Northwest Second Victim Programs

Transcription

1 Northwest Second Victim Programs The Washington Patient Safety Coalition September 30,

2 P a g e 2 Background The speakers at the closing session of the 2012 Washington Patient Safety Coalition s annual conference were Chris Jerry and Eric Cropp, who spoke together about a terrible event that occurred several years ago and its effects on both their lives: Chris young daughter died as the result of a medication error for which Eric (as the supervising pharmacist) was held responsible. During the discussion several attendees described their organizations interest in, and/or work pertaining to, supporting Second Victims more effectively. (See below for definition.) Subsequently the Coalition began to facilitate meetings of anyone interested in learning from others and sharing this work. This document is one of the products of those discussions: the desire to share what has been learned in the form of an overview of SV programs and resources. Purpose of Paper This document is intended to be a resource to the community by summarizing Second Victim work that is currently underway at various Northwest organizations. It is a working document and will be updated on a regular basis so that it reflects the most current developments. The Coalition hopes that by making available these program descriptions, organizations will learn from work underway as they develop or improve their own SV support activities. What is a Second Victim? A health care provider involved in an unanticipated adverse patient event, medical error, and/or a patient related injury who become victimized in the sense that the provider is traumatized by the event. Frequently second victims feel personally responsible for the unexpected patient outcomes and feel as though they have failed their patient, second guessing their clinical skills and knowledge base. (Seys, et al., 2012) The negative consequences of second victims trauma often are ignored or missed. This is significant and problematic because the effects of SV impairment may cause additional damage and costs beyond the initial harm to the primary victim. For example, second victims without support and fair follow-up to adverse outcomes may cause more medical errors, have riskier prescribing profiles, and display less empathy. Physicians in this situation often change specialties or practices, work less, or leave patient care altogether. (Physicians Insurance, 2012)

3 P a g e 3 Second Victim Term Both patients and providers have expressed dissatisfaction with the term Second Victim because they do not feel that it accurately represents what it is meant to describe. Accordingly, there is a movement to change the term, and as we write this paper, it continues to evolve. However, because no consensus has been reached for a replacement, we will use the term Second Victim until there is agreement on new terminology. Why a Second Victim Program? The negative effects of SV issues produce the need for effective programs which aim to minimize negative outcomes of initial trauma and support the SV throughout his or her healing process. These programs help not only providers, but ultimately patients and families as well. Northwest Region Examples of Second Victim Programs Each of the following tables presents an overview of key parts of different SV programs, and will be updated on a regular basis. Information for these programs will vary. Please direct questions about a particular program to the contact(s) listed. We welcome additional regional programs for inclusion in future versions, and always welcome new members to the SV workgroup discussions: please contact the Coalition s Program Director at (206) ext. 11 or msmith@qualityhealth.org. Acknowledgements The Coalition thanks everyone who has participated in the SV meetings and discussions, and those who have shared information about their programs, especially the lessons learned.

4 P a g e 4 Source Program name Overview Goals and Objectives Status Progress to date Providence Everett Regional Medical Center Paula Bradlee Care for the Caregiver: Providence Peer Support Team The program is intended to assure that healthcare professionals have the support systems in place to assist them when they are involved in an adverse event or other difficult situations (e.g., the pain of losing a patient or if they have been assaulted by a patient). To develop a process that will support PRMCE staff when they are involved in difficult situations where debriefing and understanding available resources will assist them during this time. Pilot begun. Identified support personnel. 8 Hour Education Program developed and will take place in late August. Developed program, policy, forms, name, leadership involvement, provided one educational session, educational program developed, ongoing meetings scheduled for support personnel, working closing with EAP who has added additional support structure to their program and will be involved and support the education that occurs. Challenges/barriers Successes/lessons learned Supporting a new service, without additional staffing. Employee will be supported and appreciate this new process. Employees have a hard time contacting EAP. We can now contact EAP for them. Resources/time involved or required Metrics: how will effectiveness/success be measured? Confidentiality and Privileges Contact(s) Approximately 80 hours program development 8 hour classes (will probably occur 2 times a year or more) 1 hour quarterly for all support persons Administrative time Support-employee time Have not solidified exact metrics yet. Possibilities include, number of interventions (e.g. number of EAP visits or calls, number of support visits, or number of debriefs) or survey (e.g. for providers or EAP staff) responses. All discussions are confidential to the support person and employee. Paula Bradlee Director of Organizational Quality Paula.bradlee@providence.org (425) Nancy Reese Patient Safety Consultant (425)

5 P a g e 5 Physicians Insurance Source Patricia McCotter Program name Physicians Insurance Peer Support Program Overview Physicians Insurance Peer Support Program relies on volunteer clinician members, retained as consultants to the Claims Department, who are trained to contact members by telephone to offer short-term, confidential, emotional support and resources following report of an adverse event to the Claims Department. Reported events are notification in anticipation of litigation. The Peer Support Program is voluntary and members may independently request or decline services. Goals and Objectives Purpose: (1) Clinician-to-clinician, confidential support following an adverse event and (2) Provide information regarding the impact of adverse events on the health care team and how to access available resources. Inclusion criteria for offer of services: study event in DRP; contemporaneous report of an unanticipated outcome of care that involves or may involve level of harm to the patient such that a precautionary reserve would be set; adverse event known to impact the involved clinician such that support from a colleague would be of benefit; or member request for services. Status Pilot program launched June 1, Progress to date Challenges/barriers Successes/lessons learned Resources/time involved or required Metrics: how will effectiveness/success be measured? Confidentiality and Privileges Contact(s) Trained 15 physicians as peer support consultants. Program launched June 1, Member marketing is underway. Pilot program. Will supplement. Peer Support Consultants eager to offer support. Member response encouraging. Currently in pilot status. 6 months to develop and launch program. Dr. Jo Shapiro trained physicians May 4, To evaluate the program process and participants satisfaction, Peer Support Consultants will identify the number of times contact was attempted, the successful mode of contact, and number of conversations with each member. Peer Support Consultants will be surveyed regarding their satisfaction with the program, their training, and the process. Members will be surveyed regarding the value of the program. The Peer Support Program relies on volunteer clinician members, retained as consultants to the Claims Department, who are trained to contact members by telephone to offer short-term, confidential, emotional support and resources following report of an adverse event to the Claims Department. Reported events are notification in anticipation of litigation. Patricia I. McCotter Director, Facility Risk Management and Provider Support PatMc@phyins.com (206)

6 P a g e 6 Source Overview Evergreen Health Kathy Schoenrock No formal SV program. Instead, they use an Employee Assistance Program (EAP). Goals and Objectives Status Raise awareness of need to consider additional support, not only at the time of the event, but later as well. Include in Standard Work for investigation and follow up of patient safety events. See progress to date. Progress to date Challenges/barriers Established Standard Work for investigation and follow up of patient safety events by leaders; incorporated step to encourage leaders to consider needed support for staff and/or physicians involved in the event. Discussed in leadership training sessions. Revising Standard Work for the Critical Event Response Team; will emphasize physician and staff support. Two physicians have completed peer support training at Physicians insurance. There is no specific way to measure. Finding a good alternative to Second Victim terminology. Successes/lessons learned Part of Standard Work for leaders, launched July 2013 Resources/time involved or required Leaders feel that EAP does a good job. Metrics: how will effectiveness/success be measured? QM Staff review of the investigation with leaders. Confidentiality and Privileges Contact(s) Peter Bresko Patient Safety Officer PGBresko@evergreenhealth.com (425)

7 P a g e 7 Source Program name Overview St. Luke s Boise/Meridian (Idaho) Catherine Gundlach After the Event: Care Provider Recovery Toolkit Patient Safety Developed Second Victim Toolkit after Medication Safety Team reviewed topic from ISMP Medication Safety Alert (July 14, 2011). Goals and Objectives Status Progress to date Toolkit was developed as a resource for managers to supplement Employee Assistance Program (EAP), and Critical Incident Stress Management (CISM) team. Toolkit includes background slides, talking points for managers to review, videos. Piloted summer and fall 2012 with 3 nursing managers who provided feedback on materials. Toolkit now posted on St. Luke s Intranet site as a resource. Patient Safety also shared Toolkit with managers for their use with staff after events. Available as resource on St. Luke s intranet site for use by managers. Challenges/barriers Lack of model resources from other organizations. Not a focus project for leadership. Successes/lessons learned It was important to work with owner of CISM policy (Director of Social Work) and also to pilot it with several nursing managers. Resources/time involved or required Patient Safety Clinicians develop toolkit took about 20 hours to develop. Metrics: how will effectiveness/success be measured? Follow up with managers after their use. Confidentiality and Privileges All follow up between manager and staff is confidential. Contact(s) Catherine Gundlach Medication Safety Coordinator Quality and Patient Safety/Pharmacy gundlacc@slhs.org (208)

8 P a g e 8 Source Program name Overview Goals and Objectives Status Progress to date Challenges/barriers Successes/lessons learned Resources/time involved or required Metrics: how will effectiveness/success be measured? Confidentiality and Privileges Contact(s) The Everett Clinic Carrie Johnsen Provider Support Group The Everett Clinic Provider Support Group (PSG) is dedicated to coming along side of and supporting those providers who are involved in adverse events, potential claims or lawsuits, or the litigation process. Support is provided through the matching of physician mentors that have been involved in similar types of events to those that have recently experienced an adverse event and/or claim/lawsuit. To provide support and tools to healthcare providers so that they are able to better cope with an adverse event or pending lawsuit and deal effectively with the pressures of the claims investigation and litigation. The program has been in operations since early in At this time support is provided to Advanced Clinical Practitioners and Physicians with plans to expand to all healthcare professionals in the near future. There are approximately nine identified mentors in the program and that have supported over 20 providers mentees. A mentee committee meets quarterly to discuss progress and barriers of providing support services. It is challenging to keep mentors up to speed on the status of lawsuits and claims so that they can reach out to their mentees. It has been challenging to get some mentee s involved without making the process mandatory. The lack of resources to manage the program is also challenging. We have continued to build on the program since initiating in We have held training sessions for the mentors and we have successfully walked providers though claims/lawsuits with positive feedback from their experiences. We continue to seek feedback to enhance the program. The PSG Mentor Committee meets quarterly. Medical Director time to oversee and manage the program (meets with each mentee prior to enrolling in the program). Administrative time to manage meetings and setting up mentor/mentee meetings. Administrative time to notify mentors of claim/lawsuit status. Mentor/mentee meeting or discussion time. Annual education. Director of Risk time to develop and maintain the program with Medical Director and support of Administrative time. We provide a post mentor/mentee survey to the mentees after the partnership has ended. The Mentors meet monthly to address barriers. We feel we are successful if the mentees provide positive feedback on the experience and feel they were supported in the process. The PSG was formed under the parameters of the Quality Improvement Department functions, giving it a confidential status and a safe harbor for discussing the stress that often accompanies an adverse event, claims or lawsuits. Carrie Johnson Director of Patient Safety & Risk cjohnsen@everettclinic.com

9 P a g e 9 Annotated Resource List Denham, C.R. (2007). Trust: The 5 Rights of the Second Victim. Patient Safety, This article suggests that as part of a just culture, there exists 5 rights of a caregiver, and recommends investing in the systems and tools needed to adequately respond to adverse events so that the rights of a caregiver can be met. Hu, Y.-Y., Fix, M.L., Hevelone, N.D., Lipitz, S.R., Greenberg, C.C., Weissman, J.S., et al. (2012). Physicians Needs in Coping with Emotional Stressors: The Case for Peer Support. The Journal of the American Medical Association: Surgery, Findings and recommendations from an evidence-based study to address physician distress after an adverse patient or personal event. Researchers recommend peer support over any other type of service as being most effective. Physicians Insurance. (2012). Ensuring 360 Compassion: The Value of Provider Support Programs. Seattle: Physicians Insurance. This document describes a second victim and the associated costs of failing to address the needs of a caregiver after an adverse event. SafetyLeaders.org. (2011). A Hospital Accident: Lessons Learned A Death, A Conviction, and A Healing. Webinar transcript. Webinar transcript of patient safety advocates Christopher Jerry and Eric Cropp s first meeting. The webinar includes a history/account concerning an error on the part of pharmacist Eric Cropp that led to the death of Christopher Jerry s two-year-old daughter, Emily Jerry. Scott, S. D., Hirschinger, L.E., Cox, K.R., McCoig, M., Hahn-Cover, K., Epperly, K.M., et al. (2010). Caring for Our Own: Deploying a Systemwide Second Victim Rapid Response Team. The Joint Commission Journal on Quality and Patient Safety, Article describes the deployment efforts of an institutional (University of Missouri Health Care) rapid response system (RRS) for second victims. Based on their experience, the authors believe that the necessary components of a second victim RRS exist within most health care organizations. Seys, D., Wu, A. W., Van Gerven, E., Vleugals, A., Euwema, M., Panella, M., et al. (2012). Health Care Professionals as Second Victims after Adverse Events: A Systematic Review. Evaluation & the Health Professions, 12. A review of existing literature regarding the impact of adverse events on second victims, a call for increased awareness, and the need to offer support mechanisms to aid second victims involved in unanticipated events.

10 P a g e 10 Seys, D., Scott, S., Wu, A.W., Van Gerven, E., Vleugals, A., Euwema, M., Panella, M., et al. (2012). Supporting Involved Health Care Professionals (second victims) Following and Adverse Health Event: A Literature Review. International Journal of Nursing Studies, This study reviewed existing literature in order to identify supportive interventional strategies for second victims. It concluded that second victim support is needed to improve the quality of care for patients. Video: Dr. Albert Wu, practicing internist and professor at Johns Hopkins, and James (Jim) Conway, adjunct faculty at Harvard School of Public Health and senior Fellow with the Institute for Healthcare Improvement, discuss issues regarding second victims, and what is needed to start a second victim program. Programs: MITSS (Medically Induced Trauma Support Services) Tools Tools and other resources to aid with second victim/provider support programs. In addition to providers support, MITSS also includes help for families and patients. University of Missouri A second victim program that provides their tools to aid other programs/efforts.

11 P a g e 11 Bibliography Denham, C. R. (2007). Trust: The 5 Rights of the Second Victim. Patient Safety, Hu, Y.-Y., Fix, M. L., Hevelone, N. D., Lipitz, S. R., Greenberg, C. C., Weissman, J. S., et al. (2011). Physicians' Needs in Coping With Emotional Stressors: The Case for Peer Support. The Journal of the American Medical Association: Surgery. Physicians Insurance. (2012). Ensuring 360 Compassion: The Value of Provider Support Programs. Seattle: Physicians Insurance. Scott, S. D., Hirschinger, L. E., Cox, K. R., McCoig, M., Hahn-Cover, K., Epperly, K. M., et al. (2010). Caring for Our Own: Deploying a Systemwide Second Victim Rapid Response Team. The Joint Commission Journal on Quality and Patient Safety, Seys, D., Wu, A. W., Van Gerven, E., Vleugals, A., Euwema, M., Panella, M., et al. (2012). Health Care Professionals as Second Victims After Adverse Events: A Systematic Review. Evaluation & the Health Professions, 12.