Tim McDonald, M.D., J.D., one of the nation’s foremost patient-safety experts, gave the keynote address during Christiana Care Health System’s 10th Annual Focus on Excellence Awards on Friday, Dec. 14, at the John H. Ammon Medical Education Center.
Dr. McDonald, co-executive director for the University of Illinois at Chicago’s Institute for Patient Safety Excellence, created a nationally-recognized, pro-patient philosophy known as the “Seven Pillars.” Those pillars include:
- Incident reporting: the reporting of cases or close calls in which patients were or could have been harmed.
- Investigation: the investigating of every report within 72 hours and providing the findings to the patient and their family.
- Disclosure and communication: the maintaining of open communication between the patient and their family until the issue is resolved.
- Apology and remediation: apologizing and offering a solution when the hospital does not meet its standard of care, including compensation when possible.
- System improvements: making improvements to the health care system to prevent the recurrence of the problem.
- Data tracking and analysis: the collection and analysis of patient safety incidents in order to improve quality and safety in the health system.
- Education and training: enabling doctors, nurses, administrators and support staff to take competency exams and attend patient safety meetings to improve their skills.
“We wanted to put a process in place at the hospital that would hug and love the patient and the family throughout their ordeal,” Dr. McDonald said. “The goal for us was to maintain trust with the patient and their family, even after the medical error occurred.”
Dr. McDonald gave a poignant example of one patient at the University of Illinois Medical Center. In 2008, Michelle Malizzo Ballog was under anesthesia during a surgery to replace a temporary stent in her liver. Monitoring errors were made while she was sedated and she went into cardiac arrest, dying nine days later at age 39.
Instead of ducking the questions or hiding behind lawyers, Dr. McDonald said his hospital officials shared the tragic details of the medical mistakes that resulted in Ballog’s death. Her family did no sue. Instead, they now sit as members on the hospital’s patient safety committee.
In a video clip played during Dr. McDonald’s presentation, Bob Malizzo, Ballog’s father, said he would still be willing to be a patient at the medical center because of the way the hospital handled the medical error that took his daughter’s life.
The Seven Pillars philosophy may seem counter-intuitive from a bottom-line perspective, given that it notifies patients early on about medical mistakes — opening up the opportunity for lawsuits — and the fact that medical bills are waived by the hospital when they commit a medical error that harms a patient.
But since instituting the Seven Pillars philosophy at his health system, the overall malpractice premium expenses have dropped by $22 million during the past three years, Dr. McDonald said. Patients are less likely to sue when a hospital is so forthcoming and transparent. The medical societies, patient advocates, legal groups and even insurance companies support the program. Additionally, the patient safety incident reports at the University of Illinois Medical Center have risen tremendously, providing hospital officials with valuable insight as to where mistakes are occurring and how to fix them.
Dr. McDonald said the Seven Pillars philosophy is grounded in honesty and transparency.
“We want to encourage reporting of incidents immediately after they are known,” Dr. McDonald said. “If the first way we hear about the incident is through a lawsuit, there is a $50,000 fine levied to the department where it occurred.”
Dr. McDonald toured Christiana Hospital and stayed after his presentation to watch the Focus on Excellence awards, Christiana Care’s annual recognition ceremony for teams of employees whose projects demonstrated improvement in process or outcomes. He said the Seven Pillars program — or any type of transparent patient safety program — will thrive at Christiana Care because of its culture.
“I see a strong commitment at Christiana Care to quality and safety, from the board director to the clinical staff that treats the patients,” Dr. McDonald said. “It is the reason that Christiana Care is recognized as one of the top health care systems on the East Coast.”