1. © 2008 The Board of Trustees of the University of Illinois Learning From the Patient’s Experience: Opportunities to Improve Patient Safety AHRQ 2009 Annual Conference Timothy B McDonald, MD JD Professor, Anesthesiology and Pediatrics Chief Safety and Risk Officer for Health Affairs University of Illinois at Chicago tmcd@uic.edu

2. © 2008 The Board of Trustees of the University of Illinois Principles of Transparency and Patient Engagement We will provide effective and honest communication to patients and families following adverse patient events We will apologize and compensate quickly and fairly when inappropriate medical care causes injury We will reduce patient injuries by learning from the past – and with the involvement of patients and families

3. © 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 [accepted] Reporting Investigation Communication Apology with remediation Process and performance improvement Data tracking and analysis Education – of the entire process

4. © 2008 The Board of Trustees of the University of Illinois The Seven Pillars: A “Principled Approach” to Adverse Patient Events Yes No Concern or unexpected event reported to Safety/Risk Management Patient Harm? Event Investigation Consider “Care for Care Provider” hold bills? Unreasonable Care? Full Disclosure with Apology and Remedy Process Improvements Data Base Patient Communication Consult Service “Near misses” Activation of Crisis Management Team

5. © 2008 The Board of Trustees of the University of Illinois Opportunities for Patient Engagement Within The Seven Pillars: A “Principled Approach” to Adverse Patient Events Yes No Concern or unexpected event reported to Safety/Risk Management Patient Harm? Event Investigation Consider “Care for Care Provider” hold bills? Unreasonable Care? Full Disclosure with Apology and Remedy Process Improvements Data Base Patient Communication Consult Service “Near misses” Activation of Crisis Management Team

6. © 2008 The Board of Trustees of the University of Illinois Opportunities for Patient Engagement Reporting – incidents, provider behavior Investigation – have critical pieces of information Communication – teach and provide feedback Apology with remediation - assessment Process and performance improvement Education – inspire and motivate

7. © 2008 The Board of Trustees of the University of Illinois Linking transparency with patient safety Transparency with Accountability Event Becomes the Trojan Horse for Cultural Transformation

8. © 2008 The Board of Trustees of the University of Illinois Why is this so important? > 250 Patient Communication Consults >50 cases of unnecessary harm with apology Over 190 performance improvement Over 190 performance improvement Several cases [6] with $ added to waiver of bill One lawsuit with inability to agree on damages

9. © 2008 The Board of Trustees of the University of Illinois August 23, 2009

10. © 2008 The Board of Trustees of the University of Illinois Litmus test for “change in culture”: the first big case “The patient’s family continues to seek care at the University.” Family continues to seek care at the University of Illinois