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.

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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?