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The “ Seven Pillars ” Approach: Improving Patient Safety and Decreasing Liability Through Transparency Timothy McDonald, M.D., J.D. The Problem. Institute of Medicine report To Err is Human: Building a Safer Health System

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The “Seven Pillars” Approach: Improving Patient Safety and Decreasing Liability Through TransparencyTimothy McDonald, M.D., J.D.

the problem
The Problem
  • 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

Institute of Medicine:

1999 report that shook the medical world

Making Matters Worse

the uic experience prior to 2004
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
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
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
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

Taking a “Principled Approach”
adding to the lack of confidence oct 2008 the defense rests
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)

fears
Fears
  • Based on two Illinois Appellate Court cases
    • Occurrence reports are discoverable
    • Without proper By-Laws and Committee structure investigations are discoverable
    • All process improvements are discoverable
    • Lawyers consistently advise physicians to not participate
2005 uic board approves patient safety transparency program
2005 UIC Board approves “Patient Safety-Transparency” program
  • Comprehensive
  • Integration of safety, risk, quality and credentials
  • Linkage to claims and legal – deal with the fears
  • Longitudinal patient safety education plan
    • UGME
    • GME
    • CME
the seven pillars a comprehensive approach to adverse patient events
The Seven Pillars:A Comprehensive Approach to Adverse Patient Events

Data Base

Unexpected Event reported to

Safety/Risk Management

“Near misses”

Patient Harm?

No

Patient

Communication

Consult Service

24/7

Immediately

Available

Yes

Consider “Second Patient”

Error Investigation

Hold bills

Process Improvement

Activation of Crisis Management Team

No

Inappropriate

Care?

Yes

Full Disclosure with

Rapid Apology and Remedy

slide12
A Comprehensive Response to Patient Incidents:The Seven Pillars. McDonald et al Quality and Safety in Health Care, Jan 2010
  • Reporting
  • Investigation
  • Communication
  • Apology with remediation
  • Process and performance improvement
  • Data tracking and analysis
  • Education – of the entire process
the seven pillars a comprehensive approach to adverse patient events1
The Seven Pillars:A Comprehensive Approach to Adverse Patient Events

Data Base

Unexpected Event reported to

Safety/Risk Management

“Near misses”

Patient Harm?

No

Patient

Communication

Consult Service

24/7

Immediately

Available

Yes

Consider “Second Patient”

Error Investigation

Hold bills

Process Improvement

Activation of Crisis Management Team

No

Inappropriate

Care?

Yes

Full Disclosure with

Rapid Apology and Remedy

acgme core competencies
ACGME core competencies
  • Patient Care
  • Medical Knowledge
  • Practice-Based Learning & Improvement
  • Interpersonal and Communication Skills
  • Professionalism
  • Systems-based Practices
the seven pillars a comprehensive approach to adverse patient events2
The Seven Pillars:A Comprehensive Approach to Adverse Patient Events

Data Base

Unexpected Event reported to

Safety/Risk Management

“Near misses”

Patient Harm?

No

Patient

Communication

Consult Service

24/7

Immediately

Available

Yes

Consider “Second Patient”

Error Investigation

Hold bills

Process Improvement

Activation of Crisis Management Team

No

Inappropriate

Care?

Yes

Full Disclosure with

Rapid Apology and Remedy

the patient communication consult service
The Patient Communication Consult Service
  • PCCS – immediately available 24/7
  • Current options
  • Empowerment
  • Participation
  • Expectations
  • Physician involvement
  • Patient-family involvement
the seven pillars a comprehensive approach to adverse patient events3
The Seven Pillars:A Comprehensive Approach to Adverse Patient Events

Data Base

Unexpected Event reported to

Safety/Risk Management

“Near misses”

Patient Harm?

No

Patient

Communication

Consult Service

24/7

Immediately

Available

Yes

Consider “Second Patient”

Error Investigation

Hold bills

Process Improvement

Activation of Crisis Management Team

No

Inappropriate

Care?

Yes

Full Disclosure with

Rapid Apology and Remedy

the seven pillars a comprehensive approach to adverse patient events4
The Seven Pillars:A Comprehensive Approach to Adverse Patient Events

Data Base

Unexpected Event reported to

Safety/Risk Management

“Near misses”

Patient Harm?

No

Patient

Communication

Consult Service

24/7

Immediately

Available

Yes

Consider “Second Patient”

Error Investigation

Hold bills

Process Improvement

Activation of Crisis Management Team

No

Inappropriate

Care?

Yes

Full Disclosure with

Rapid Apology and Remedy

roi for institutions improving safety reduces liability
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 focus
AHRQ/Seven Pillars Project focus
  • Patient Safety first
  • Improved communication
  • Reduce preventable injuries
  • Compensate patients/families fairly and timely
  • Reduced medical malpractice liability
what next
What next
  • 10 hospitals in Chicago
  • 8 hospitals in South Carolina with SCHA
  • 2 hospitals in New Jersey
  • Collaboration with other grantees in Colorado, Washington, Massachusetts, Texas
  • Begin to work with Policy Makers on removing barriers and creating incentives
next steps
Next steps
  • Commitment: Leadership
    • Medical Centers
    • State Societies
    • Insurers
  • Gap Analysis
  • Identify teams
  • Metrics
  • Timeline for implementation
  • Implement
  • Measurement
  • Feedback
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