No-Charge Policy for Serious Adverse Events An AHA Member Teleconference Series No-Charge Policy for Serious Adverse Events

No-Charge Policy for Serious Adverse Events The Experience of the Exempla Health System April 18, 2008, 1:00 pm ET Featured Speakers Jeff Selberg, President and CEO, Exempla Health System & AHA Board of Trustees David Munch, M.D., Chief Clinical and Quality Officer, Exempla Lutheran Medical Center Nancy Foster, Vice President Quality and Patient Safety Policy, American Hospital Association For Assistance: 1-800-424-4301 or express@aha.org

No-Charge Policy for Serious Adverse Events Introduction Past Experience Current Expectations Future Goals

No-Charge Policy for Serious Adverse Events The Exempla Experience What We Believe What We’re Doing What We’ve Learned

No-Charge Policy for Serious Adverse Events Best in the Nation Strategy Our Goals Our Report Card From the Boardroom to the Bedside Transparency Accountable to the Public and Patient Hosting the National Quality Forum

No-Charge Policy for Serious Adverse Events

No-Charge Policy for Serious Adverse Events

No-Charge Policy for Serious Adverse Events The Leapfrog Group asks hospitals to commit to 4 actions if a never-event occurs within their facilities. Apologize to the patient. Report the event. Perform a root cause analysis. Waive costs directly related to the event.

No-Charge Policy for Serious Adverse Events Burning the Ships The Denver Post interview Commitment to the Leapfrog Group Development, implementation, learning and improvement

No-Charge Policy for Serious Adverse Events Policy, Procedure and Practice Development Horizontal Collaboration All hospitals Legal, Risk Management, Business Office, Quality Data Systems Vertical Collaboration Board approval August 15th Executives, management, staff

No-Charge Policy for Serious Adverse Events A Learning Effort “Perfection is the Enemy of Progress” A Committee of Scientists Monthly analysis of adverse event activity and use of the policy/ procedure Revisions based on experience Focused Coordination of Activity Patient Safety Officers Just-in-time teaching and use

No-Charge Policy for Serious Adverse Events Adverse Events, Including Sentinel and Never Events Policy Statement Confirmation/Notification Analysis Action Plans Procedures Adverse Events Sentinel Events Never Events Disclosure/Apology

No-Charge Policy for Serious Adverse Events Adverse Events Procedure Notify - Occurrence report, director, patient safety Investigate - RCA (full or abbreviated), CCA, FMEA Analyze Develop action plan Review with executive Implement and monitor

No-Charge Policy for Serious Adverse Events Sentinel Events Procedure Notify patient Safety, senior staff, others Take immediate corrective action Disclose to patient/family Investigate  Analyze  Action Plan Report: Executive, Site Performance Excellence Committee, Board of Directors, external agency Monitor action plans

No-Charge Policy for Serious Adverse Events Never Events Procedures Determine if incident is a never event Hold billing until confirmation and RCA completed Follow Sentinel Event procedures Determine charges directly related to never-event to be waived Communicate to patient/family

Adapted from the work of James Reason on systems approaches to managing the risks of organizational accidents

No-Charge Policy for Serious Adverse Events Disclosure and Apology Don’t Blow the Opportunity - From Policy to Practice Organizational awareness campaign: What it is? Why we do it? Who to notify? When it is done? Team of coaches - 24/7 presence: Rapid Response Team concept Delivering the message to the patient Physician lead: nursing, others Supporting your staff When Things go Wrong: Responding to Adverse Events: A Consensus Statement of the Harvard Hospitals

No-Charge Policy for Serious Adverse Events Disclosure and Apology Coordinated by subject matter experts Patient safety officers Performance improvement staff Medical staff presidents and elects Clinical risk managers Senior teams

No-Charge Policy for Serious Adverse Events Reporting Dilemma State health department Law enforcement JCAHO Other: State hospital association

No-Charge Policy for Serious Adverse Events Other Opportunities Take advantage of the discomfort - have conversations about support, learning, improvement and patient safety. Feedback to operational plans Make never events a priority for improvement. Set up database to track types, costs, locations, root causes. Don’t forget to support the staff.

No-Charge Policy for Serious Adverse Events Resources and Follow-up Go to: http://www.aha.org/aha/issues/BCC/080418-materials.html Download additional resources and send AHA your questions, comments, feedback. Upcoming Teleconferences Thursday May 1, 11:30 am ET, featuring HCA, Inc. Tuesday, May 24, 1:00pm ET, featuring Children’s Hospital and Regional Medical Center, Seattle Register at www.aha.org/aha/issues/BCC/080418-teleconference-registration.html