© 2008 The Board of Trustees of the University of Illinois 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

© 2008 The Board of Trustees of the University of Illinois Grant announcement

© 2008 The Board of Trustees of the University of Illinois 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

© 2008 The Board of Trustees of the University of Illinois Some background Institute of Medicine: 1999 report that shook the medical world Making Matters Worse

© 2008 The Board of Trustees of the University of Illinois February 2012, Volume 31, Issue 2 Part of the issue

© 2008 The Board of Trustees of the University of Illinois Adding to the equation Journal of Trauma, September, % 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

© 2008 The Board of Trustees of the University of Illinois More value to communication July 2011, Volume 30, Issue 7 70% of claims dropped once information shared

© 2008 The Board of Trustees of the University of Illinois 2005 U of I leadership approvescommunication- 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

© 2008 The Board of Trustees of the University of Illinois 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

© 2008 The Board of Trustees of the University of Illinois 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

© 2008 The Board of Trustees of the University of Illinois The Seven Pillars: A Comprehensive Approach to the Prevention and Response to Patient Events Unexpected Event reported to Safety/Risk Management Patient Harm? Consider Second Patient Error Investigation Hold bills Inappropriate Care? Full Disclosure with Rapid Apology and Remedy Process Improvement Data Base Patient Communication Consult Service 24/7 Immediately Available Yes No Near misses Activation of Crisis Management Team

© 2008 The Board of Trustees of the University of Illinois 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

© 2008 The Board of Trustees of the University of Illinois 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

© 2008 The Board of Trustees of the University of Illinois The Seven Pillars: A Comprehensive Approach to Adverse Patient Events Unexpected Event reported to Safety/Risk Management Patient Harm? Consider Second Patient Error Investigation Hold bills Inappropriate Care? Full Disclosure with Rapid Apology and Remedy Process Improvement Data Base Patient Communication Consult Service 24/7 Immediately Available Yes No Near misses Activation of Crisis Management Team

© 2008 The Board of Trustees of the University of Illinois Elements of resolution/remediation Patient Safety Compensation Card – given to patients if harm caused by inappropriate care, serves as their ongoing insurance card

© 2008 The Board of Trustees of the University of Illinois Putting it all together

© 2008 The Board of Trustees of the University of Illinois October 7, 2011

© 2008 The Board of Trustees of the University of Illinois Another communicating openly and resolving early

© 2008 The Board of Trustees of the University of Illinois October 7, 2011

© 2008 The Board of Trustees of the University of Illinois The Seven Pillars: A Comprehensive Approach to Adverse Patient Events Unexpected Event reported to Safety/Risk Management Patient Harm? Consider Second Patient Error Investigation Hold bills Inappropriate Care? Full Disclosure with Rapid Apology and Remedy Process Improvement Data Base Patient Communication Consult Service 24/7 Immediately Available Yes No Near misses Activation of Crisis Management Team

© 2008 The Board of Trustees of the University of Illinois Process improvement: Significant change in national guidelines July 1, 2011 ASA Specifically, in section 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.

© 2008 The Board of Trustees of the University of Illinois The Seven Pillars: A Comprehensive Approach to the Prevention and Response to Patient Events Unexpected Event reported to Safety/Risk Management Patient Harm? Consider Second Patient Error Investigation Hold bills Inappropriate Care? Full Disclosure with Rapid Apology and Remedy Process Improvement Data Base Patient Communication Consult Service 24/7 Immediately Available Yes No Near misses Activation of Crisis Management Team

© 2008 The Board of Trustees of the University of Illinois Pillar #6 Data

© 2008 The Board of Trustees of the University of Illinois

Educating the next generation: Reporting Data from Resident Physicians

© 2008 The Board of Trustees of the University of Illinois Reporting established as an expectation and part of Core Competency assessment

© 2008 The Board of Trustees of the University of Illinois Resident physician occurrence reporting data Journal of Graduate Medical Education, June 2010

© 2008 The Board of Trustees of the University of Illinois Event data

© 2008 The Board of Trustees of the University of Illinois Communication Consults

© 2008 The Board of Trustees of the University of Illinois UHC Derived Safety Data

© 2008 The Board of Trustees of the University of Illinois ROI for institutions: Improving safety reduces liability Reducing Patient Safety Incidents by 10 decreased claims by

© 2008 The Board of Trustees of the University of Illinois Impact of comprehensive effort Increased reporting Rapid, effective ongoing communication Rapid cycle improvements and harm prevention Early resolution

© 2008 The Board of Trustees of the University of Illinois

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 – SIP $45MM underfunded 2012 – SIP $8MM in excess

© 2008 The Board of Trustees of the University of Illinois 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

© 2008 The Board of Trustees of the University of Illinois 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

© 2008 The Board of Trustees of the University of Illinois 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

© 2008 The Board of Trustees of the University of Illinois Collaboration with Professional Liability Insurers

© 2008 The Board of Trustees of the University of Illinois 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

© 2008 The Board of Trustees of the University of Illinois Data from one grant hospital Large reduction in serious reportable events Already experiencing reduction in liability claims Have waived > $150K in Medicare charges Intervention

© 2008 The Board of Trustees of the University of Illinois 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 Doctors Company

© 2008 The Board of Trustees of the University of Illinois Questions?