© 2008 the board of trustees of the university of illinois learning from the patient’s...
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© 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
© 2008 The Board of Trustees of the University of Illinois
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
© 2008 The Board of Trustees of the University of Illinois
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
© 2008 The Board of Trustees of the University of Illinois
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
© 2008 The Board of Trustees of the University of Illinois
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
© 2008 The Board of Trustees of the University of Illinois
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
© 2008 The Board of Trustees of the University of Illinois
Linking transparency with patient safety
Transparency with Accountability
Event
Becomes the Trojan Horse for Cultural Transformation
© 2008 The Board of Trustees of the University of Illinois
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