Massachusetts Risk Management Survey (MaRMS) of teaching hospital physicians.

OBJECTIVE: To assess and compare the risk management knowledge of physicians from Massachusetts teaching hospitals. DESIGN: A survey. SETTING: Participating Massachusetts teaching hospitals. PARTICIPANTS: 639 of some 2,000 staff physicians of participant hospitals who were sent surveys. An additional 174 postgraduate year 1 (PGY1) and PGY3 house officers also completed the survey. MAIN OUTCOME MEASURES: Percent of questions answered correctly, and comparisons between staff physicians and house officers. RESULTS: Staff physicians scored higher (87%) than PGY1s and PGY3s combined (81%), P<0.001. Scores among staff physicians did not differ according to field of medicine, age, proportion of time spent in clinical practice, or years in practice. PGY3s did not score significantly higher than PGY1s (82% vs. 80%). Some 40% of physicians said they ordered more tests than necessary because of malpractice worries; they indicated 72% of their colleagues do so as well. Physicians in obstetrics-gynecology and emergency medicine were more likely to respond yes to this question than physicians in other fields of medicine (P<0.001), as were physicians who had been defendants in a malpractice suit (88 P=0.013). CONCLUSIONS: Surveyed staff physicians have an adequate risk management knowledge. Training directors should encourage house officers to attend risk management programs to improve their knowledge. Physicians might overestimate the amount spent on defense medicine based on their perceptions of other physicians.

Quality assurance and medical outcomes in the era of cost containment.

Market forces are driving health care organizations to "prove" quality while diminishing costs. Payers for health care, led by large employers and insurance companies, are demanding clinical, financial, and satisfaction outcomes from providers. To meet the challenge, traditional quality assurance based on inspection and rooting out "bad apples" is rapidly being replaced by the industrial engineering principles of continuous quality improvement. A philosophical shift is occurring from a focus on episodes of care delivered by physicians to the delivery of processes of care by teams of health care personnel. We are seeing a shift in emphasis from a fascination with intensive care delivered to sick patients to cost-effective preventive services delivered to populations of well patients. The locus of care delivery is moving from inpatient hospitals to ambulatory clinics and home care. The need for this information is leading to innovation in computer systems and health care organizations. New partnerships are emerging between physicians, nurses, and hospitals. Traditional oversight bodies including the JCAHO and the HCFA-sponsored PROs are restructuring to meet these new demands. New organizations such as the National Committee on Quality Assurance and state governmental agencies are being established to fill the perceived void. Individual surgeons have begun to receive performance data on their individual and group practices. Professional societies have collaborated in the development of clinical guidelines and outcomes data bases. This massive reorganization will take several more years to play out. With careful development it has the potential to dramatically improve patient care through the efficient application of new scientific knowledge and the sustained flow of information back to physicians and patients.