IHI Releases 2nd Edition of “Respectful Management of Serious Clinical Adverse Events” at ASHRM Conference

Cambridge, MA, Oct. 18, 2011 – The Institute for Healthcare
Improvement (IHI) is publishing today an updated version of a white
paper on “Respectful Management of Serious Clinical Adverse Events” – a
resource that, in just one year, has become a landmark document in
use around the world. The updated version is being announced by
co-author Jim Conway, IHI Senior Fellow, during an October 18
presentation at the annual conference of the American Society for
Healthcare Risk Management in front of more than 1700 risk management
professionals. The conference is taking place from October 16 to 19 at
the Phoenix (AZ) Convention Center. The white paper is available at www.IHI.org at no cost.

IHI originally developed the document in response to numerous requests from organizations seeking assistance in the aftermath of an adverse event. Most striking about these requests is the recognition that organizations typically build their responses from scratch, in a reactive mode, rather than from an existing clinical crisis management plan. IHI’s approach draws on patient- and family-centered care, patient safety, crisis management, and disaster planning, and on the experiences of health care organizations that have attempted to manage such crises in a respectful and effective manner. This work complements the ASHRM publications on disclosure of adverse events which address communication models and policy development.

The second version of the IHI white paper includes a new foreword, sections on reimbursement and compensation and disclosure of errors that have occurred at another institution. Data from Stanford University Medical Center is also being shared for the first time. Stanford utilizes a seven-day PEARL investigatory process to determine whether a care outcome is preventable. If the care outcome is deemed preventable, Stanford estimates compensation utilizing decision analysis methodologies. Stanford’s data reveals that claim frequency over seven post-PEARL periods (six months each period) has dropped 36% in comparison with the prior four pre-PEARL periods. Since the inception of PEARL, Stanford is achieving savings of $3.2 million per fiscal year on an expected average annual funding requirement of $10.1 million since the inception of PEARL.

“Most hospitals have detailed response plans for fires, hurricanes, tornadoes, and terrorist attacks, but too few have detailed plans for handling adverse events and medical errors,” said co-author Jim Conway, who brings to the writing of the white paper his previous experience as Executive Vice President and COO of Dana-Farber Cancer Institute for 10 years.

“What a tremendous resource this white paper is for a hospital that wants to get serious about culture change,” said Dr. Lucian Leape, Chair of the Lucian Leape Institute of the National Patient Safety Foundation. “And the appendices are fabulous. The paper takes away all the excuses!”

“The IHI and ASHRM publications are excellent documents to support the management of serious safety events with empathy, honesty and urgency, all core values for risk management,” said Michelle Hoppes, President of ASHRM.

The risk of not responding to adverse events in a timely and effective manner is significant. Consequences include loss of trust, absence of healing, missed opportunity for learning and improvement, sending mixed messages about what is really important to the organization, increased likelihood of regulatory action or lawsuits, and media challenges.

Version I of the white paper was published to wide acclaim last October:

• Its content has been used in presentations from Harvard Business School and the Harvard School of Public Health to institutions across the United States and in Australia, Ireland, Israel, Scotland, and Singapore, among many others.
• Health care organizations around the world are using the white paper to help guide the management of serious adverse events.
• It has been viewed more than 33,000 times and downloaded more than 10,000 times on www.IHI.org.

Both the original and updated versions of the white paper are co-authored by Jim Conway, MS, FACHE, IHI Senior Fellow; Frank Federico, RPh, Executive Director, IHI; Kevin Stewart, MB, BCh, FRCP, Health Foundation/IHI Fellow 2009-2010; and Mark J. Campbell, MEd, Adjunct Instructor, Harvard School of Public Health.