1. © 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

2. © 2008 The Board of Trustees of the University of Illinois Grant opportunity with PSO component

3. © 2008 The Board of Trustees of the University of Illinois The Seven Pillars: Crossing the Patient Safety – Medical Liability Chasm

4. © 2008 The Board of Trustees of the University of Illinois The Problem Institute of Medicine: 1999 report that shook the medical world Making Matters Worse

5. © 2008 The Board of Trustees of the University of Illinois One potential solution: 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

6. © 2008 The Board of Trustees of the University of Illinois 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

7. © 2008 The Board of Trustees of the University of Illinois AHRQ/Seven Pillars Project focus Patient Safety first Improved communication Reduce preventable injuries Compensate patients/families fairly and timely Reduced medical malpractice liability

8. © 2008 The Board of Trustees of the University of Illinois 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

9. © 2008 The Board of Trustees of the University of Illinois 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

10. © 2008 The Board of Trustees of the University of Illinois 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

11. © 2008 The Board of Trustees of the University of Illinois 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

12. © 2008 The Board of Trustees of the University of Illinois One more benefit to PSOs Resident Duty Hours: Enhancing Sleep, Supervision and Safety

13. © 2008 The Board of Trustees of the University of Illinois 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

14. © 2008 The Board of Trustees of the University of Illinois Highlights of IOM report Bottom line: without changes “the residency programs are not providing what the next generation of doctors or their patients deserve”.

15. © 2008 The Board of Trustees of the University of Illinois Dealing with the fears: the critical value of PSOs

16. © 2008 The Board of Trustees of the University of Illinois The Seven Pillars: A Comprehensive Approach to Adverse Patient Events Points of PSO Value 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

17. © 2008 The Board of Trustees of the University of Illinois PSO value Patient Safety Evaluation System Port Patient Safety Organization Federal “Protections” PSO with abundant learning opportunities Other education PSES removal process Other PSOs

18. © 2008 The Board of Trustees of the University of Illinois Using PSO to allay fears Based on two Illinois Appellate Court cases Occurrence reports are discoverable Construct reporting portal as part of PSES Without proper By-Laws and Committee structure investigations are discoverable Work with Safety, Risk, Quality to modify by-laws, restructure committees, create PSES All process improvements are discoverable Push 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

19. © 2008 The Board of Trustees of the University of Illinois The Seven Pillars and PSOs One critically necessary design and process feature Disclosure

20. © 2008 The Board of Trustees of the University of Illinois PSES value Patient Safety Evaluation System Port Patient Safety Organization Federal “Protections” PSO with abundant learning opportunities Other education PSES removal process for Disclosure to Patients and Families Other PSOs

21. © 2008 The Board of Trustees of the University of Illinois The Seven Pillars and PSOs One critically necessary design and process feature Disclosure Before “analysis” Include patients and families Obtain consent from participants

22. © 2008 The Board of Trustees of the University of Illinois 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

23. © 2008 The Board of Trustees of the University of Illinois Next steps Intense coordination between grant researchers and hospital/system safety-risk managers System and process re-design to facilitate learning Close interface with PSO[s]

24. © 2008 The Board of Trustees of the University of Illinois Questions?