When bad things happen to good hospitals

Don't rely on a generic emergency plan

A report from the Health and Human Services' Office of Inspector General released at the end of October concluded that the Centers for Medicare & Medicaid Services isn't addressing some of the serious events that happen in hospitals or letting The Joint Commission know about them in a timely manner. However, hospitals are taking corrective actions, according to the report (http://oig.hhs.gov/oei/reports/oei-01-08-00590.pdf), making policy changes and providing training so that they don't happen again.

What else should hospitals be doing that they might not be when something bad happens? According to the Institute of Healthcare Improvement's re-released white paper, "Respectful Management of Adverse Events" (http://www.ihi.org/knowledge/Pages/), only 30% of hospitals have crisis management plans in place to deal with serious events. This is a mistake, says one of the authors of the report, James Conway.

So just what does a policy look like? At the University Health System of Eastern Carolina, being transparent is a long-standing goal, says Joan Wynn, chief quality officer for the system. "We started in 2008 because we wanted to be a leader in transparency," she says. "We wanted to be a learning organization, with everyone knowing what is happening and what you have to do differently." That transparency applies not just to the 10 hospitals of the system — who share information about events and near misses on a system intranet — but to patients and their families, too, when there is an error. "Transparency is a lever on building the will to get better," says Wynn.

And while some people balk at the idea of being open about errors and events, Vicki Haddock, administrator of risk management at the system, says that increasingly, even the most cautious of people understand that this "is the right thing to do."

The policy used for serious adverse events has actually been in place since the 1990s in some form. It is reviewed at least once a year, though, and changed as warranted, says Haddock. If a best practice is identified in literature or from another organization, Wynn notes, they may pull the policy out early for revision. Routine evaluation of the policy is done with representatives of risk management, quality, patient safety and patient advisory directors. Any changes are reviewed and approved by senior leadership.

Take the example of a medication error that results in a patient being transferred to a higher level of care, Haddock says. The staff involved call the on-call risk manager, who speaks with the physician. The physician and risk manager then meet with the patient and family to tell them exactly what is known. They also assure the patient and family that there will be a full review and any information from that review will be relayed.

Initial investigations start next and involve a review of the record, analysis by a pharmacist, and interviews of all of the providers and caregivers who were present or involved. The hospital then calls a Code E conference, which involves quality staff, accreditation, risk management, legal, on-site leadership, and medical leadership. They determine how to classify the event — serious, sentinel, or a precursor event. They determine whether a root cause or other analysis needs to be done, whether to refer the case to peer review, and whether to call in any external reviewer or ask for analysis by an outside pharmacist or physician. A specific time frame is set for any analysis requested.

The patient safety committee reviews the case and creates an action plan to prevent such an error from happening again. The entire incident is reported throughout the system as a lesson learned. The patient and family are kept advised throughout the process.

If the case is serious enough to merit media interest, the public relations staff will advise senior leadership on what action to take, along with input from risk management and legal staff, says Barbara Dunn, director of public and consumer relations for the system. That's only happened once in the last seven years, she says. "We were getting calls from media from around the region, and we felt it was important to address it fully, with full transparency, taking responsibility for our role in the event and assuring the public that we were working to ensure it never happened again."

The entire process can take a year or more to complete, says Haddock. Throughout that time, another element of the policy is to ensure the staff involved have the support they need, whether it is personal counseling, an opportunity to teach others what they have learned from the event, or something else.

Wynn says organizations that are sitting down to create a crisis policy should not assume that they can quickly become as transparent as they want to be. "We created a sequential time line. It can't happen tomorrow."

If you have senior leadership that thinks such events will never happen at your facility — and thus you don't need such a policy — you need to work to shift their view, Wynn says. "Share the stories in the press of other places where this is happening. It can happen to you, too, and you need a plan for what to do."

When they created their policy, Wynn says they did a survey of what other organizations in their state were doing. Having legal departments talk to outside counsel, determine what is happening in other facilities and the legal and regulatory realities in your state and others can help bring about change.

Haddock recommends letting risk management act as a conduit between the legal department, which might be more conservative, and quality, which might see the value in this based on literature and anecdotal evidence. "We sit in the middle between quality and legal. The dialog and planning between them is important. You have to engage in conscious decision-making about whatever policy you create."

Dunn says to make use of your friends and allies in organizations and at other facilities, not just when you create your policy, but also as events unfold. "A year after we had our event, we had a call from another organization that had the same thing happen to them. They wanted to know how we dealt with the media." She was happy to share their policies and experience, and says she'd feel comfortable calling that peer or any number of other people she knows to either find out how to handle a situation, what they learned from a situation, and even if they needed any help handling something. It's just another element of transparency.

For more information on this topic, contact:

* Barbara D. Dunn, Director of Public and Customer Relations; Joan Wynn, Chief Quality Oficer; Vicki Haddock, Administrator of Risk Management; University Health Systems of Eastern Carolina, Greenville, NC. Telephone: (252) 847-7599.