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Pipelining is the accumulation of unrecognized liability. This occurs when a health care provider maintains the status quo approach (or a sham program) to the management of a specific risk while the probability of a loss due to that risk has substantially increased. Changes in the chance of a loss can be overlooked for a certain period of time because of the long interval between the occurrence of an injury and the payment of a claim for compensation. In medical malpractice litigation, this delay can be five or more years. During this period, a large number of persons can be injured before the health care provider becomes aware of the accumulating liability.

A dramatic example of pipelining occurred in the Davis Medical School at the University of California. Over a 22-month period, the cardiac surgery and kidney transplant services experienced a dramatic rise in mobidity and mortality. This was ignored (allowing more people to be injured) until other physicians at the university stopped referring patients to the affected services. The publicity surrounding this incident caused the injured patients to become aware of the problem, resulting in $500 million in lawsuits. While this is an extreme example, it does illustrate the risks of an ineffective risk program.

A problem that is related to pipelining is the exacerbation of existing liability through inflexible administrative procedures. A successful quality control program must increase patient satisfaction if it is to reduce litigation losses. Patients do not want to sue health care providers; they sue only when they are left without any other recourse. Inflexible rules about handling patient complaints can cause a patient to feel that litigation is the only recourse. The quality control manager must remember that in today's litigation climate it may cost as much to win a suit as to lose it. The success of a quality control program is determined by the potential suits that are never filed, not the suits that are won after costly an divisive litigation.

This principle is especially important when evaluating legal advice. Lawyers are accustomed to thinking in terms of winning lawsuits, not preventing lawsuits. If the quality control manager can avoid a suit by a small extra effort, this is preferable even if the hospital's attorney feels that the suit will be easy to win. Most attorneys do not appreciate the highly charged emotional climate surrounding health care delivery. Most businessmen negotiate through their attorneys with no personal ill will whatsoever. However, most physicians, when confronted by an attorney, become angry and tend to harden their positions rather than rationally evaluate the alternatives. The concept of negotiation between health care providers and patients is not well understood by most providers. The quality control manager must carefully scrutinize legal advice that suggests that a given course of action may not result in legal liability. The question should not be, "Can we do this without losing a lawsuit?" (the question that lawyers are trained to deal with), but rather, "How can we avoid litigation without adversely influencing patient care or increasing costs unreasonably?" The risk of potential litigation must be borne in many in many situations. The important quality control decision is whether the risk of litigation is balanced by a gain that can be realized only if the risk is taken.

As later chapter will illustrate, there are many situations in which health care providers risk litigation without any gain. A common example is patient access to medical records. Many health care providers refuse to allow patients access to their own medical records. As noted in our discussion of medical records, there is no legal risk and no evidence of medical risk in allowing patients access to their own records. Yet, despite the negligible risk of litigation resulting from patient access to records, some providers even require patients to get an attorney before releasing records. The result of this attitude is to turn a curious patient into an angry patient who feels forced to see an attorney. In many cases, the attorney will not just obtain the records but will also search them for grounds for filing a malpractice suit. Attorneys assume, usually rightly, that a party will not withhold a document unless it is incriminating. The quality control manager must realize that secrecy is a red flag to an attorney. Withholding a medical record is an example of a policy that has no gain to the provider but can often lead to otherwise avoidable litigation.

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