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

2. 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: or

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

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

5. 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

6. No-Charge Policy for Serious Adverse Events

7. No-Charge Policy for Serious Adverse Events

8. 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.

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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

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

18. 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

19. 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

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

21. 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.

22. No-Charge Policy for Serious Adverse Events
Resources and Follow-up
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Upcoming Teleconferences
Thursday May 1, 11:30 am ET, featuring HCA, Inc.
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