As She Lay Dying: How I Fought to Stop Medical Errors From Killing My Mom

Transcription

1 Promoting a Culture of Quality Jonathan Welch, M.D. Brigham and Women s Hospital Boston, Mass. S. Allan Adelman, Esq. Adelman, Sheff & Smith, LLC Annapolis, Md. As She Lay Dying: How I Fought to Stop Medical Errors From Killing My Mom Dr. Welch s experience 2 1

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3 Questions A Board Should Ask Do we have a culture where nurses are afraid to call or challenge physicians? Would our nursing staff question why the sepsis protocol was not instituted? Why didn t the physician institute the sepsis protocol? 5 Questions A Board Should Ask Do we have political, economic or cultural barriers that interfere with a patient receiving appropriate care? Is there reluctance to transfer cases to ICU and intensivists for political or economic reasons? Would our nurse managers have been aware of this situation and responded? 6 3

4 Questions A Board Should Ask Would this death have been identified as unanticipated and investigated Would our medical staff be willing to investigate and if appropriate initiate corrective action regarding any members of the medical staff involved in this case? Would this case have been picked up by the peer review process? 7 Questions A Board Should Ask Do we have a policy on discussing adverse outcomes with patients and their families? Would we acknowledge to the family that mistakes were made? Would we respond promptly to family questions such as those raised by Dr. Welch? 8 4

5 Questions A Board Should Ask Would this adverse outcome generate a root cause analysis to determine- Did the nursing staff recognize the significance of deteriorating vital signs? Why wasn t the attending physician notified? Why wasn t the rapid response team called? 9 Questions A Board Should Ask Would this adverse outcome generate a root cause analysis to determine- Why didn t the nurse call the oncologist to suggest using the sepsis protocol or transfer to ICU? Are there appropriate treatment protocols in place for sepsis, stroke, heart attack, etc.? 10 5

6 Is the Board Actively Involved in Promoting A Culture of Quality? Structure Agenda Education/Training 11 Board Practices Associated With Better Proceses And Outcomes Having a dedicated quality committee Quality/patient safety measures part of senior executives evaluation and compensation Board discussion of quality specific issues Board establishing strategic quality goals Board involvement in setting quality agenda J. Jiang et al., Board Oversight of Quality: Any Differences in Process of Care and Mortality, J. Healthcare Mgmt. 54:1 (2009) 12 6

7 Does The Board Promote a Culture of Quality? Having a Quality Committee is associated with Having quality dashboards (91% vs. 79%) Board established quality goals (89% v. 68% Board involved in setting board quality agenda (49% vs. 33% Quality measures used for evaluation of executive performance ( 78% vs. 59%) J. Jiang et al., Board Engagement in Quality: Findings of a Survey of Hospital and Health System Leaders, 53 J. Healthcare Mgmt. 121 (2008) 13 Does Board Structure/Agenda Facilitate a Culture of Quality? Where is Quality on the Board Meeting Agenda? Time spent on quality vs. Time spent on finances 14 7

8 Board Focus on Quality National Hi-perform Lo-perform (%) (%) (%) Quality on every board agenda At least 20% of time on quality Quality Subcommittee Regular dashboard review At least quarterly review of Hospital acquired infections Medication errors TJC core measures Patient satisfaction Jha, Epstein; Hospital Governance and Quality of Care, Health Affairs, January The Board Agenda : Making Quality a Priority Is there a quality of care presentation at every meeting? Does the Board received quality metrics and dashboard indicators? How frequently does the Board get updates on strategic quality goals? 16 8

9 Quality Presentations at Every Board Meeting? POSSIBLE TOPICS OF DISCUSSION Falls Hospital acquired infections Unplanned readmissions Missed diagnoses Medication errors Decubitus ulcers Unanticipated adverse outcomes 17 Quality Presentations at Every Board Meeting? Powerful message generated by asking staff to present on these issues at board meetings The Board really cares about quality 18 9

10 Does Board Receive Data on Quality Metrics? Dashboard indicators Presented to Board or only Quality Committee? How often? Every meeting? How is data presented? Percentages or actual numbers? e.g. medication error rate of.004% vs. 35 patients with medication errors Internal data and national benchmarks 19 Does Board Receive Data on Quality Metrics? Is the Board Involved in Selecting Dashboard Indicators & Thresholds? Does the Board get information on significant adverse events? Wrong site surgeries Unanticipated deaths Retained foreign objects Blood incompatibility Avoidable deaths and morbidity 20 10

11 Does Board Receive Data on Quality Metrics? Institution specific surveys Patient/physician satisfaction surveys Staff surveys Comparison with national benchmarks National survey data Leapfrog - HealthGrades - US News - Joint Commission Does the Board Set or Approve an Annual Quality Improvement Plan? Are there specific annual Quality Goals? 22 11

12 Is the Board Familiar with Medical Staff Credentialing Criteria & Processes? Importance of Credentialing as a Quality Process 23 Does the Board Determine What Information it Wants about Each Applicant? Malpractice claims Medical records issues Behavioral incidents Quality metrics - OPPE FPPEs Unanticipated outcomes Results of Peer Review 24 12

13 Use of credentialing tracks or categories to facilitate focus on appropriate issues Track 1 clean application Track 2 minor issues Track 3 significant issues to be considered by board Track 4 denial recommended 25 In-house Counsel s Role in Promoting a Culture of Quality The results of poor quality invariably end up on the general counsel s door step. Malpractice litigation State licensure actions QIO investigations Credentialing litigation Disgruntled staff and employment related litigation Government quality/compliance investigations Accreditation issues 26 13

14 In-house Counsel s Role in Promoting a Culture of Quality Compliance Issues Often Begin as Quality Issues Peninsula Regional Medical Center, Salisbury, Maryland $2.8 Million settlement with government for unnecessary stents St. Joseph Medical Center, Baltimore, Maryland $22 Million settlement with government for unnecessary stents Redding Medical Center (2003) $59.5 settlement for unnecessary heart surgeries 27 Linking Quality with Cost Ban on Medicaid payment for health care-acquired conditions. (2012) (PPACA 2702) Value-Based Purchasing Effective October 2012 (PPACA 3001) Penalty for excessive readmissions October (Hospital Readmissions Reduction Program, PPACA 3025) 28 14

15 Linking Quality with Compliance Worthless services Medically unnecessary services Possible False Claims Act enforcement Possible exclusion 29 Linking Quality with Compliance Union Memorial Hospital, Michigan (2008) Dr. Jeffrey Askanazi, pain management Substandard care, unnecessary services $1.8 Million fines and restitution Deferred Prosecution Agreement Criminal conviction of Dr. Askanazi (mail fraud) 30 15

16 Linking Quality with Compliance United States of America ex rel. Lana Rogers v. Najam Azmat, M.D., et. al. (S.D. Ga., No. 5:07- cv-00092) Lack of documented training and experience Allowed to perform endovascular procedures without privileges Failure to follow peer review criteria/procedures Ignoring complaints of nurses Claim of worthless services regardless of outcome 31 Quality Education for Board Members For members of quality committee For entire board Part of orientation for all new board members 32 16

17 Quality Education for Board Members How peer review works outcome identification, review, education, remediation. Understanding OPPE and FPPE Pay for performance and quality incentives Credentialing criteria 33 Quality Education for Board Members Costs of poor quality in legal terms malpractice claims Quality as a compliance issue Quality as a reimbursement issue Credentialing protections HCQIA immunity 34 17

18 Guidance for Board on Sources of Quality Information Driving for Quality in Acute Care: A Board of Directors Dashboard Government Industry Roundtable A Report on the Office of Inspector General and Health Care Compliance Association Roundtable on Hospital Board of Directors Oversight of Quality of Care A Toolkit for Health Care Boards Gregory Demske, Chief Counsel to the Inspector General, provides tips for health care boards to promote quality of care and embrace compliance with the law. Corporate Responsibility and Health Care Quality: A Resource for Health Care Boards of Directors Joint AHLA/OIG publication 07.pdf 35 If a board member were asked whether your hospital is a high quality hospital, would they say, Yes? 36 18

19 But, how would they answer the question, How do you know? 37 19