No-Charge Policy for Serious Adverse Events

1. An AHA Member Teleconference Series No-Charge Policy for Serious Adverse Events

2. No-Charge Policy for Serious Adverse Events The Experience of the Exempla Health System April 18, 2008, 1:00 pm ET • Featured Speakers • Jeff Selberg, President and CEO, Exempla Health System & AHA Board of Trustees • David Munch, M.D., Chief Clinical and Quality Officer, Exempla Lutheran Medical Center • Nancy Foster, Vice President Quality and Patient Safety Policy, American Hospital Association For Assistance: 1-800-424-4301 or express@aha.org

3. No-Charge Policy for Serious Adverse Events • Introduction • Past ExperienceCurrent ExpectationsFuture Goals

4. No-Charge Policy for Serious Adverse Events • The Exempla Experience • What We Believe • What We’re Doing • What We’ve Learned

5. No-Charge Policy for Serious Adverse Events Best in the Nation Strategy • Our Goals • Our Report Card • From the Boardroom to the Bedside Transparency • Accountable to the Public and Patient • Hosting the National Quality Forum

6. No-Charge Policy for Serious Adverse Events

7. No-Charge Policy for Serious Adverse Events

8. No-Charge Policy for Serious Adverse Events • The Leapfrog Group asks hospitals to commit to 4 actions if a never-event occurs within their facilities. • Apologize to the patient. • Report the event. • Perform a root cause analysis. • Waive costs directly related to the event.

9. No-Charge Policy for Serious Adverse Events Burning the Ships • The Denver Post interview • Commitment to the Leapfrog Group • Development, implementation, learning and improvement

10. No-Charge Policy for Serious Adverse Events • Policy, Procedure and Practice Development • Horizontal Collaboration • All hospitals • Legal, Risk Management, Business Office, Quality Data Systems • Vertical Collaboration • Board approval August 15th • Executives, management, staff

11. No-Charge Policy for Serious Adverse Events • A Learning Effort • “Perfection is the Enemy of Progress” • A Committee of Scientists • Monthly analysis of adverse event activity and use of the policy/ procedure • Revisions based on experience • Focused Coordination of Activity • Patient Safety Officers • Just-in-time teaching and use

12. No-Charge Policy for Serious Adverse Events • Adverse Events, Including Sentinel and Never Events • Policy Statement • Confirmation/Notification • Analysis • Action Plans • Procedures • Adverse Events • Sentinel Events • Never Events • Disclosure/Apology

13. No-Charge Policy for Serious Adverse Events • Adverse Events Procedure • Notify - Occurrence report, director, patient safety • Investigate - RCA (full or abbreviated), CCA, FMEA • Analyze • Develop action plan • Review with executive • Implement and monitor

14. No-Charge Policy for Serious Adverse Events • Sentinel Events Procedure • Notify patient Safety, senior staff, others • Take immediate corrective action • Disclose to patient/family • Investigate  Analyze  Action Plan • Report: Executive, Site Performance Excellence Committee, Board of Directors, external agency • Monitor action plans

15. No-Charge Policy for Serious Adverse Events • Never Events Procedures • Determine if incident is a never event • Hold billing until confirmation and RCA completed • Follow Sentinel Event procedures • Determine charges directly related to never-event • to be waived • Communicate to patient/family

17. Adapted from the work of James Reason on systems approaches to managing the risks of organizational accidents

18. No-Charge Policy for Serious Adverse Events • Disclosure and ApologyDon’t Blow the Opportunity - From Policy to Practice • Organizational awareness campaign: What it is? Why we do it? Who to notify? When it is done? • Team of coaches - 24/7 presence: Rapid Response Team concept • Delivering the message to the patient • Physician lead: nursing, others • Supporting your staff • When Things go Wrong: Responding to Adverse Events: A Consensus Statement of the Harvard Hospitals

19. No-Charge Policy for Serious Adverse Events • Disclosure and Apology • Coordinated by subject matter experts • Patient safety officers • Performance improvement staff • Medical staff presidents and elects • Clinical risk managers • Senior teams

20. No-Charge Policy for Serious Adverse Events • Reporting Dilemma • State health department • Law enforcement • JCAHO • Other: State hospital association

21. No-Charge Policy for Serious Adverse Events • Other Opportunities • Take advantage of the discomfort - have conversations about support, learning, improvement and patient safety. • Feedback to operational plans • Make never events a priority for improvement. • Set up database to track types, costs, locations, root causes. • Don’t forget to support the staff.

22. No-Charge Policy for Serious Adverse Events • Resources and Follow-up • Go to: http://www.aha.org/aha/issues/BCC/080418-materials.html • Download additional resources and send AHA your questions, comments, feedback. • Upcoming Teleconferences • Thursday May 1, 11:30 am ET, featuring HCA, Inc. • Tuesday, May 24, 1:00pm ET, featuring Children’s Hospital and Regional Medical Center, Seattle • Register at www.aha.org/aha/issues/BCC/080418-teleconference-registration.html