AHRQ Annual Meeting September 19, 2011 Timothy B McDonald, MD JD University of Illinois at Chicago

1. Collaborative Learning From Patient Safety: Presentation From PSOs and International Patient Safety Culture AHRQ Annual Meeting September 19, 2011 Timothy B McDonald, MD JD University of Illinois at Chicago

2. Grantopportunity with PSO component

3. The Seven Pillars: Crossing the Patient Safety – Medical Liability Chasm

4. The Problem Institute of Medicine: 1999 report that shook the medical world Making Matters Worse

5. One potential solution: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

6. 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

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

8. Next steps • Commitment: Leadership • Medical Center; Systems – Vanguard, Resurrection • State Societies – IHA, ISMS, Chicago Medical Society • Insurers – ISMIE, Zurich • Gap Analysis • Identify teams • Metrics • Timeline for implementation • Implement • Measurement • Feedback with shared lessons learned

9. Gap analysis • Organizational structure • By-laws • Current status of event reporting from all levels, including learners • Identify connection/coordination between safety, risk, quality, claims • Degree of integration of physicians and other professionals in analysis of harm events and input into improvements • Current knowledge of PSOs and Patient Safety Evaluation Systems • Review of training efforts around “disclosure” • Current status of “remedies” provided to patients/families • Status of support structure and services for those involved in harm or “near-harm” events

10. Gap Analysis Summary • Reporting systems at rudimentary level • Very limited learner or physician reporting • Limited physician engagement in RCAs • Multiple fears identified • Very narrow understanding of PSOs, PSES • Lack of integration within hospital • Similar lack of integration between hospitals within systems • Little sharing of lessons learned between hospital with same system • BTW, same findings in 15 other hospitals outside Illinois

11. 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

12. One more benefit to PSOsResident Duty Hours:Enhancing Sleep, Supervision and Safety

13. Highlights of IOM report • Mitigating fatigue • Un-announced visits • Protected safe harbor for reporting • Optimize education • Specialty-specific focus • Enhance “culture of safety” • Engage residents in detection of errors, improvement • Use “near misses”, unsafe conditions for learning

14. Highlights of IOM report • Bottom line: without changes “the residency programs are not providing what the next generation of doctors or their patients deserve”.

15. Dealing with the fears: the critical value of PSOs

16. The Seven Pillars:A Comprehensive Approach to Adverse Patient EventsPoints of PSO Value 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

17. PSO value Patient Safety Organization Federal “Protections” Other PSOs PSES removal process Port Patient Safety Evaluation System PSO with abundant learning opportunities Other education

18. Using PSO to allay fears • Based on two Illinois Appellate Court cases • Occurrence reports are discoverable • Construct reporting portal as part of PSES • Without proper By-Laws and Committee structure investigations are discoverable • Work with Safety, Risk, Quality to modify by-laws, restructure committees, create PSES • All process improvements are discoverable • Push RCAs and process improvements into PSO • Lawyers consistently advise physicians to not participate • Multiple meetings with stakeholders, especially malpractice insurers and lawyers – stakeholders now part of re-educating

19. The Seven Pillars and PSOs • One critically necessary design and process feature • Disclosure

20. PSES value Patient Safety Organization Federal “Protections” Other PSOs PSES removal process for Disclosure to Patients and Families Port Patient Safety Evaluation System PSO with abundant learning opportunities Other education

21. The Seven Pillars and PSOs • One critically necessary design and process feature • Disclosure • Before “analysis” • Include patients and families • Obtain consent from participants

22. The need for safe reporting of unsafe conditions • “I was sitting in the surgery clinic…when the residents got their biweekly “time sheets” to fill out. …they felt insulted by the exercise. All their time sheets were identical…they were a farce and the residents knew it…the current system within ACGME is inadequate.” John Brockman President, American Medical Student Association June 18, 2010

23. Next steps • Intense coordination between grant researchers and hospital/system safety-risk managers • System and process re-design to facilitate learning • Close interface with PSO[s]

24. Questions?