© 2008 The Board of Trustees of the University of Illinois Learning From the Patient’s Experience: Opportunities to Improve Patient Safety AHRQ 2009 Annual

© 2008 The Board of Trustees of the University of Illinois

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

AHRQ 2009 Annual Conference

Timothy B McDonald, MD JDProfessor, Anesthesiology and Pediatrics

Chief Safety and Risk Officer for Health AffairsUniversity of Illinois at Chicago

[email protected]


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


A Comprehensive Response to Patient Incidents:The Seven Pillars. McDonald et alQuality and Safety in Health Care [accepted]

Reporting InvestigationCommunicationApology with remediationProcess and performance improvementData tracking and analysisEducation – of the entire process


The Seven Pillars:A “Principled Approach” to Adverse Patient Events

Yes

Yes

No

No

Concern or unexpected event reported to

Safety/Risk Management

Patient Harm?

Event InvestigationConsider “Care for Care Provider”

hold bills?

UnreasonableCare?

Full Disclosure with Apology and Remedy

Process Improvements

Data Base

PatientCommunicationConsult Service

“Near misses”

Activation of Crisis Management Team


Opportunities for Patient Engagement WithinThe Seven Pillars:

A “Principled Approach” to Adverse Patient Events

Yes

Yes

No

No

Concern or unexpected event reported to

Safety/Risk Management

Patient Harm?

Event InvestigationConsider “Care for Care Provider”

hold bills?

UnreasonableCare?

Full Disclosure with Apology and Remedy

Process Improvements

Data Base

PatientCommunicationConsult Service

“Near misses”

Activation of Crisis Management Team


Opportunities for Patient Engagement

Reporting – incidents, provider behavior Investigation – have critical pieces of

informationCommunication – teach and provide feedbackApology with remediation - assessmentProcess and performance improvementEducation – inspire and motivate


Linking transparency with patient safety

Transparency with Accountability

Event

Becomes the Trojan Horse for Cultural Transformation


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


August 23, 2009


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

Documents

© 2008 The Board of Trustees of the University of Illinois Learning From the Patient’s Experience: Opportunities to Improve Patient Safety AHRQ 2009 Annual