The “ Seven Pillars ” Approach: Crossing the Patient Safety – Medical Liability Chasm

1. The “Seven Pillars” Approach:Crossing the Patient Safety – Medical Liability Chasm Timothy McDonald, MD JD Professor, Anesthesiology and Pediatrics Interim Assistant Vice President for Quality and Safety University of Illinois Hospital and Health Science System PI: R18

2. Grantannouncement

3. AHRQ/Seven Pillars Project focus • Patient Safety first – eliminate harm • Improve communication • Reduce preventable injuries • Compensate patients/families fairly and timely • Reduce medical malpractice liability

4. Some background Institute of Medicine: 1999 report that shook the medical world Making Matters Worse

5. Part of the issue • February 2012, Volume 31, Issue 2

6. Adding to the equation • Journal of Trauma, September, 2010 • 8% of physicians generated 34-40% of unsolicited patient complaints • Same 8 % generate 50% of risk management expenses • Physicians in bottom q-tile of patient satisfaction have 110% malpractice risk

7. More value to communication • July 2011, Volume 30, Issue 7 • 70% of claims dropped once information shared

8. 2005 U of I leadership approves “communication- resolution”program to attack medical malpractice crisis • Comprehensive program created • Integration of safety, risk, quality and credentials • Linkage to claims and legal – deal with the fears • Longitudinal patient safety education plan • UGME • GME • CME

9. 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

10. Goals of the Seven Pillars • Reduce harm thru transparency and learning • Reduce lawsuits through early, effective communication with all parties • Resolve inappropriate care cases early, efficiently • Support patient and family engagement • Support care professionals following harm events

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

12. The Patient Communication Consult Service [PCCS] • PCCS – immediately available 24/7 • Current options • Empowerment • Value of Emotional Intelligence • Expectations • Physician involvement • Patient-family involvement • Mitigates impact of “special colleagues” with low EI

13. Establishing a PCCS • Leadership buy-in • Establish policy, procedure • Rapid access 24/7 – hotline • Just in time training for those who access hotline • Command and control • Establish the “liaison” • Goal - to maintain trust and to learn • Help/support physicians overcome their fears

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

15. Elements of resolution/remediation • Patient Safety Compensation Card – given to patients if harm caused by inappropriate care, serves as their ongoing “insurance card”

16. Putting it all together

17. October 7, 2011

18. Another communicating openly and resolving early

19. October 7, 2011

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

21. Process improvement:Significant change in national guidelines • July 1, 2011 ASA • Specifically, in section 3.2.4 of the Standards for Basic Anesthetic Monitoring, the ASA states, "...During moderate or deep sedation the adequacy of ventilation shall be evaluated by continual observation of qualitative clinical signs and monitoring for the presence of exhaled carbon dioxide unless precluded or invalidated by the nature of the patient, procedure, or equipment.

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

23. Pillar #6 Data

25. Educating the next generation:Reporting Data from Resident Physicians

26. Reporting established as an expectation and part of Core Competency assessment

27. Resident physician occurrence reporting dataJournal of Graduate Medical Education, June 2010

28. Event data

29. Communication Consults

30. UHC Derived Safety Data

31. ROI for institutions:Improving safety reduces liability “Reducing Patient Safety Incidents by 10 decreased claims by 3.9.” http://www.rand.org/pubs/technical_reports/TR824.html

32. Impact of comprehensive effort • Increased reporting • Rapid, effective ongoing communication • Rapid cycle improvements and harm prevention • Early resolution

34. Other data update • Medical Malpractice Premium data • Overall reduction on premium over past three years = $22MM • FY 11 - $4.7MM less than FY 10 • FY 12 - $7.4 MM less than FY 10 • FY 13 - $10.1MM less than FY 10 • 2006 – SIP $45MM underfunded • 2012 – SIP $8MM in excess

35. Waived hospital and professional fees Hospital fees waived in first 8 months: $2.29MM Professional fees waived in first 8 months: $110K Total savings to payors in 8 months: $2.40 MM 45% Medicare/Medicaid

36. 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

37. AHRQ Grant • 10 private hospitals, self insured • Open medical staffs, private professional liability coverage • 7 from faith-based system • 2 from a “for profit” • 1 underserved inner city • Most with resident physicians

38. Collaboration with Professional Liability Insurers

39. Update from grant hospitals • Intervention [5] hospitals rolled out • Hospital and physician leadership fully engaged • Tools created or employed • gap analysis tool; videotaped communication training materials; EI assessment tools; RM/Investigation checklists; resident reporting training materials • Gap analyses completed • Communication training complete • On-line occurrence reporting begun • Disclosures, early offers have occurred • Data being analyzed • Control [5] hospitals roll out in August 2012 • Have been asked to work with > 20 hospitals in three other states since commencing grant

40. Data from one grant hospital • Large reduction in serious reportable events • Already experiencing reduction in liability claims • Have waived > $150K in Medicare charges Intervention

41. Update on other dissemination and collaborative efforts • “Tiger” with CMS Hospital Engagement Networks – AHA HRET • The Joint Commission – surveyor training • MedStar • Co-Investigator, Dave Mayer MD, appointed Senior VP for Quality and Safety, May 15 meeting • Hospital associations/systems • Illinois, Maryland, Colorado, South Carolina, New York • Medical Societies • Illinois, Colorado, Wyoming, Florida • Professional liability companies • ISMIE, COPIC, Mag Mutual, The Doctor’s Company

42. Questions?