Collaborative Learning From Patient Safety: Presentation From PSOs and International Patient Safety Culture
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
Image: A flow chart labeled "The Seven Pillars: A Comprehensive Approach to Adverse Patient Events Points of PSO Value" is shown.
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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.
- Occurrence reports are discoverable:
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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?