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No-Charge Policy for Serious Adverse No-Charge Policy for Serious Adverse EventsEvents
An AHA Member An AHA Member TeleconferenceTeleconference Series Series
Featured Speakers
Jeff Selberg, President and CEO, Exempla Health System & AHA Board of Trustees
David Munch, M.D., Chief Clinical and Quality Officer, Exempla Lutheran Medical Center
Nancy Foster, Vice President Quality and Patient Safety Policy, American Hospital Association
No-Charge Policy for Serious Adverse Events
The Experience of the Exempla Health SystemApril 18, 2008, 1:00 pm ET
For Assistance: 1-800-424-4301 or [email protected]
Introduction
Past Experience
Current Expectations
Future Goals
No-Charge Policy for Serious Adverse Events
The Exempla Experience
What We Believe
What We’re Doing
What We’ve Learned
No-Charge Policy for Serious Adverse Events
Best in the Nation Strategy– Our Goals– Our Report Card– From the Boardroom to the Bedside
Transparency– Accountable to the Public and Patient– Hosting the National Quality Forum
No-Charge Policy for Serious Adverse Events
No-Charge Policy for Serious Adverse Events
No-Charge Policy for Serious Adverse Events
No-Charge Policy for Serious Adverse Events
The Leapfrog Group asks hospitals to commit to 4 actions if a never-event occurs within their facilities.
1. Apologize to the patient.
2. Report the event.
3. Perform a root cause analysis.
4. Waive costs directly related to the event.
No-Charge Policy for Serious Adverse Events
Burning the Ships
• The Denver Post interview
• Commitment to the Leapfrog Group
• Development, implementation, learning and improvement
No-Charge Policy for Serious Adverse Events
Policy, Procedure and Practice Development
Horizontal Collaboration
• All hospitals• Legal, Risk Management, Business Office, Quality Data Systems
Vertical Collaboration• Board approval August 15th
• Executives, management, staff
No-Charge Policy for Serious Adverse Events
A Learning Effort
“Perfection is the Enemy of Progress”
A Committee of Scientists• Monthly analysis of adverse event activity and use of the policy/ procedure• Revisions based on experience
Focused Coordination of Activity• Patient Safety Officers• Just-in-time teaching and use
No-Charge Policy for Serious Adverse Events
Adverse Events, Including Sentinel and Never Events
Policy Statement• Confirmation/Notification• Analysis• Action Plans
Procedures• Adverse Events• Sentinel Events• Never Events• Disclosure/Apology
No-Charge Policy for Serious Adverse Events
Adverse Events Procedure
• Notify - Occurrence report, director, patient safety
• Investigate - RCA (full or abbreviated), CCA, FMEA
• Analyze
• Develop action plan
• Review with executive
• Implement and monitor
No-Charge Policy for Serious Adverse Events
Sentinel Events Procedure
• Notify patient Safety, senior staff, others
• Take immediate corrective action
• Disclose to patient/family•
Investigate Analyze Action Plan
• Report: Executive, Site Performance Excellence
Committee, Board of Directors, external agency
• Monitor action plans
No-Charge Policy for Serious Adverse Events
Never Events Procedures
• Determine if incident is a never event
• Hold billing until confirmation and RCA completed
• Follow Sentinel Event procedures
• Determine charges directly related to never-event
to be waived
• Communicate to patient/family
EVENT
ADVERSE EVENT PROCESS
Notification
Patient Safety Risk Management Administrator on Call
Sentinel/Never Event?
Decision made by Risk Management, Patient Safety, and unit/department Clinical Director
based on definition of a Sentinel Eventand/or from Never Event list.
Notification
Yesü Senior Team/CEO/CNO/CMOü Dept/Unit Directorü Medical Staff Leadershipü Communication Services Notify Dept/unit
Director
No
Assemble RCA Team
Gather data/infoConduct staff interviews
Establish time-line of event
Analysis of Event
Develop Action Plan
24 Hours
24 Hours
24-48 Hours
7-10 Days
10-24 Days
24-45 Days
7-10 Days
Action Plan Implemented
Event SummaryFindings
Action Plan
Responsible VPPatient Safety
Warrants Improvement
Effort?
Yes
Consult with PI/PSRe: type of analysisFacilitation needed?
· RCAo Fullo Abbreviated
· FMEA· Other
Assemble Team
Analysis of Event
ü Quarterly Summaryü Annual Reportü Priorities for future learningü Shared learning between sites
09/26/07
Occurrence Report
TrendingNo
Immediate corrective action
Risk Management:Required reports to:· CMS· CDPHE· FDA· Law Enforecement
PEC/QCB[Next Meeting]
1. Disclosure to patient/family by licensed independent provider and clinical operations
2. Voluntary reports by Risk Management
3. RCA completed by unit/department and Patient Safety
4. Waive costs directly related to Never Event by the Never Event Team (hold all billing until Never Event confirmed)
Never Event Team:· Risk Management· Patient Safety· Finance/Business Services· HIM/Coding· Clinical Director· Operational Executive· Physician Representative
Develop Action Plan
If potential “never event”, notify
business services to hold pt. bill
Discriminating individual safety problems from good people working in unsafe systems
Were theactions as intended?
Unauthorized substance?
No
Knowinglyviolate safe operating
procedures?
PassSubstitution
test?*
Historyof unsafe
acts?
No
No
Yes
Were the consequences as
intended?Yes
Sabotage, malevolent damage, suicide, etc.
Yes
No
Medical condition?
Yes
Substance abuse without mitigation
Substance abuse with mitigation
No
Yes
Wereprocedures
available, workable, intelligible, and
correct?
Yes
Possible reckless violation
System induced violation
Yes
No
Deficienciesin training & selection,
or inexperience?No
Possible negligenterror
System-induced error requiring corrective
training
No
Yes
Blameless error but corrective training, counseling needed
Blameless error
Yes
No
Dim
inishing culpability
Did person try to stop
the line or raise concern?
No
Yes
Blameless error but counseling needed
(behavior issue)
* Substitution test = ask 2-3 peers of the individual if they could have made the same error. If not, this may be an
issue of competency.
Adapted from the work of James Reason on systems
approaches to managing the risks of organizational
accidents
No-Charge Policy for Serious Adverse Events
Disclosure and ApologyDon’t Blow the Opportunity - From Policy to Practice
• Organizational awareness campaign: What it is? Why we do it? Who to notify? When it is done?
• Team of coaches - 24/7 presence: Rapid Response Team concept
• Delivering the message to the patient
• Physician lead: nursing, others
• Supporting your staff
When Things go Wrong: Responding to Adverse Events: A Consensus Statement of the Harvard Hospitals
No-Charge Policy for Serious Adverse Events
Disclosure and Apology Coordinated by subject matter experts
• Patient safety officers
• Performance improvement staff
• Medical staff presidents and elects
• Clinical risk managers
• Senior teams
No-Charge Policy for Serious Adverse Events
Reporting Dilemma
• State health department
• Law enforcement
• JCAHO
• Other: State hospital association
No-Charge Policy for Serious Adverse Events
Other Opportunities
Take advantage of the discomfort - have conversations about support, learning, improvement and patient safety.
Feedback to operational plans
• Make never events a priority for improvement.
• Set up database to track types, costs, locations, root causes.
• Don’t forget to support the staff.
Resources and Follow-upGo to: http://www.aha.org/aha/issues/BCC/080418-materials.html
Download additional resources and send AHA your questions, comments, feedback.
Upcoming Teleconferences• Thursday May 1, 11:30 am ET, featuring HCA, Inc.
• Tuesday, May 24, 1:00pm ET, featuring Children’s Hospital and Regional Medical Center, Seattle
Register at www.aha.org/aha/issues/BCC/080418-teleconference-registration.html
No-Charge Policy for Serious Adverse Events
