© 2008 the board of trustees of the university of illinois collaborative learning from patient...

© 2008 The Board of Trustees of the University of Illinois

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


Grant opportunity with PSO component


The Seven Pillars: Crossing the Patient Safety – Medical Liability

Chasm


The Problem

Institute of Medicine:1999 report that shook the medical world

Making Matters Worse


One potential solution: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


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


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


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


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


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


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


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


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


Highlights of IOM report

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


Dealing with the fears: the critical value of PSOs


The Seven Pillars:A Comprehensive Approach to Adverse Patient Events

Points of PSO Value

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


PSO value

Pat

ient

Saf

ety

Eva

luat

ion

Sys

tem

Por

t

Patient Safety OrganizationFederal “Protections”

PSO with abundant learning

opportunities

Other education

PSES removal process

OtherPSOs


Using PSO to allay fearsBased on two Illinois Appellate Court cases

Occurrence reports are discoverableConstruct reporting portal as part of PSES

Without proper By-Laws and Committee structure investigations are discoverableWork with Safety, Risk, Quality to modify by-laws, restructure

committees, create PSES

All process improvements are discoverablePush 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


The Seven Pillars and PSOsOne critically necessary design and process

featureDisclosure


PSES value

Pat

ient

Saf

ety

Eva

luat

ion

Sys

tem

Por

t

Patient Safety OrganizationFederal “Protections”

PSO with abundant learning

opportunities

Other education

PSES removal process for Disclosure to Patients and Families

OtherPSOs


The Seven Pillars and PSOsOne critically necessary design and process

featureDisclosure

Before “analysis” Include patients and familiesObtain consent from participants


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


Next steps Intense coordination between grant researchers

and hospital/system safety-risk managersSystem and process re-design to facilitate

learningClose interface with PSO[s]


Questions?

© 2008 the board of trustees of the university of illinois collaborative learning from patient...

Documents

board of trustees

md jd university of

chicago slide

patient incidents

entire process slide

analysis of harm events

pso component slide

matters worse slide