Learning From the Patient's Experience: Opportunities to Improve Patient Safety

Slide presentation from the AHRQ 2009 conference

On September 14, 2009, Timothy B. McDonald, MD JD made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (4.4 MB) (Plugin Software Help).

Slide 1

Slide 1. Learning From the Patient's Experience: Opportunities to Improve Patient Safety

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

 

Slide 2

Slide 2. Principles of Transparency and Patient Engagement

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

 

Slide 3

Slide 3. A Comprehensive Response to Patient Incidents: The Seven Pillars

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

 

Slide 4

Slide 4. The Seven Pillars: A "Principled Approach" to Adverse Patient Events

The Seven Pillars: A "Principled Approach" to Adverse Patient Events

 

Slide 5

Slide 5. Opportunities for Patient Engagement Within The Seven Pillars: A "Principled Approach" to Adverse Patient Events

Opportunities for Patient Engagement Within
The Seven Pillars: A "Principled Approach" to Adverse Patient Events

 

Slide 6

Slide 6. Opportunities for Patient Engagement

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

 

Slide 7

Slide 7. Linking transparency with patient safety

Linking transparency with patient safety

 

Slide 8

Slide 8. Why is this so important?

Why is this so important?

  • > 250 Patient Communication Consults
  • > 50 cases of unnecessary harm with apology
  • Over 190 performance improvement
  • Several cases [6] with $ added to waiver of bill
  • One lawsuit with inability to agree on damages

 

Slide 9

Slide 9. August 23, 2009, The Wall Street Journal

August 23, 2009

 

Slide 10

Slide 10. Litmus test for 'change in culture': the first big case

Litmus test for "change in culture": the first big case

I give the University and the doctors a lot of credit for being forthright about what happened to this young man and working with us to resolve the case without any court proceedings. Everyone who provided care to the brothers at the hospital were just devastated by his death. This is a wonderful family and this young man's death has effected them all very deeply. Hopefully this early resolution will help them in the healing process.

Family continues to seek care at the University of Illinois

Current as of December 2009
Internet Citation: Learning From the Patient's Experience: Opportunities to Improve Patient Safety. December 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2009/mcdonald3/index.html