Two patients died from prescription drug overdoses after receiving high volumes of narcotics from a physician at Branford Medical Center. An investigation was launched to analyze the root causes of these deaths and make recommendations. Issues identified included lack of oversight over physician prescribing, absence of accountability, unhealthy work environment, and lack of infrastructure like an electronic medical record. Recommendations included establishing committees to oversee prescribing and quality, implementing an electronic documentation and monitoring system, conducting employee training on collaboration and accountability, and creating confidential reporting systems. The goal was to change the culture and improve communication, oversight, and patient safety.

1. Branford Medical CenterCase Evaluation ACME Health Care Consulting, LLC Katie Faella Matt Morrisette Joe Gandy Christine Cameron

2. How it all began… Jason Prescott -Passed away at age 35 secondary to a MVA September 25, 2010 -Toxicology screen was + for alcohol & narcotics PmHx: Chronic neck, low back, and shoulder pain following a motorcycle accident at age 25 High volume of narcotics for chronic pain were prescribed by physician at Branford Medical Center

3. More pain… Mary Backus -Passed away at age 40 secondary to an accidental prescription overdose at the end of July, 2010 -Toxicology screen was positive + for narcotics and benzodiazepines PmHx: -Severe anxiety and chronic low back pain - High volume of prescriptions written by physician at Branford Medical Center

4. “No snowflake in an avalanche ever feels responsible.” -George Burns

5. “In recent years, prescription drug poisoning has surpassed automobile accidents as the leading cause of unintentional injury death among people between the ages of 35 and 54...” http://www.aboutlawsuits.com/fentanyl-overdose-wrongful-death-lawsuit-15551/

6. “In 2007, there were 38,371 drug overdose deaths reported in the U.S., outnumbering gun and alcohol-related deaths.” http://www.aboutlawsuits.com/pill-mill-verdict-16012/

7. “…There was 65% increase in prescription drug overdoses between 1999 and 2005, commonly involving overdoses of morphone, OxyContin, and fentanyl.” http://www.aboutlawsuits.com/fentanyl-overdose-wrongful-death-lawsuit-15551/

8. Overview of catalysts for these outcomes:

9. Root Cause Analysis

12. Overview of catalysts for these outcomes: Deaths of Jason Prescott and Mary Backus

13. Recommendations

14. Plan of Action

15. Unhealthy Work Environment http://mentalselfhelp.net/blog/wp-content/uploads/2010/10/anger_2.jpg

16. Changing the Health System Culture http://www.ismp.org/newsletters/acutecare/articles/20040325.asp

17. Changing the Health System Culture http://www.ismp.org/newsletters/acutecare/articles/20040325.asp

18. Employee Implementation -Collaborative Skills for Teams Goals of program: Create more effective team performance Reconcile differences in team member personalities Reduce team conflict Reduce miscommunication Give meetings a purpose Manage time efficiently http://www.corexcel.com/idX/team-collaboration.htm

19. Oversight and Effectiveness Quality Manager Onsite point of contact Oversees behavior Contract an outside consulting group Unbiased employee satisfaction surveys Monitor from a third person standing http://www.pinnacleqi.com/products/

20. Outcomes http://www.qaproject.org/training/ipc/ref.pdf

21. Financial Impact Collaboration Skills Training Program- $995 Human Resources Officer- avg $65,000/year Consulting Group- price to come http://www.corexcel.com/idX/team-collaboration.htm

22. Financial Reward Quantitative Results General improvement in patient satisfaction $500,000-$1.2 million in additional revenue annually Avoided lawsuits save $53,000 in preparation and $173,000 in payments http://findarticles.com/p/articles/mi_m3257/is_10_62/ai_n31329893/?tag=content;col1

23. Financial Balance - $$$.... +$$$$$$$$$....

24. Lack of Infrastructure EHR -Amend Bylaws -Pain Committee EHR Sync Bylaws EHR -Oversight Committee -24/7 Reporting System

25. Unify Communication

26. Absence of Accountability

27. Continuing Education New legislature Bylaws of BMC Ensure each employee is aware of what is expected of them Article II, Section 3

28. “What you permit, you promote” Recommended additions: System for ensuring this event never happens again Mandatory patient medication reviews quarterly No prescribing narcotics for chronic pain in ED Strict guidelines for dealing with substance abuse problems Standard protocol for situations involving substance abuse Establish standards of behavior for all employees Have each employee sign off showing understanding

29. Physician Prescribing Monitoring Require electronic documentation of each prescription prescribed by physicians at BMC Incorporate system in EMR Evaluation of prescribing practices are performed monthly and reported quarterly at committee level as per Article XI 3.1.3 Quality and Peer Review specialist in conjunction with the CEO handles instances that arise Standard protocol for evaluation and management of illegal prescribing practices

30. Peer Review Establish a system of peer review Establish a separate position for Quality Care and Peer Review specialist Leads and organizes peer review program Position is a part of the executive committee Article XI 1.1.6 Allows for a continuous review of each employee The medical staff Executive Committee meets monthly (Article XI 1.3) At monthly meeting, discuss and evaluate situations with peer review Upholds Article II, Section 2 of bylaws

31. Confidential Reporting A 24/7 system for confidential reporting Allows for anonymous reporting of problems/situations within the medical center (include hospital and clinic) Headed by administrator and situations handled by the Quality and Peer Review position **Details on how system will work Goal for short term: promote/increase reporting from employees

32. Monitoring the system AHRQ’s culture and safety survey Take a baseline measurement for comparison Helps uphold Article XI 3.1 of bylaws **Add details about the survey Voluntary employee satisfaction survey Offered quarterly www.ahrq.gov

33. A New Day For Branford Medical Center Market to the community Branford Medical Center’s new approach to healthcare: The patients interests are number 1 BMC’s main focus is to increase the quality of care offered to each patient – Article II, Section 1 Start by creating a friendly, welcoming environment for the patient Free healthcare for citizens of Branford to market new goals and vision of BMC

34. A New Day For Branford Medical Center Tell the employees of BMC that their interests are a major concern as well. Show them you are on their side by implementing a plan to help create a more pleasant, safe, employee friendly work environment **Add details here Make it known that all employees are looked upon as equals no matter what position they hold Each employee is a critical component in providing the best healthcare possible to each patient of BMC

35. Cost Analysis – Current Costs to BMC

36. Cost Analysis Incurred Costs EMR EPA Quality and Peer Review specialist Free public healthcare Cost Neutral Employee evaluations Confidential reporting system Savings Lawsuit Rise in malpractice premiums

37. Timeline for Success

38. Implementation

39. Monitoring Progress ** Previous Clarion winners developed a timeline here, explaining how at set future timepoints they would evaluate for improvement of these intervening measures

40. Cost-analysis

41. Benefits/ Gains:

42. Statement of ‘Core Values’ Prev Clarion winners made a statement of ‘Core Values’, which seems to be more of a Mission Statement, something we may want to consider

43. Overall Vision

44. References Image 1- http://www.world-english.org/friends6.htm Image 2-http://www.motherinc.com.au/magazine/everything-for-mum/life-balance/pamper-me/7-skin-through-the-agestaking-care-of-you http://www.google.com/images?hl=en&biw=1280&bih=615&gbv=2&tbs=isch%3A1&sa=1&q=fear+eye&aq=f&aqi=g1&aql=&oq= http://semstreetcred.com/wp-content/uploads/2009/07/4622501_blog-300x300.jpg

45. Joe’s resources Hire a human resources officer http://www.payscale.com/research/US/Job=Human_Resources_(HR)_Manager/Salary Outside consulting group - http://www.pinnacleqi.com/ Training resources http://www.corexcel.com/idX/team-collaboration.htm Monitoring outcomes http://findarticles.com/p/articles/mi_m3257/is_n2_v45/ai_10328657/?tag=content;col1 Surveys and inspections Financial rewards Rush University Medical Center, Chicago, calculated that improving patient satisfaction scores resulted in $2.3 million in additional revenues annually from repeat customers (Garman, A.N., Garcia, J., and Hargreaves, M., "Patient Satisfaction as a Predictor of Return-to-Provider Behavior: Analysis and Assessment of Financial Implications," Quality Management in Health Care 13, no. l, 2004). REVIEWING THE NUMBERS: PATIENT SATISFACTION PAYSImproving patient satisfaction has a clear and direct impact on organizational results:* For a hospital with annual revenues of $120 million, improving patient satisfaction generates an estimated $2.2 million to $5.4 million in additional revenue every year.* For every 10 patients who complain to hospitals, there are up to 200 who do not and will tell their family, friends, co-workers, and physicians.* For every lawsuit avoided by improving patient satisfaction, hospitals save approximately $53,000 in costs to prepare cases and $173,000 in payments.Source: Press Ganey ROI Calculators. Used with permission.Melvin F. Hall, PhD, is president and CEO, Press Ganey Associates, Inc., South Bend, Ind. (mhall@pressganey.com). http://findarticles.com/p/articles/mi_m3257/is_10_62/ai_n31329893/

47. Pain management group

48. Hospital education committee- keep employees up to date

50. Define roles of each employee--- each person should know that he/she is accountable

51. Create culture of higher standards/ ie.) like MUSC’s ‘Culture of Compliance’

52. E-value-like system for evaluation from administration and peer evaluation

54. Resource line for reporting problems

55. Conflict resolution, team building retreat, individual empowerment

56. Make board meetings available to all employees- both through the ‘minutes’ for each meeting and attendance- create transparency