Learning From the Patient's Experience: Opportunities to Improve Patient Safety (Text Version)

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).

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Slide 1

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

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

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 

Slide 4

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

 Image of a flowchart of the seven pillars.

Slide 5

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

 Image of a flowchart of the seven pillars with the main processes circled.

Slide 6

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

Linking transparency with patient safety

 Image showing an event linked to transparency with acccountability. An arrow from the transparency with accountability box says "Becomes the Trojan Horse for Cultural Transformation".

Slide 8

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

August 23, 2009

 Image of an article headline from The Wall Street Journal titled: "Hospitals Own Up to Errors: Some Find That Confronting Mistakes Reduce Litigation-and Future Mishaps".

Slide 10

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

Corboy & Dememtrio

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