The Problem

1. The “Seven Pillars” Approach: Improving Patient Safety and Decreasing Liability Through TransparencyTimothy McDonald, M.D., J.D.

2. The Problem • Institute of Medicine report To Err is Human: Building a Safer Health System • Wall of Silence: The Untold Story of the Medical Mistakes that Kill and Injure Millions of Americans by Rosemary Gibson and Janardan Prasad Singh Institute of Medicine: 1999 report that shook the medical world Making Matters Worse

3. The UIC experience prior to 2004 • “Deny and Defend” approach to all patient harm • Loss of patient and family trust • Minimal internal or external transparency • Non-existent learning from harm events or “claims” • Progress in patient safety stymied • Occurrence reports – only 1,500 per year • No resident physician occurrence reports • Resident Patient Safety education confined to orientation • Inconsistent participation on hospital-wide committees

4. A “less than honest” approach when things went wrong years ago • The beginning circa 2000 • The K.C. case, COO of sister hospital • Preoperative testing prior to plastic surgical procedure • Evening before surgery - lab tests done • WBC <1,000 (normal value 4-12,000) • Only Hgb & Hct checked on day of surgery • Repeated CBC (complete blood count) postop • WBC <600 • Called as critical result to the unit – reported to “Mary, RN” • Never found out who “Mary, RN” was

5. A “less than honest” approach when things went wrong • Patient discharged from hospital on post-op day 3 • Died 6 weeks later from leukemia • Physician colleagues/friends reported death to Risk Management • Legal Counsel & Claims Office were approached with a plan for “making it right” • All attempts to disclose, apologize, or provide remedy were rejected by University

6. Barriers Benefits What about an Extremely Honest “Principled Approach”?

7. Benefits Maintain trust Learn from mistakes Improve patient safety Employee morale Psychological well-being Accountability Money Less litigation Barriers Lack of skill Loss of job Reputation “Shame and blame” Loss of control Loss of license Fear of lawyers, litigation Non-standard process Money Taking a “Principled Approach”

8. Adding to the lack of confidenceOct 2008, the defense rests……. John Stalmack article “It Is a Mistake to Admit a Mistake,” Vol. 6, Issue 8, Chicago Hospital News, 7 (October, 2008)

9. Fears • Based on two Illinois Appellate Court cases • Occurrence reports are discoverable • Without proper By-Laws and Committee structure investigations are discoverable • All process improvements are discoverable • Lawyers consistently advise physicians to not participate

10. 2005 UIC Board approves “Patient Safety-Transparency” program • Comprehensive • Integration of safety, risk, quality and credentials • Linkage to claims and legal – deal with the fears • Longitudinal patient safety education plan • UGME • GME • CME

11. The Seven Pillars:A Comprehensive Approach to Adverse Patient Events Data Base Unexpected Event reported to Safety/Risk Management “Near misses” Patient Harm? No Patient Communication Consult Service 24/7 Immediately Available Yes Consider “Second Patient” Error Investigation Hold bills Process Improvement Activation of Crisis Management Team No Inappropriate Care? Yes Full Disclosure with Rapid Apology and Remedy

12. A Comprehensive Response to Patient Incidents:The Seven Pillars. McDonald et al Quality and Safety in Health Care, Jan 2010 • Reporting • Investigation • Communication • Apology with remediation • Process and performance improvement • Data tracking and analysis • Education – of the entire process

13. The Seven Pillars:A Comprehensive Approach to Adverse Patient Events Data Base Unexpected Event reported to Safety/Risk Management “Near misses” Patient Harm? No Patient Communication Consult Service 24/7 Immediately Available Yes Consider “Second Patient” Error Investigation Hold bills Process Improvement Activation of Crisis Management Team No Inappropriate Care? Yes Full Disclosure with Rapid Apology and Remedy

14. Occurrence reports: if you don’t know about it you can’t fix it

15. ACGME core competencies • Patient Care • Medical Knowledge • Practice-Based Learning & Improvement • Interpersonal and Communication Skills • Professionalism • Systems-based Practices

16. Aggregate resident physician occurrence reporting data

17. The Seven Pillars:A Comprehensive Approach to Adverse Patient Events Data Base Unexpected Event reported to Safety/Risk Management “Near misses” Patient Harm? No Patient Communication Consult Service 24/7 Immediately Available Yes Consider “Second Patient” Error Investigation Hold bills Process Improvement Activation of Crisis Management Team No Inappropriate Care? Yes Full Disclosure with Rapid Apology and Remedy

18. The Patient Communication Consult Service • PCCS – immediately available 24/7 • Current options • Empowerment • Participation • Expectations • Physician involvement • Patient-family involvement

19. Communication is the key

20. The Seven Pillars:A Comprehensive Approach to Adverse Patient Events Data Base Unexpected Event reported to Safety/Risk Management “Near misses” Patient Harm? No Patient Communication Consult Service 24/7 Immediately Available Yes Consider “Second Patient” Error Investigation Hold bills Process Improvement Activation of Crisis Management Team No Inappropriate Care? Yes Full Disclosure with Rapid Apology and Remedy

21. UHC Derived Safety and Quality Measures

22. The Seven Pillars:A Comprehensive Approach to Adverse Patient Events Data Base Unexpected Event reported to Safety/Risk Management “Near misses” Patient Harm? No Patient Communication Consult Service 24/7 Immediately Available Yes Consider “Second Patient” Error Investigation Hold bills Process Improvement Activation of Crisis Management Team No Inappropriate Care? Yes Full Disclosure with Rapid Apology and Remedy

23. Claims experience

24. ROI for institutions:Improving safety reduces liability “Reducing Patient Safety Incidents by 10 decreased claims by 3.9.” http://www.rand.org/pubs/technical_reports/TR824.html

25. AHRQ/Seven Pillars Project focus • Patient Safety first • Improved communication • Reduce preventable injuries • Compensate patients/families fairly and timely • Reduced medical malpractice liability

26. Pillar #6 Data

27. What next • 10 hospitals in Chicago • 8 hospitals in South Carolina with SCHA • 2 hospitals in New Jersey • Collaboration with other grantees in Colorado, Washington, Massachusetts, Texas • Begin to work with Policy Makers on removing barriers and creating incentives

28. Next steps • Commitment: Leadership • Medical Centers • State Societies • Insurers • Gap Analysis • Identify teams • Metrics • Timeline for implementation • Implement • Measurement • Feedback

29. Questions