Collaborative Learning From Patient Safety: Presentation From PSOs and International Patient Safety Culture

Slide Presentation from the AHRQ 2011 Annual Conference

On September 19, 2011, Timothy McDonald made this presentation at the 2011 Annual Conference. Select to access the PowerPoint® presentation (730 KB). Plugin Software Help.

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Collaborative Learning From Patient Safety: Presentation From PSOs and International Patient Safety Culture

AHRQ Annual Meeting
September 19, 2011

Timothy B. McDonald, MD, JD
University of Illinois at Chicago

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Grant Opportunity with PSO Component

Image: A news release and a demonstration grant are shown.

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The Seven Pillars: Crossing the Patient Safety—Medical Liability Chasm

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The Problem

Image: Two books titled "To Err is Human" and "Wall of Silence" are shown.

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One Potential Solution: 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.
  • Process and performance improvement.
  • Data tracking and analysis.
  • Education—of the entire process.

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The Seven Pillars: A Comprehensive Approach to Adverse Patient Events

Image: A flow chart titled "The Seven Pillars: A Comprehensive Approach to Adverse Patient Events" is shown.

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AHRQ/Seven Pillars Project Focus

  • Patient Safety first.
  • Improved communication.
  • Reduce preventable injuries.
  • Compensate patients/families fairly and timely.
  • Reduced medical malpractice liability.

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Next Steps

  • Commitment: Leadership:
    • Medical Center; Systems—Vanguard, Resurrection.
    • State Societies—IHA, ISMS, Chicago Medical Society.
    • Insurers—ISMIE, Zurich.
  • Gap Analysis.
  • Identify teams.
  • Metrics.
  • Timeline for implementation.
  • Implement.
  • Measurement.
  • Feedback with shared lessons learned.

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Gap Analysis

  • Organizational structure.
  • By-laws.
  • Current status of event reporting from all levels, including learners.
  • Identify connection/coordination between safety, risk, quality, claims.
  • Degree of integration of physicians and other professionals in analysis of harm events and input into improvements.
  • Current knowledge of PSOs and Patient Safety Evaluation Systems.
  • Review of training efforts around "disclosure".
  • Current status of "remedies" provided to patients/families.
  • Status of support structure and services for those involved in harm or "near-harm" events.

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Gap Analysis Summary

  • Reporting systems at rudimentary level.
  • Very limited learner or physician reporting.
  • Limited physician engagement in RCAs.
  • Multiple fears identified.
  • Very narrow understanding of PSOs, PSES.
  • Lack of integration within hospital.
  • Similar lack of integration between hospitals within systems.
  • Little sharing of lessons learned between hospital with same system.
  • BTW, same findings in 15 other hospitals outside Illinois.

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Fears

  • Based on two Illinois Appellate Court cases:
    • Occurrence reports are discoverable.
    • Without proper By-Laws and Committee structure investigations are discoverable.
    • All process improvements are discoverable.
    • Lawyers consistently advise physicians to not participate.

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One More Benefit to PSOs
Resident Duty Hours: Enhancing Sleep, Supervision and Safety

Image" The cover page of the report "Resident Duty Hour: Enhancing Sleep, Supervision, and Safety" is shown.

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Highlights of IOM Report
Resident Duty Hours
Enhancing Sleep Supervision and Safety

  • Mitigating fatigue.
  • Un-announced visits.
  • Protected safe harbor for reporting.
  • Optimize education.
  • Specialty-specific focus.
  • Enhance "culture of safety".
  • Engage residents in detection of errors, improvement.
  • Use "near misses", unsafe conditions for learning.

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Highlights of IOM Report
Resident Duty Hours
Enhancing Sleep Supervision and Safety
 

  • Bottom line: without changes "the residency programs are not providing what the next generation of doctors or their patients deserve".

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Dealing With the Fears: the Critical Value of PSOs

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The Seven Pillars: A Comprehensive Approach to Adverse Patient Events Points of PSO Value

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PSO Value

Image: A flow chart labeled Patient Safety Organization is shown.

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Using PSO to Allay Fears

  • Based on two Illinois Appellate Court cases:
    • Occurrence reports are discoverable:
      • Construct reporting portal as part of PSES.
    • Without proper By-Laws and Committee structure investigations are discoverable:
      • Work with Safety, Risk, Quality to modify by-laws, restructure committees, create PSES.
    • All process improvements are discoverable:
      • Push RCAs and process improvements into PSO.
    • Lawyers consistently advise physicians to not participate:
      • Multiple meetings with stakeholders, especially malpractice insurers and lawyers—stakeholders now part of re-educating.

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The Seven Pillars and PSOs

  • One critically necessary design and process feature.
  • Disclosure.

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PSES Value

Image: A flow chart labeled PSES value is shown.

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The Seven Pillars and PSOs

  • One critically necessary design and process feature.
  • Disclosure:
    • Before "analysis".
    • Include patients and families.
    • Obtain consent from participants.

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The Need for Safe Reporting of Unsafe Conditions

  • "I was sitting in the surgery clinic...when the residents got their biweekly "time sheets" to fill out. ...they felt insulted by the exercise. All their time sheets were identical...they were a farce and the residents knew it...the current system within ACGME is inadequate."

John Brockman
President, American Medical Student Association
June 18, 2010

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Next Steps

  • Intense coordination between grant researchers and hospital/system safety-risk managers.
  • System and process re-design to facilitate learning.
  • Close interface with PSO[s].

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Questions?

Current as of March 2012
Internet Citation: Collaborative Learning From Patient Safety: Presentation From PSOs and International Patient Safety Culture. March 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2011/mcdonald/index.html