2008 The Board of Trustees of the University of Illinois

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1

2 The Case for Candor: Bridging the Patient Safety Medical Liability Chasm:

3 Conflict of interest The Agency for Healthcare Research and Quality [AHRQ] provides substantial funding for my work in patient safety and medical liability

4 Health Affairs. Jan 2014 V.33 I.1

5 Some background

6 Overview of Patient Safety April, 1982 ABC 20/20 show: The Deep Sleep 6,000 will die or suffer brain damage from carelessness

7 Overview of Patient Safety April, 1982 ABC 20/20 show: The Deep Sleep 6,000 will die or suffer brain damage from carelessness 1983 ASA Committee on Patient Safety and Risk Management created closed claims analysis 1984 Anesthesia Patient Safety Foundation 1986 Monitoring standards established

8 Overview of Patient Safety and medical liability Anesthesia Mortality Risk : :300,000 Substantial reduction in malpractice premiums

9 Some more patient safety background Institute of Medicine: 1999 report that shook the medical world

10 Some more patient safety background Institute of Medicine: 1999 report that shook the medical world

11 The need for candor Institute of Medicine: 1999 report that shook the medical world Making Matters Worse

12 Specific case in need of candor 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

13 Specific case in need of candor 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

14 Extreme Honesty Barriers Benefits

15 Extreme Honesty Barriers Fears Inertia Litigation Licensing boards NPDB Shame, blame Reputation Lack of skills Lack of process Benefits Learning Improving Less litigation Lower costs Integrity Morale Healing

16 Lack of candor continues February 2012, Volume 31, Issue 2

17 Unaccountable? Impact on the medical malpractice community Credit to Dr Martin Makary

18 2005 University of Illinois approves Comprehensive communication- resolution program prevent and respond to harm Comprehensive Integrate safety, risk, quality and credentialing Linkage to claims and legal Linking transparency to learning: patient safety education plan UGME GME CME

19 The Candor Project Communication and Optimal Resolution

20 Candor Definitions: unreserved, honest, or sincere expression : forthrightness

21 Candor Definitions: unreserved, honest, or sincere expression : forthrightness the quality of being honest and telling the truth, especially about a difficult or embarrassing subject

22 The Candor Project What do patients and care professionals want? To know what happened. Empathy. Apology, if indicated. Non-Abandonment. Future prevention. Remedy.

23 The Candor Project What do patients and care professionals want? To know what happened. Empathy. Apology, if indicated. Non-Abandonment. Future prevention. Remedy. Candor

24 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 including waiver of hospital and professional fees Process and performance improvement Data tracking and analysis Education of the entire process

25 Goals of the Seven Pillars Reduce harm thru transparency and learning Reduce lawsuits through early, effective communication [candor] with all parties Resolve inappropriate care cases early, efficiently Defend appropriate care vigorously Support patient and family engagement Support care professionals following harm events

26 The Original Seven Pillars: A Comprehensive Approach to the Prevention and Response to Patient Events Data Base No Patient Harm? Unexpected Event reported to Safety/Risk Management Yes Consider Second Patient Error Investigation Hold bills Process Improvement Inappropriate Care? Yes Full Disclosure with Rapid Apology and Remedy

27 What s wrong with this picture????? Data Base No Patient Harm? Unexpected Event reported to Safety/Risk Management Yes Consider Second Patient Error Investigation Hold bills Process Improvement Inappropriate Care? Yes Full Disclosure with Rapid Apology and Remedy

28 After Patient Advocate input in 2006

29 The Seven Pillars: A Comprehensive Approach to the Prevention and Response to Patient Events Data Base No Patient Harm? Unexpected Event reported to Safety/Risk Management Near misses Yes Patient Communication Consult Service 24/7 Immediately Available No Consider Second Patient Error Investigation Hold bills Inappropriate Care? Yes Activation of Crisis Management Team emotional first aid Process Improvement Full Disclosure with Rapid Apology and Remedy

30 The Seven Pillars: A Comprehensive Approach to the Prevention and Response to Patient Events Data Base No Patient Harm? Unexpected Event reported to Safety/Risk Management Near misses Yes Patient Communication Consult Service 24/7 Immediately Available No Consider Second Patient Error Investigation Hold bills Inappropriate Care? Yes Activation of Crisis Management Team emotional first aid Process Improvement Full Disclosure with Rapid Apology and Remedy

31 The Seven Pillars: A Comprehensive Approach to the Prevention and Response to Patient Events Data Base No Patient Harm? Unexpected Event reported to Safety/Risk Management Near misses Yes Patient Communication Consult Service 24/7 Immediately Available No Consider Second Patient Error Investigation Hold bills Inappropriate Care? Yes Activation of Crisis Management Team emotional first aid Process Improvement Full Disclosure with Rapid Apology and Remedy

32 Resident Duty Hours: Enhancing Sleep, Supervision and Safety

33 Highlights of IOM report Preventing and mitigating fatigue Specialty-specific educational focus Enhance culture of safety Engage residents in detection of errors, quality improvement ( moral agents ) Use near misses and unsafe conditions as educational opportunities for learners Protected reporting

34 Resident physician occurrence reporting data Journal of Graduate Medical Education, June 2010

35 The Seven Pillars: A Comprehensive Approach to the Prevention and Response to Patient Events Data Base No Patient Harm? Unexpected Event reported to Safety/Risk Management Near misses Yes Patient Communication Consult Service 24/7 Immediately Available No Consider Second Patient Error Investigation Hold bills Inappropriate Care? Yes Activation of Crisis Management Team emotional first aid Process Improvement Full Disclosure with Rapid Apology and Remedy

36 Peer to peer support: for physicians by physicians

37 The Seven Pillars: A Comprehensive Approach to the Prevention and Response to Patient Events Data Base No Patient Harm? Unexpected Event reported to Safety/Risk Management Near misses Yes Patient Communication Consult Service 24/7 Immediately Available No Consider Second Patient Error Investigation Hold bills Inappropriate Care? Yes Activation of Crisis Management Team emotional first aid Process Improvement Full Disclosure with Rapid Apology and Remedy

38 Pillar 2 - investigation What happened and why?

39 A human factors story

40 Human Factors Engineering and Safety Examples of Humans being Human: Forgetting the gas cap on the top of your car (or even the gas hose) Forgetting an ATM card at a teller machine Construction crew forgot to return a mainline track switch back to the normal position after a days work (NTSB, 2005) Doctors forgot to logoff patient order entry system patients receive wrong medications (Koppel et al., 2005) 40

41 Human Factor Issues in Healthcare 41

42 The Seven Pillars: A Comprehensive Approach to the Prevention and Response to Patient Events Data Base No Patient Harm? Unexpected Event reported to Safety/Risk Management Near misses Yes Patient Communication Consult Service 24/7 Immediately Available No Consider Second Patient Error Investigation Hold bills Inappropriate Care? Yes Activation of Crisis Management Team emotional first aid Process Improvement Full Disclosure with Rapid Apology and Remedy

43 Creating a communication consult service Communications assessment tool Measures emotional intelligence Assesses cognitive complexity Identifies highly skilled communicators in complex social situations Balances out the special colleague issue

44 Individual Differences in Communication Competence Some people are more skillful communicators than others. Some communication tasks/situations are much more difficult than others Easy: describe your apartment Hard: disclose a medical error to a grieving family Differences in skill most visible in hard situations 44

45 One hospital s data

46 The Power of Candor Cases

47 The Seven Pillars: A Comprehensive Approach to the Prevention and Response to Patient Events Data Base No Patient Harm? Unexpected Event reported to Safety/Risk Management Near misses Yes Patient Communication Consult Service 24/7 Immediately Available No Consider Second Patient Error Investigation Hold bills Inappropriate Care? Yes Activation of Crisis Management Team emotional first aid Process Improvement Full Disclosure with Rapid Apology and Remedy

48 Pillar 6 - data

49

50

51

52 Other positive financial data Reduction in costs associated with defensive medicine Lab tests Radiology tests CT scans, MRIs Large savings for third party payors private and government funded Waiver of hospital bills and professional fees Assumption of costs of ongoing care.

53 Patient Safety metrics Large improvement in HCAPS Substantial reduction in SSEs Mortality Was lower 50%-ile Now in top 15% of UHC

54 Other stakeholder buy-in prior to grant Medical Societies Professional liability companies hospital and physician Hospital Association Legal groups Consumers Advancing Patient Safety Project Patient Care Individual hospital boards, medical staffs

55 Data from one grant hospital Large reduction in serious reportable events Already experiencing reduction in liability claims Intervention

56 Next steps AHRQ Task Order

57 Next steps AHRQ Task Order Create comprehensive set of validated and tested tools to facilitate the implementation of the Seven Pillars across all hospitals

58 Next steps AHRQ Task Order Create comprehensive set of validated and tested tools to facilitate the implementation of the Seven Pillars across all hospitals Working with AHA HRET Agency for Healthcare Research and Quality announcement was going to happen this week

59 Questions?

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