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 EvaluationACME Health Care Consulting, LLCKatie Faella Matt MorrisetteJoe 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 & narcoticsPmHx: Chronic neck, low back, and shoulder pain following amotorcycle accident at age 25High 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 Environmenthttp://mentalselfhelp.net/blog/wp-content/uploads/2010/10/anger_2.jpg

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

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

18. Employee Implementation -Collaborative Skills for TeamsGoals of program:Create more effective team performanceReconcile differences in team member personalitiesReduce team conflict Reduce miscommunicationGive meetings a purposeManage time efficientlyhttp://www.corexcel.com/idX/team-collaboration.htm

19. Oversight and EffectivenessQuality ManagerOnsite point of contactOversees behaviorContract an outside consulting groupUnbiased employee satisfaction surveysMonitor from a third person standinghttp://www.pinnacleqi.com/products/

20. Outcomeshttp://www.qaproject.org/training/ipc/ref.pdf

21. Financial ImpactCollaboration Skills Training Program- $995Human Resources Officer- avg $65,000/yearConsulting Group- price to comehttp://www.corexcel.com/idX/team-collaboration.htm

22. Financial RewardQuantitative ResultsGeneral improvement in patient satisfaction$500,000-$1.2 million in additional revenue annuallyAvoided lawsuitssave $53,000 in preparation and $173,000 in paymentshttp://findarticles.com/p/articles/mi_m3257/is_10_62/ai_n31329893/?tag=content;col1

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

24. Lack of InfrastructureEHR-Amend Bylaws-Pain CommitteeEHRSync BylawsEHR-Oversight Committee-24/7 Reporting System

25. Unify Communication

26. Absence of Accountability

27. Continuing EducationNew legislatureBylaws of BMCEnsure each employee is aware of what is expected of themArticle II, Section 3

28. “What you permit, you promote”Recommended additions:System for ensuring this event never happens againMandatory patient medication reviews quarterlyNo prescribing narcotics for chronic pain in EDStrict guidelines for dealing with substance abuse problemsStandard protocol for situations involving substance abuseEstablish standards of behavior for all employeesHave each employee sign off showing understanding

29. Physician Prescribing MonitoringRequire electronic documentation of each prescription prescribed by physicians at BMCIncorporate system in EMREvaluation of prescribing practices are performed monthly and reported quarterly at committee level as per Article XI 3.1.3Quality and Peer Review specialist in conjunction with the CEO handles instances that ariseStandard protocol for evaluation and management of illegal prescribing practices

30. Peer ReviewEstablish a system of peer reviewEstablish a separate position for Quality Care and Peer Review specialistLeads and organizes peer review programPosition is a part of the executive committeeArticle XI 1.1.6Allows for a continuous review of each employeeThe medical staff Executive Committee meets monthly (Article XI 1.3)At monthly meeting, discuss and evaluate situations with peer reviewUpholds Article II, Section 2 of bylaws

31. Confidential ReportingA 24/7 system for confidential reportingAllows 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 workGoal for short term: promote/increase reporting from employees

32. Monitoring the systemAHRQ’s culture and safety surveyTake a baseline measurement for comparisonHelps uphold Article XI 3.1 of bylaws**Add details about the surveyVoluntary employee satisfaction surveyOffered quarterlywww.ahrq.gov

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

34. A New Day For Branford Medical CenterTell 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 hereMake it known that all employees are looked upon as equals no matter what position they holdEach 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 AnalysisIncurred CostsEMREPAQuality and Peer Review specialistFree public healthcareCost NeutralEmployee evaluationsConfidential reporting systemSavingsLawsuitRise 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. ReferencesImage 1- http://www.world-english.org/friends6.htmImage 2-http://www.motherinc.com.au/magazine/everything-for-mum/life-balance/pamper-me/7-skin-through-the-agestaking-care-of-youhttp://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 resourcesHire a human resources officerhttp://www.payscale.com/research/US/Job=Human_Resources_(HR)_Manager/SalaryOutside consulting group - http://www.pinnacleqi.com/Training resourceshttp://www.corexcel.com/idX/team-collaboration.htmMonitoring outcomeshttp://findarticles.com/p/articles/mi_m3257/is_n2_v45/ai_10328657/?tag=content;col1Surveys and inspectionsFinancial rewardsRush 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/

46. Recommendations Infrastructure:EMR, iPads