Intro to Standard of Care In Medical Malpractice

Every year in the United States over 1.5 million patients are harmed due to an error made by a health care professional which results in over 20,000 medical malpractice claims filed by patients and their families. Doctors are required to provide a certain level of care to their patients or else risk being held liable for any resulting injuries. The "standard of care" is the ruler used to measure the quality, efficiency, and appropriateness of healthcare.

More Than One Medical Malpractice Standard Of Care

The “standard of care” is a measurement of risk of a medical procedure weighed against the usefulness of the procedure. Other factors that influence the standard of care include the competency of the health care professions, lack of due care by the doctor, lack of informed consent, vicarious liability, failure to disclose risks of a procedure, failing to follow-up with a patient or abandoning a patient.

Though the “standard of care” sounds like one overarching rule, it is actually a term that refers to a large group of standards that are used to evaluate the care provided by a healthcare professional. The 1990 publication Clinical Practice Guidelines: Directions for a New Program by the Institute of Medicine recommended four standards to measure the quality of care provided by a health care professional. These standards are:

Practice Guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.

Standards of Quality are authoritative statements of (1) minimum levels of acceptable performance or results, (2) excellent levels of performance or results, or (3) the range of acceptable performance or results.

Medical Review Criteria are systematically developed statements that can be used to assess the appropriateness of specific health care decisions, services, and outcomes.

Performance Measures are methods or instruments to estimate or monitor the extent to which the actions of a health care practitioner or provider conform to practice guidelines, medical review criteria, or standards of quality.

Practice Guidelines (For Avoiding Medical Malpractice)

Practice guidelines are standards of appropriate care that have broad agreement and consensus among medical researchers, practicing health care professionals, medical organizations, and insurers. Practice guidelines clearly separate “good” and “appropriate” care from “bad” or “inappropriate” care. Practice guidelines must be supported by clear evidence of success and by almost unanimous backing to be considered as a medical standard.

To create effective practice guidelines, the guidelines should:

  1. Be developed by multidisciplinary teams of experts in fields related to the guideline
  2. Specify why one form of practice is better than another form of practice, specifically, why the benefits of the new guideline outweigh the risks of other possible guidelines
  3. Be revised in conjunction with new developments in the field of medicine

The most important part of a new practice guideline is identifying risks of the guideline through clinical trials and studies, and proving without a doubt that the new guideline offers less risk in relation to its positive effect compared to an old guideline. Health care professionals are expected to provide care to their patients that is clearly backed by evidence of successful outcomes. The only exception to this rule is when patients choose to have a more risky treatment when they understand the full risks and benefits of the procedure and understand other treatment options.

One practice guideline that was updated within the last few years is the frequency of mammogram screenings. Doctors used to recommend annual mammogram screenings beginning at the age of 40, but new studies found that women with average or low risk of breast cancer who are screened before the age of 45 or 50 are more likely to be diagnosed with and treated for cancer and other conditions that may never cause harm.

Early mammograms are more likely to detect non-harmful abnormalities in women that result in excessive care in the form of biopsies or cancer treatments. See the results of the guideline update from the U.S. Preventive Services Task Force. The new recommendations ask for annual mammograms for women aged 45-50 or older.

Standards of Quality in Medical Malpractice Cases

Standards of quality of care refer to a wide range of care services that can be grouped into patterns and measured against results of clinical trials and against standard practices by other doctors in the same field. Standards of quality will differ for specialty fields of medicine, and may be unique to certain fields.

To develop standards of quality there must first be a consensus about the acceptable forms of care. In the case of breast cancer screening, doctors universally agree that mammograms should not be given annually to all women aged 18 or older. Doctors agree that too many early mammograms can hurt a patient. Doctors also unanimously agree that women over 50 should receive regular mammograms. How doctors make the decision that one guideline is bad and one is good is the standard of quality of the guideline. In other words, the standard of quality is a guideline for critiquing criteria of practice guidelines. The U.S. Preventative Services Task Force (USPSTF) gave a “C” grade to the recommendation that women under 50 receive mammograms, and a “B” grade to the recommendation that women over 50 receive mammograms.

The task force reached those grades by using these criteria:

A – Strongly recommended. The USPSTF recommends the service. There is high certainty that the net benefit is substantial. (The USPSTF found good evidence that [the service] improves important health outcomes and concludes that benefits substantially outweigh harms.)

B – Recommended. The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. (USPSTF found at least fair evidence that [the service] improves important health outcomes and concludes that benefits outweigh harms.)

Level of Certainty          

Description

High

The available evidence usually includes consistent results from well-designed, well-conducted studies in representative primary care populations. These studies assess the effects of the preventive service on health outcomes. This conclusion is therefore unlikely to be strongly affected by the results of future studies.

Moderate          

The available evidence is sufficient to determine the effects of the preventive service on health outcomes, but confidence in the estimate is constrained by such factors as:

  • The number, size, or quality of individual studies.
  • Inconsistency of findings across individual studies.
  • Limited generalizability of findings to routine primary care practice.
  • Lack of coherence in the chain of evidence.

As more information becomes available, the magnitude or direction of the observed effect could change, and this change may be large enough to alter the conclusion.

Low

The available evidence is insufficient to assess effects on health outcomes. Evidence is insufficient because of:

  • The limited number or size of studies.
  • Important flaws in study design or methods.
  • Inconsistency of findings across individual studies.
  • Gaps in the chain of evidence.
  • Findings not generalizable to routine primary care practice.
  • Lack of information on important health outcomes.

More information may allow estimation of effects on health outcomes.

Evidence standards:

Good: Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes.

Fair: Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies, generalizability to routine practice, or indirect nature of the evidence on health outcomes.

Poor: Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in their design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes.

Medical Review Criteria

Medical review criteria are standards used to judge the quality and purpose of medical treatments and services, and to assess the quality of the outcome of the patient. This criteria does not create standards doctors follow in clinical settings, but rather creates standards that allow others to evaluate medical decisions already made by doctors and healthcare professionals.

Medical review criteria set standards for appropriate care. Doctors and health care professionals must answer and document questions about the patient's condition and the possible treatment options to show that the doctor chose the best option based on the facts of the patient.

Medical review criteria can include information like:

  • Do medical standards dictate that the patient should have a preference and was the patient given that opportunity?
  • Did the doctor miss key medical information about the patient and was that information readily available to the doctor?
  • Are there multiple guidelines the doctor could follow?

The Institute of Medicine and other medical organizations have created guidelines for medical review criteria that hospital administration, insurance companies, and other healthcare professionals can follow to best evaluate the situation.

Performance Measures

Performance measures analyze the extent to which a health care professional provides care that falls under practice guidelines. Health care is expected to be safe, effective, efficient, timely, patient-focused, and equitable. Good health care should avoid unnecessary injuries, provide timely treatments based on evidence, not provide excessive treatment nor under treatment, and should allow the patient a role in deciding treatment plans. Performance measures may hold true for all doctors, or be unique to specific specialty doctors or to doctors facing patients with specific conditions.

A 2003 study by the Rand Corporation of a group of patients representative of the American population found that only 54.9% of all patients receive the care they needed based on their age, gender, and medical condition. Performance care standards are in place to make sure doctors provide the care their patients need.

Performance measures assess the quality and value of the care in relationship to other current practices of doctors and health care professionals in the given field. For example, a performance measure for Emergency Medical Technicians (EMTs) might be the time interval between a 9-1-1 call and the arrival of the EMTs, or the time between EMT arrival and the beginning of chest compressing procedures and defibrillation.

Performance measures will also evaluate the cost of the care in relation to its necessity and effectiveness. According to the New York Times, in 2014, an ambulance ride of 200 ft could cost $3,421 and a 20-minute visit to the doctor to get stitches in a cut could cost $40,000. Performance measures include a weighted assessment of the care provided in relation to the outcome and the cost on the patient and entire health care system.

A general physician who orders an MRI for every patient he sees is exposing patients to more harm than good and is costing both the patient and entire health care system unnecessary money.

Learn More about the Standard of Care in Medical Malpractice Cases

These four factors contribute to the definition of the “standard of care” a doctor must provide to patients. To learn more about the specifics of the standard of care in medical malpractice, continue reading:

If you have specific questions about the standard of care, or if you suspect that a physician may have breached the standard of care in your case (or that of a loved one), we offer a free medical malpractice case evaluation. We recommend contacting us as quickly as possible because the statute of limitations can doom a medical malpractice case if action is delayed.

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