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Learning From the Patient’s Experience: Opportunities to Improve Patient Safety

Learning From the Patient’s Experience: Opportunities to Improve Patient Safety. AHRQ 2009 Annual Conference Timothy B McDonald, MD JD Professor, Anesthesiology and Pediatrics Chief Safety and Risk Officer for Health Affairs University of Illinois at Chicago tmcd@uic.edu.

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Learning From the Patient’s Experience: Opportunities to Improve Patient Safety

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  1. Learning From the Patient’s Experience:Opportunities to Improve Patient Safety AHRQ 2009 Annual Conference Timothy B McDonald, MD JD Professor, Anesthesiology and Pediatrics Chief Safety and Risk Officer for Health Affairs University of Illinois at Chicago tmcd@uic.edu

  2. Principles of Transparency and Patient Engagement • We will provide effective and honest communication to patients and families following adverse patient events • We will apologize and compensate quickly and fairly when inappropriate medical care causes injury • We will reduce patient injuries by learning from the past – and with the involvement of patients and families

  3. A Comprehensive Response to Patient Incidents:The Seven Pillars. McDonald et alQuality and Safety in Health Care [accepted] • Reporting • Investigation • Communication • Apology with remediation • Process and performance improvement • Data tracking and analysis • Education – of the entire process

  4. Concern or unexpected event reported to Safety/Risk Management Data Base “Near misses” Patient Harm? Patient Communication Consult Service Event Investigation Consider “Care for Care Provider” hold bills? Process Improvements Unreasonable Care? Activation of Crisis Management Team Full Disclosure with Apology and Remedy The Seven Pillars:A “Principled Approach” to Adverse Patient Events No Yes No Yes

  5. Concern or unexpected event reported to Safety/Risk Management Data Base “Near misses” Patient Harm? Patient Communication Consult Service Event Investigation Consider “Care for Care Provider” hold bills? Process Improvements Unreasonable Care? Activation of Crisis Management Team Full Disclosure with Apology and Remedy Opportunities for Patient Engagement WithinThe Seven Pillars:A “Principled Approach” to Adverse Patient Events No Yes No Yes

  6. Opportunities for Patient Engagement • Reporting – incidents, provider behavior • Investigation – have critical pieces of information • Communication – teach and provide feedback • Apology with remediation - assessment • Process and performance improvement • Education – inspire and motivate

  7. Linking transparency with patient safety Event Becomes the Trojan Horse for Cultural Transformation Transparency with Accountability

  8. Why is this so important? • > 250 Patient Communication Consults • >50 cases of unnecessary harm with apology • Over 190 performance improvement • Several cases [6] with $ added to waiver of bill • One lawsuit with inability to agree on damages

  9. August 23, 2009

  10. Litmus test for “change in culture”:the first big case “The patient’s family continues to seek care at the University.” Family continues to seek care at the University of Illinois

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