By: Andy Furman, MD, vice president medical affairs; Jennifer Williams, MD, physician chair of multidisciplinary peer review committee; Pam Cortez, director patient safety and clinical support; Ellen Hampton, director Corporate Integrity, patient safety and risk
The Oregon Patient Safety Commission recently hosted Rick Boothman, chief risk officer, University of Michigan Health System. He presented his story about why early disclosure of bad outcomes is the best approach to learning from and reducing mistakes in health care for both patients and providers..
Mistakes are inherent to medicine. Our mission as a Lean organization is to continuously improve by understanding and learning from these mistakes in order to build systems to prevent future mistakes.
Mr. Boothman described his organization at the University of Michigan as one of “normalized honesty and transparency.” Since the norm is to divulge when a mistake has occurred, there isn’t any angst over what might happen. He has reams of data to support why this is the right approach for anyone interested in discussing more.
We want to create more transparency about the PSA/peer system and disclosures. Our goal is to build a reporting system and a tracking system for quality and safety opportunities, and allow for the careful evaluation of circumstances to inform improvement work.
In addition, a patient who has a less-than-desirable experience can generate a wide variety of emotions and concerns among all members of the care team. We want to focus on your well-being after experiencing and reporting events by developing a peer support system. Once a system is in place, following an adverse event, someone will reach out to see how you are doing while system-level quality improvement is evaluated.
Much more to come. Thank you for all you do!