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    1. 1. Jeffrey F. Driver, JD Executive Vice President Chief Risk Officer Stanford University Medical Indemnity and Trust Insurance Company Stanford University Medical Center November 18, 2008 The Model Methodology Part III Solutions and Implementation
    2. 2. The Model Methodology: Data Into Action <ul><li>Capture vulnerabilities as they occur </li></ul><ul><ul><li>Contemporaneous analysis of asserted malpractice cases </li></ul></ul><ul><li>Put them into context </li></ul><ul><ul><li>Integration of relevant denominator data and peer comparative data </li></ul></ul><ul><li>Are you still vulnerable? </li></ul><ul><ul><li>Assessment of present-tense risk through risk assessments, focus groups </li></ul></ul><ul><li>Determine potential solutions </li></ul><ul><ul><li>Continuous identification of relevant models, processes, education, and training programs that address key risk areas </li></ul></ul><ul><li>Implement, educate, train </li></ul><ul><ul><li>Championship by high-level leadership to effect real change and to sustain it </li></ul></ul><ul><li>Measure/Metrics </li></ul><ul><ul><li>Measure the impact in the near term (with a predictive eye for the long term) </li></ul></ul>
    3. 3. PEARL – Process for Early Assessment and Resolution of Loss Process for the Early Assessment & Resolution of Loss (PEARL)
    4. 4. PEARL Process Flow
    5. 5. Summary of Model Patient Safety Initiatives <ul><li>clinical judgement—sel/mgmt med </li></ul><ul><li>pt monitoring— med regimen </li></ul><ul><li>commun among prov—pt cond </li></ul><ul><li>pt/fam edu— risks of meds </li></ul><ul><li>med error—dispensing </li></ul><ul><li>incorrect drug administration </li></ul><ul><li>supervision— house staff </li></ul><ul><li>sel/mgmt therapy—labor & delivery </li></ul><ul><li>sel/mgmt therapy—pregnancy </li></ul><ul><li>supervision— nursing </li></ul><ul><li>fail/delay obtain consult/ref </li></ul><ul><li>commun among prov—pt cond </li></ul><ul><li>fail/delay ordering dx test </li></ul><ul><li>pt monitoring—physiological </li></ul>RM Issues <ul><li>Decision Making Support in EHR </li></ul><ul><li>Diagnostic guidelines </li></ul><ul><li>Diagnostic algorithms </li></ul><ul><li>Closed Loop Communication </li></ul><ul><li>Results Manager </li></ul><ul><li>Referral Manager </li></ul><ul><li>Pt. access to results </li></ul><ul><li>Tickler files for test & referral follow- </li></ul><ul><li>up </li></ul><ul><li>Incidental Findings Follow-up </li></ul><ul><li>Communicating </li></ul><ul><li>Critical Test Results </li></ul>Models/ Solutions <ul><li>Team Training: Improve Communication (e.g.) </li></ul><ul><li>Improved Consent Process </li></ul><ul><li>Surgical Safety </li></ul><ul><li>Checklist </li></ul><ul><li>Briefings (e.g., OR, </li></ul><ul><li>morning/ shift) </li></ul><ul><li>Timeouts </li></ul><ul><li>Use of Critical </li></ul><ul><li>Language / SBAR </li></ul><ul><li>Communication triggers, residents to attendings </li></ul><ul><li>Bar Coding /RFID </li></ul><ul><li>Retained FBs </li></ul><ul><li>Simulation (e.g.) </li></ul><ul><li>FLS: Fundamentals of </li></ul><ul><li>Laparascopic Surgery </li></ul><ul><li>▪ Team Training </li></ul><ul><li>▪ In-Situ Emergency Recognition training </li></ul><ul><li>Informed Consent Enhancement </li></ul><ul><li>▪ EMMI </li></ul><ul><li>Proactive Risk mAssessments </li></ul><ul><li>Team Training: Improve Communication (e.g.) </li></ul><ul><li>Briefings (e.g., OR, </li></ul><ul><li>morning / shift) </li></ul><ul><li>Use of Critical </li></ul><ul><li>Language </li></ul><ul><li>EFM: Electronic Fetal Monitoring Education </li></ul><ul><li>▪ Existing education and APS </li></ul><ul><li>Decision Support (e.g., Obstetrical Care Guidelines) Embedded in EMR </li></ul><ul><li>Shoulder Dystocia Drills </li></ul><ul><li>Simulation (e.g.) </li></ul><ul><li>Shoulder Dystocia </li></ul><ul><li>Crisis response </li></ul><ul><li>Team Training </li></ul><ul><li>Proactive Risk Assessments </li></ul><ul><li>▪ Labor and Delivery </li></ul><ul><li>▪ Nurseries </li></ul><ul><li>Informed Consent Enhancement </li></ul><ul><li>EMMI </li></ul><ul><li>Medication Reconciliation (at all transition points) </li></ul><ul><li>▪ Yes at SUMC </li></ul><ul><li>Improve Ordering Process (e.g.) </li></ul><ul><li>CPOE: computerized </li></ul><ul><li>physician order entry </li></ul><ul><li>E-Prescribing </li></ul><ul><li>Bar Coding </li></ul><ul><li>▪ Yes at SUMC </li></ul><ul><li>Improve Documentation </li></ul><ul><li>EMAR: electronic medication </li></ul><ul><li>administration record </li></ul><ul><li>SHC Medication Administration “quiet time” </li></ul>Diagnostic Surgical OB Medication Target
    6. 6. Summary of Model Patient Safety Initiatives <ul><li>misinterp of dx studies </li></ul><ul><li>patient did not receive result </li></ul><ul><li>commun among prov—pt cond </li></ul><ul><li>fail to est differential dx </li></ul><ul><li>fail in f/u sys—new finding </li></ul><ul><li>lack/inad— history & physical </li></ul><ul><li>result not recv'd by clin—oth </li></ul><ul><li>results filed b/f clin review </li></ul><ul><li>supervision—hosue staff </li></ul><ul><li>commun among prov—pt cond </li></ul><ul><li>poss tech prob </li></ul><ul><li>fail to respond—pts concerns </li></ul><ul><li>fail/delay order dx test </li></ul><ul><li>misinterp of dx studies </li></ul><ul><li>inadequate cons for surg proc </li></ul><ul><li>fail to ensure patient safety </li></ul><ul><li>policy/protocol not followed </li></ul><ul><li>pt monitoring—physiological </li></ul><ul><li>improperly utilized equip </li></ul><ul><li>fail to respond—pts concerns </li></ul><ul><li>staff training/ education </li></ul><ul><li>insuf/lack doc—clin findings </li></ul><ul><li>pt monitoring—med regimen </li></ul><ul><li>lack/inad asses—premature d/c </li></ul><ul><li>fail to est differential dx </li></ul><ul><li>access/scheduling/waiting </li></ul><ul><li>supervision— house staff </li></ul><ul><li>fail to read medical record </li></ul><ul><li>insuf/lack doc—clin findings </li></ul><ul><li>sel/mgmt therapy—medical </li></ul>RM Issues Models/ Solutions <ul><li>Team Training: Improve Communication (e.g.) </li></ul><ul><li>Briefings (e.g., OR, </li></ul><ul><li>morning / shift ) </li></ul><ul><li>SBAR (or other agreed upon </li></ul><ul><li>tool) </li></ul><ul><li>Dashboard </li></ul><ul><li>Use of Critical </li></ul><ul><li>Language </li></ul><ul><li>Simulation Training: Crisis Response, Cognitive, Technical skills </li></ul><ul><li>▪ Yes at SUMC </li></ul><ul><li>Organizational Policy re: Inpatient Boarders </li></ul><ul><li>Improve Communication (e.g.) </li></ul><ul><li>Briefings (e.g., OR, </li></ul><ul><li>morning / shift) </li></ul><ul><li>Use of Critical </li></ul><ul><li>Language </li></ul><ul><li>Triggers (e.g., </li></ul><ul><li>surgical care </li></ul><ul><li>guidelines) </li></ul><ul><li>Fall Prevention Protocols </li></ul><ul><li>▪ Safe Patient Handling Programs </li></ul><ul><li>Infection Control Protocols (e.g.) </li></ul><ul><li>Wound Care Team </li></ul><ul><li>Improve Communication (e.g.) </li></ul><ul><li>Briefings (e.g., OR, </li></ul><ul><li>morning / shift) </li></ul><ul><li>Care Guidelines </li></ul><ul><li>(triggers when to </li></ul><ul><li>notify supervising </li></ul><ul><li>attending) </li></ul><ul><li>SBAR for handoffs </li></ul><ul><li>Team Training </li></ul><ul><li>Simulation Training </li></ul><ul><li>▪ All surgical residents get Simulation Training and new interns now receive patient safety training via simulation </li></ul><ul><li>Communication of Test Results per ACR Guidelines </li></ul><ul><li>Preliminary reports </li></ul><ul><li>Failsafe procedures </li></ul><ul><li>Documentation (e.g., </li></ul><ul><li>clarity of report, re: </li></ul><ul><li>communication of results) </li></ul><ul><li>Triggers embedded in EMR (e.g., allergies, medications, health history) </li></ul><ul><li>▪ Yes at SUMC </li></ul><ul><li>Double Reads (e.g., audits) </li></ul><ul><li>▪ Yes at SUMC </li></ul><ul><li>Tickler System for Ensuring Follow-up </li></ul>Nursing ED Residents Radiology Target
    7. 7. The Model Methodology: Data Into Action Engagement in High Risk Areas – RMF Data – Fully-coded SHC Cases by responsible service N=270 fully-coded SHC PL cases asserted 1/1/03-5/7/08. *Other includes Pathology, Allied Health, and Pharmacy. Total Incurred =aggregate of expenses, reserves, and payments on open and closed cases. Surgery =General Surgery, Orthopedics, Neurosurgery, Bariatric Surgery, Colorectal Surgery, Cardiac Surgery, Otorhinolaryngology (with Plastic), Hand Surgery, Ophthalmology, Otolaryngology (No plastic), Plastic (NOC), Pediatric Surgery, Oncology (Surgical), Thoracic Surgery, Urology Surgery, Vascular Surgery, Transplant, Podiatry. Medicine Subspecialty =Cardiology, Dermatology, Endocrinology, Gastroenterology, Genetics, Geriatrics, Hematology, Hospitalist, Immunology and Allergy, Infectious Disease, Oncology (Medical), Nephrology, Neurology, Physical Medicine/Rehabilitation, Pulmonary Disease, Rheumatology.
    8. 8. Perioperative Services Review Based on Claims Data <ul><li>Surgical Specialties are inherently high risk </li></ul><ul><li>Besides RMF coded data, a number of unusual events within perioperative services </li></ul><ul><li>Led to engagement of an outside consultant to assist SUMC with a full scale peri-operative services risk assessment (% day review, 4 consultants) </li></ul>
    9. 9. Results <ul><li>85 page report from the consultants outlining both best practices and areas that could be improved </li></ul><ul><li>Report also listed recommendations from the consultants as well as evidence based solutions </li></ul><ul><li>55 page action plan developed by internal experts </li></ul><ul><ul><li>Policies re-written </li></ul></ul><ul><ul><li>Recommended improvements put in place by Medical Leadership and Nursing Leadership </li></ul></ul><ul><ul><li>Partnership between Risk Management and Quality Improvement and Patient Safety Departments for action planning and implementation </li></ul></ul>
    10. 10. Other Action Items from Deep Coded Data <ul><li>Simulation programs funded by SUMIT to address areas of vulnerability </li></ul><ul><li>APS education to be offered to physicians in the next few months </li></ul><ul><li>PEARL process implemented to assist physicians with disclosure of unanticipated and adverse outcomes, to learn from preventable outcomes on a real-time basis, and to compensate patients for injuries </li></ul><ul><li>EMMI programs available for physicians to enhance the informed consent process and patient education </li></ul><ul><ul><li>One early success story (ENT case) </li></ul></ul>
    11. 11. <ul><li>Questions? </li></ul><ul><li>Thank you!!! </li></ul>