© 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 Illinois McDonald 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

© 2008 The Board of Trustees of the University of Illinois McDonald 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

© 2008 The Board of Trustees of the University of Illinois McDonald 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

© 2008 The Board of Trustees of the University of Illinois McDonald 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

© 2008 The Board of Trustees of the University of Illinois McDonald What about an Extremely Honest “Principled Approach”? Barriers Benefits

© 2008 The Board of Trustees of the University of Illinois McDonald 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

© 2008 The Board of Trustees of the University of Illinois McDonald Adding to the lack of confidence Oct 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)

© 2008 The Board of Trustees of the University of Illinois McDonald 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

© 2008 The Board of Trustees of the University of Illinois McDonald 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

© 2008 The Board of Trustees of the University of Illinois McDonald The Seven Pillars: A Comprehensive Approach to Adverse Patient Events Unexpected Event reported to Safety/Risk Management Patient Harm? Consider “Second Patient” Error Investigation Hold bills Inappropriate Care? Full Disclosure with Rapid Apology and Remedy Process Improvement Data Base Patient Communication Consult Service 24/7 Immediately Available Yes No “Near misses” Activation of Crisis Management Team

© 2008 The Board of Trustees of the University of Illinois McDonald 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

© 2008 The Board of Trustees of the University of Illinois McDonald The Seven Pillars: A Comprehensive Approach to Adverse Patient Events Unexpected Event reported to Safety/Risk Management Patient Harm? Consider “Second Patient” Error Investigation Hold bills Inappropriate Care? Full Disclosure with Rapid Apology and Remedy Process Improvement Data Base Patient Communication Consult Service 24/7 Immediately Available Yes No “Near misses” Activation of Crisis Management Team

© 2008 The Board of Trustees of the University of Illinois McDonald Occurrence reports: if you don’t know about it you can’t fix it

© 2008 The Board of Trustees of the University of Illinois McDonald ACGME core competencies Patient Care Medical Knowledge Practice-Based Learning & Improvement Interpersonal and Communication Skills Professionalism Systems-based Practices

© 2008 The Board of Trustees of the University of Illinois McDonald Aggregate resident physician occurrence reporting data

© 2008 The Board of Trustees of the University of Illinois McDonald The Seven Pillars: A Comprehensive Approach to Adverse Patient Events Unexpected Event reported to Safety/Risk Management Patient Harm? Consider “Second Patient” Error Investigation Hold bills Inappropriate Care? Full Disclosure with Rapid Apology and Remedy Process Improvement Data Base Patient Communication Consult Service 24/7 Immediately Available Yes No “Near misses” Activation of Crisis Management Team

© 2008 The Board of Trustees of the University of Illinois McDonald The Patient Communication Consult Service PCCS – immediately available 24/7 Current options Empowerment Participation Expectations Physician involvement Patient-family involvement

© 2008 The Board of Trustees of the University of Illinois McDonald Communication is the key

© 2008 The Board of Trustees of the University of Illinois McDonald The Seven Pillars: A Comprehensive Approach to Adverse Patient Events Unexpected Event reported to Safety/Risk Management Patient Harm? Consider “Second Patient” Error Investigation Hold bills Inappropriate Care? Full Disclosure with Rapid Apology and Remedy Process Improvement Data Base Patient Communication Consult Service 24/7 Immediately Available Yes No “Near misses” Activation of Crisis Management Team

© 2008 The Board of Trustees of the University of Illinois McDonald UHC Derived Safety and Quality Measures

© 2008 The Board of Trustees of the University of Illinois McDonald The Seven Pillars: A Comprehensive Approach to Adverse Patient Events Unexpected Event reported to Safety/Risk Management Patient Harm? Consider “Second Patient” Error Investigation Hold bills Inappropriate Care? Full Disclosure with Rapid Apology and Remedy Process Improvement Data Base Patient Communication Consult Service 24/7 Immediately Available Yes No “Near misses” Activation of Crisis Management Team

© 2008 The Board of Trustees of the University of Illinois McDonald Claims experience

© 2008 The Board of Trustees of the University of Illinois McDonald ROI for institutions: Improving safety reduces liability “Reducing Patient Safety Incidents by 10 decreased claims by 3.9.”

© 2008 The Board of Trustees of the University of Illinois McDonald AHRQ/Seven Pillars Project focus Patient Safety first Improved communication Reduce preventable injuries Compensate patients/families fairly and timely Reduced medical malpractice liability

© 2008 The Board of Trustees of the University of Illinois McDonald Pillar #6 Data

© 2008 The Board of Trustees of the University of Illinois McDonald 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

© 2008 The Board of Trustees of the University of Illinois McDonald Next steps Commitment: Leadership Medical Centers State Societies Insurers Gap Analysis Identify teams Metrics Timeline for implementation Implement Measurement Feedback

© 2008 The Board of Trustees of the University of Illinois McDonald Questions