© 2008 The Board of Trustees of the University of Illinois The “Seven Pillars” Approach: Improving Patient Safety and Decreasing Liability Through Transparency

© 2008 The Board of Trustees of the University of Illinois

The “Seven Pillars” Approach: Improving Patient Safety and Decreasing

Liability Through Transparency

Timothy McDonald, M.D., J.D.

© 2008 The Board of Trustees of the University of IllinoisMcDonald

The Problem

Institute of Medicine:1999 report that shook the medical world

Making Matters Worse

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


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


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


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


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


Taking a “Principled Approach” 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


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)


FearsBased on two Illinois Appellate Court cases

Occurrence reports are discoverableWithout proper By-Laws and Committee structure

investigations are discoverableAll process improvements are discoverableLawyers consistently advise physicians to not

participate


2005 UIC Board approves “Patient Safety-Transparency” program

Comprehensive Integration of safety, risk, quality and credentialsLinkage to claims and legal – deal with the fearsLongitudinal patient safety education plan

UGMEGMECME


The Seven Pillars:A Comprehensive Approach to Adverse 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


A Comprehensive Response to Patient Incidents:The Seven Pillars. McDonald et al Quality and Safety in Health Care, Jan 2010

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




Patient Harm?


Hold bills

InappropriateCare?


Process Improvement

Data Base


24/7Immediately

Available

Yes

Yes

No

No

“Near misses”



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


ACGME core competenciesPatient CareMedical KnowledgePractice-Based Learning & Improvement Interpersonal and Communication SkillsProfessionalismSystems-based Practices


Aggregate resident physician occurrence reporting data




Patient Harm?


Hold bills

InappropriateCare?


Process Improvement

Data Base


24/7Immediately

Available

Yes

Yes

No

No

“Near misses”



The Patient Communication Consult Service PCCS – immediately available

24/7 Current options Empowerment Participation Expectations Physician involvement Patient-family involvement


Communication is the key




Patient Harm?


Hold bills

InappropriateCare?


Process Improvement

Data Base


24/7Immediately

Available

Yes

Yes

No

No

“Near misses”



UHC Derived Safety and Quality Measures

2010 Quality Index Report

0

50

100

150

200

250

300

350

400

450

2008 2009 2010

Calendar Year

Safety

Core Measures

Readmission




Patient Harm?


Hold bills

InappropriateCare?


Process Improvement

Data Base


24/7Immediately

Available

Yes

Yes

No

No

“Near misses”



Claims experience


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


AHRQ/Seven Pillars Project focusPatient Safety first Improved communicationReduce preventable injuriesCompensate patients/families fairly and timelyReduced medical malpractice liability


Pillar #6 Data


What next10 hospitals in Chicago8 hospitals in South Carolina with SCHA2 hospitals in New JerseyCollaboration with other grantees in Colorado,

Washington, Massachusetts, TexasBegin to work with Policy Makers on removing

barriers and creating incentives


Next steps Commitment: Leadership

Medical Centers State Societies Insurers

Gap Analysis Identify teams Metrics Timeline for implementation Implement Measurement Feedback


Questions

Documents

© 2008 The Board of Trustees of the University of Illinois The “Seven Pillars” Approach: Improving Patient Safety and Decreasing Liability Through Transparency