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© 2008 The Board of Trustees of the University of Illinois
New Approaches to Transparency
Timothy B McDonald, MD JD Professor, Anesthesiology and Pediatrics University of Illinois College of Medicine
Chief Safety and Risk Officer for Health Affairs University of Illinois Hospital and Health Sciences System
© 2008 The Board of Trustees of the University of Illinois
© 2008 The Board of Trustees of the University of Illinois
Quality Colloquium “Communication” Boot Camp Faculty
Rick Boothman JD, University of MichiganBill Sage MD JD, University of TexasTom Gallagher MD, University of WashingtonMichelle Mello JD PhD, Harvard SPHAlan Lembitz MD, COPICJeff Driver JD, StanfordAlan Woodward MD, MMSKen Sands MD, Beth IsraelJanet Cohn JD, NYSDPHChristine McCoy JD, Ascension HealthTim McDonald MD JD, University of Illinois
© 2008 The Board of Trustees of the University of Illinois
Some more background
Institute of Medicine:1999 report that shook the medical world
© 2008 The Board of Trustees of the University of Illinois
Some more background
Institute of Medicine:1999 report that shook the medical world
© 2008 The Board of Trustees of the University of Illinois
Some more background
Institute of Medicine:1999 report that shook the medical world
Making Matters Worse
© 2008 The Board of Trustees of the University of Illinois
February 2012, Volume 31, Issue 2
Part of the issue
© 2008 The Board of Trustees of the University of Illinois
Impact on the medical malpractice community
© 2008 The Board of Trustees of the University of Illinois
Extreme Honesty and TransparencyBarriers Benefits
© 2008 The Board of Trustees of the University of Illinois
Extreme Honesty and TransparencyBarriers
FearsLitigationNational Practitioner Data BankShame, blameReputationLack of skillsLack of process
BenefitsLearningImprovingLess litigationLower costsIntegrityMoraleHealing
© 2008 The Board of Trustees of the University of Illinois
Bottom linePatient Safety benefits far outweigh risks.
© 2008 The Board of Trustees of the University of Illinois
A Comprehensive Response to Patient Incidents: The Seven Pillars. McDonald et al Quality and Safety in Health Care, Jan 2010
ReportingInvestigationCommunicationApology with remediation – including waiver of hospital and professional feesProcess and performance improvementData tracking and analysisEducation – of the entire process
© 2008 The Board of Trustees of the University of Illinois
Goals of the Seven PillarsReduce harm thru transparency and learningReduce lawsuits through early, effective communication with all partiesResolve inappropriate care cases early, efficientlyDefend appropriate care vigorouslySupport patient and family engagementSupport care professionals following harm events
© 2008 The Board of Trustees of the University of Illinois
The Original Seven Pillars: A Comprehensive Approach to the Prevention and
Response to Patient Events
Unexpected Event reported toSafety/Risk Management
Patient Harm?
Consider “Second Patient”Error Investigation
Hold bills
InappropriateCare?
Full Disclosure with Rapid Apology and Remedy
Process Improvement
Data Base
Yes
Yes
No
© 2008 The Board of Trustees of the University of Illinois
What’s wrong with this picture?????
Unexpected Event reported toSafety/Risk Management
Patient Harm?
Consider “Second Patient”Error Investigation
Hold bills
InappropriateCare?
Full Disclosure with Rapid Apology and Remedy
Process Improvement
Data Base
Yes
Yes
No
© 2008 The Board of Trustees of the University of Illinois
After Patient and Family Engagement in Telluride 2006
© 2008 The Board of Trustees of the University of Illinois
The Seven Pillars: A Comprehensive Approach to the Prevention and
Response to Patient Events
Unexpected Event reported toSafety/Risk Management
Patient Harm?
Consider “Second Patient”Error Investigation
Hold bills
InappropriateCare?
Full Disclosure with Rapid Apology and Remedy
Process Improvement
Data Base
PatientCommunicationConsult Service
24/7Immediately
Available
Yes
Yes
No
No
“Near misses”
Activation of Crisis Management Team –
emotional first aid
© 2008 The Board of Trustees of the University of Illinois
You cannot fix what you do not know about
© 2008 The Board of Trustees of the University of Illinois
Challenges to reportingOvercoming fears
Shame and blameAngering supervisors, co-workersProgram punishment
Establishing relevanceReporter apathy – No feedback
Health system – no QI feedback for reporterIndividual – no learning for reporting
© 2008 The Board of Trustees of the University of Illinois
Addressing the challengesProvide method for safe, confidential reportingEnsure non-retribution to reportersProvide immediate educational feedback to learner (experiential – foundational and customized)Provide regular aggregated, de-identified educational feedback to hospitals, programs, reportersLink to quality and safety process improvementsAlso focus on important learner specific issues such as fatigue, supervision, hand-offs, professionalism.
© 2008 The Board of Trustees of the University of Illinois
ReportingReporting established as an expectation and part of Core Competency assessment
© 2008 The Board of Trustees of the University of Illinois
© 2008 The Board of Trustees of the University of Illinois
Resident physician occurrence reporting data Journal of Graduate Medical Education, June 2010
© 2008 The Board of Trustees of the University of Illinois
Event data
© 2008 The Board of Trustees of the University of Illinois
The Seven Pillars: A Comprehensive Approach to the Prevention and
Response to Patient Events
Unexpected Event reported toSafety/Risk Management
Patient Harm?
Consider “Second Patient”Error Investigation
Hold bills
InappropriateCare?
Full Disclosure with Rapid Apology and Remedy
Process Improvement
Data Base
PatientCommunicationConsult Service
24/7Immediately
Available
Yes
Yes
No
No
“Near misses”
Activation of Crisis Management Team –
emotional first aid
© 2008 The Board of Trustees of the University of Illinois
Peer to peer support: for physicians by physicians
© 2008 The Board of Trustees of the University of Illinois
The Seven Pillars: A Comprehensive Approach to the Prevention and
Response to Patient Events
Unexpected Event reported toSafety/Risk Management
Patient Harm?
Consider “Second Patient”Error Investigation
Hold bills
InappropriateCare?
Full Disclosure with Rapid Apology and Remedy
Process Improvement
Data Base
PatientCommunicationConsult Service
24/7Immediately
Available
Yes
Yes
No
No
“Near misses”
Activation of Crisis Management Team –
emotional first aid
© 2008 The Board of Trustees of the University of Illinois
Pillar 2 - investigationWhat happened and why?
© 2008 The Board of Trustees of the University of Illinois
Human Factors Input
© 2008 The Board of Trustees of the University of Illinois
The Seven Pillars: A Comprehensive Approach to the Prevention and
Response to Patient Events
Unexpected Event reported toSafety/Risk Management
Patient Harm?
Consider “Second Patient”Error Investigation
Hold bills
InappropriateCare?
Full Disclosure with Rapid Apology and Remedy
Process Improvement
Data Base
PatientCommunicationConsult Service
24/7Immediately
Available
Yes
Yes
No
No
“Near misses”
Activation of Crisis Management Team –
emotional first aid
© 2008 The Board of Trustees of the University of Illinois
CommunicationTimelyEffectiveCoordinatedOngoingEngagement of highly competent communicators – case exampleJust in time supportInterdisciplinary
© 2008 The Board of Trustees of the University of Illinois
Creating a communication consult service
Communications assessment toolMeasures emotional intelligenceAssesses cognitive complexityIdentifies highly skilled communicators in complex social situationsBalances out the “special colleague” issue
© 2008 The Board of Trustees of the University of Illinois
Individual Differences in Communication Competence
Some people are more skillful communicators than others.Some communication tasks/situations are much more difficult than others
Easy: describe your apartmentHard: disclose a medical error to a grieving family
Differences in skill most visible in hard situations
33
© 2008 The Board of Trustees of the University of Illinois
One hospital’s data
© 2008 The Board of Trustees of the University of Illinois
The Seven Pillars: A Comprehensive Approach to the Prevention and
Response to Patient Events
Unexpected Event reported toSafety/Risk Management
Patient Harm?
Consider “Second Patient”Error Investigation
Hold bills
InappropriateCare?
Full Disclosure with Rapid Apology and Remedy
Process Improvement
Data Base
PatientCommunicationConsult Service
24/7Immediately
Available
Yes
Yes
No
No
“Near misses”
Activation of Crisis Management Team –
emotional first aid
© 2008 The Board of Trustees of the University of Illinois
Elements of resolution/remediation• Patient Safety Compensation Card – given to
patients if harm caused by inappropriate care, serves as their ongoing “insurance card”
© 2008 The Board of Trustees of the University of Illinois
Putting it all together
© 2008 The Board of Trustees of the University of Illinois
October 7, 2011
© 2008 The Board of Trustees of the University of Illinois
Another communicating openly and resolving early
© 2008 The Board of Trustees of the University of Illinois
October 7, 2011
© 2008 The Board of Trustees of the University of Illinois
Pillar 6 - data
© 2008 The Board of Trustees of the University of Illinois
© 2008 The Board of Trustees of the University of Illinois
© 2008 The Board of Trustees of the University of Illinois
Other stakeholder buy-in prior to grantMedical SocietiesProfessional liability companies – hospital and physicianHospital AssociationLegal groupsConsumers Advancing Patient SafetyProject Patient CareIndividual hospital boards, medical staffs
© 2008 The Board of Trustees of the University of Illinois
AHRQ Grant10 private hospitals, self insuredOpen medical staffs, private professional liability coverage7 from faith-based system2 from a “for profit”1 underserved inner cityMost with resident physicians
© 2008 The Board of Trustees of the University of Illinois
Next stepsAHRQ Task Order
© 2008 The Board of Trustees of the University of Illinois
Next steps to new approachesAHRQ Task OrderCreate comprehensive set of validated and tested tools to facilitate the implementation of the Seven Pillars across all hospitals
© 2008 The Board of Trustees of the University of Illinois
Next steps to new approachesAHRQ Task OrderCreate comprehensive set of validated and tested tools to facilitate the implementation of the Seven Pillars across all hospitalsAgency for Healthcare Research and Quality announcement soon
© 2008 The Board of Trustees of the University of Illinois
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