Presentation on theme: "No-Charge Policy for Serious Adverse Events"— Presentation transcript:
1 No-Charge Policy for Serious Adverse Events An AHA Member Teleconference SeriesNo-Charge Policy for Serious Adverse Events
2 No-Charge Policy for Serious Adverse Events The Experience of the Exempla Health SystemApril 18, 2008, 1:00 pm ETFeatured SpeakersJeff Selberg, President and CEO, Exempla Health System & AHA Board of TrusteesDavid Munch, M.D., Chief Clinical and Quality Officer, Exempla Lutheran Medical CenterNancy Foster, Vice President Quality and Patient Safety Policy, American Hospital AssociationFor Assistance: or
3 No-Charge Policy for Serious Adverse Events IntroductionPast Experience Current Expectations Future Goals
4 No-Charge Policy for Serious Adverse Events The Exempla ExperienceWhat We BelieveWhat We’re DoingWhat We’ve Learned
5 No-Charge Policy for Serious Adverse Events Best in the Nation StrategyOur GoalsOur Report CardFrom the Boardroom to the BedsideTransparencyAccountable to the Public and PatientHosting the National Quality Forum
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 ShipsThe Denver Post interviewCommitment to the Leapfrog GroupDevelopment, implementation, learning and improvement
10 No-Charge Policy for Serious Adverse Events Policy, Procedure and Practice DevelopmentHorizontal CollaborationAll hospitalsLegal, Risk Management, Business Office, Quality Data SystemsVertical CollaborationBoard approval August 15thExecutives, management, staff
11 No-Charge Policy for Serious Adverse Events A Learning Effort“Perfection is the Enemy of Progress”A Committee of ScientistsMonthly analysis of adverse event activity and use of the policy/ procedureRevisions based on experienceFocused Coordination of ActivityPatient Safety OfficersJust-in-time teaching and use
12 No-Charge Policy for Serious Adverse Events Adverse Events, Including Sentinel and Never EventsPolicy StatementConfirmation/NotificationAnalysisAction PlansProceduresAdverse EventsSentinel EventsNever EventsDisclosure/Apology
13 No-Charge Policy for Serious Adverse Events Adverse Events ProcedureNotify - Occurrence report, director, patient safetyInvestigate - RCA (full or abbreviated), CCA, FMEAAnalyzeDevelop action planReview with executiveImplement and monitor
14 No-Charge Policy for Serious Adverse Events Sentinel Events ProcedureNotify patient Safety, senior staff, othersTake immediate corrective actionDisclose to patient/familyInvestigate Analyze Action PlanReport: Executive, Site Performance Excellence Committee, Board of Directors, external agencyMonitor action plans
15 No-Charge Policy for Serious Adverse Events Never Events ProceduresDetermine if incident is a never eventHold billing until confirmation and RCA completedFollow Sentinel Event proceduresDetermine charges directly related to never-eventto be waivedCommunicate 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 PracticeOrganizational 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 conceptDelivering the message to the patientPhysician lead: nursing, othersSupporting your staffWhen Things go Wrong: Responding to Adverse Events: A Consensus Statement of the Harvard Hospitals
19 No-Charge Policy for Serious Adverse Events Disclosure and ApologyCoordinated by subject matter expertsPatient safety officersPerformance improvement staffMedical staff presidents and electsClinical risk managersSenior teams
20 No-Charge Policy for Serious Adverse Events Reporting DilemmaState health departmentLaw enforcementJCAHOOther: State hospital association
21 No-Charge Policy for Serious Adverse Events Other OpportunitiesTake advantage of the discomfort - have conversations about support, learning, improvement and patient safety.Feedback to operational plansMake 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-upGo to:Download additional resources and send AHA your questions, comments, feedback.Upcoming TeleconferencesThursday May 1, 11:30 am ET, featuring HCA, Inc.Tuesday, May 24, 1:00pm ET, featuring Children’s Hospital and Regional Medical Center, SeattleRegister at
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