Ms X was afforded time to think about the procedure. She returned a week later and agreed to undergo the procedure.

During a visit to a different practice, the doctor could not retrieve patient records for a child he saw twelve years prior. The doctor stated that he thought patient records are only stored for six years, instead of up to 21 years for minor patients.

Informed consent:

In discussing Ms X’s claim, informed consent became central. Ms X signed a hospital informed consent form, not Dr Y’s informed consent form. The understanding from Dr Y was that any informed consent is valid if there is a signed one. Reviewing the hospital informed consent, it did not meet the minimum standard expected by the HPCSA. However, Dr Y’s patient notes were clear enough that Ms X was fully informed of the procedure before the operation. The important lesson is that patient records and the informed consent form, complement each other.

The role of the HPCSA:

The role of the HPCSA is one of the contentious discussions during the physical reviews. Dr Y believed that the HPCSA is failing doctors by not protecting them against frivolous claims by patients. “Why do we have to pay these annual HPCSA fees, if they cannot protect us? Are we paying them to punish us?” This is a sentiment shared by a few doctors that we visited. In our interactions with doctors, it has become important to discuss the role of the HPCSA and not assume that all doctors are aware of the statutory role of the HPCSA.

Improved relationships and responsiveness:  

The physical risk management practice reviews have created an avenue where our doctors have been able to contact us for advice and guidance. At the end of the reviews, most doctors appreciate the visit and the knowledge shared during the review. We gain a better understanding of the doctor’s environment and have adjusted our approach to risk management. From all the doctors we have visited, we are seeing improved responsiveness and proactive interaction. One of the doctors said, “I have been in private practice for 37 years and no insurer has ever visited my practice. I am very happy with EthiQal.”