Task Force on Resolution of Adverse Healthcare Incidents Meeting Minutes

March 9, 2016, 2:30 p.m., at Ride Connection, 9955 NE Glisan St. Portland, OR 97220

Attendees

Members Present Robert Beatty-Walters (present by videoconference), Robert Dannenhoffer, Gayle Evans, Anthony Jackson, Richard Lane, John Moorhead, Tina Stupasky (present by videoconference)

Members Absent Michelle Graham, Sen. Jeff Kruse, Rep. Ann Lininger, LeAnn Locher, Carla McKelvey, Sen. Floyd Prozanski

OPSC Staff Bethany Walmsley, Executive director; Melissa Parkerton, Director, Early Discussion and Resolution; Beth Kaye, Program Manager, Early Discussion and Resolution; Nicole Staudinger, Communications Specialist

Guests Jeff Merrick, Merrick Mediation

Agenda Items

Call to Order and Introductions

This meeting of the Task Force on Resolution of Adverse Healthcare Incidents was called to order at 2:35 p.m. with a quorum present; members and staff introduced themselves.

Patient Story Task Force member Anthony Jackson shared an experience he had volunteering as mediator for the Multnomah County Small Claims Court. After a dentist visit, an elderly gentleman was dissatisfied with the services he received and felt that he should be compensated. The dentist involved concurred, and during their conversation (outside of EDR process, with a mediator), expressed the desire to reach an agreement in which she would compensate her patient. However, the dentist was apprehensive that if she admitted to payment, she would be reported to the National Practitioner Data Base (NPDB). As she was willing to own up to her mistake and have the conversation and make things right, neither she nor the patient wanted the incident to appear as a blemish on her career, and they ended up dismissing the case and resolving the matter outside of the court system.

Executive Director Bethany Walmsley explained that the EDR statute and on-line system were structured to avoid automatic triggering mandatory reporting, and that the EDR Request for Conversation does not contain elements that would suggest reporting to NPDB. She also referred people to a 2014 Health and Human Services department memo specifically addresses this issue.

Anthony voiced concern that fears of NPDB reporting may present a barrier to participation for healthcare professionals and inquired as to efforts being made to educate them.

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Bethany explained that the Oregon Patient Safety Commission (OPSC) EDR education and outreach efforts have continued to make a concerted effort to communicate this. She added that if there was ever an opportunity in the future, the Task Force should consider requests for clarity at the national level around NPDP. She also emphasized the importance of clear and accurate messaging around the issue, given its sensitivity and high profile. In no way do we want to imply that EDR provides a loophole for doctors with a history of malpractice to endanger other patients.

There was a brief discussion about whether EDR Requests must be reported to licensing boards. Melissa will look into this.

Big Picture and Updates Bethany announced that she will be leaving the OPSC at the end of April. The OPSC board of directors has convened a recruitment committee with the aim of finding a replacement by the end of April. Bethany commended the Task Force on their dedication and commitment to the creation of Early Discussion and Resolution and expressed her gratitude for the opportunity to be a part of it.

Process Updates Program Use As of January 29, 2016, 54 EDR requests for conversations have been filed. 82 percent have filed by patients or representatives, and 18 percent have been filed by facilities or providers.

The website has received a consistent flow of new visitors each month. A recent spike in traffic of returning visitors is likely attributable to the recruitment efforts for the Oregon Collaboration on Communication and Resolution Programs (OCCRP) that took place in February.

The majority of phone calls the EDR team receives are about specific adverse events and requests for conversation that have already been filed. In an effort to capture a broader picture of amount of interaction that occurs, the EDR team has implemented a new tracking system that includes personal phone line calls and email communications, as well as direct EDR line calls.

Of the 64 calls about specific incidents thus far, 48% did not meet the criteria for EDR. To assist those callers, the EDR team encourages patients to work with the facility or provider(s) involved in the incident and provides appropriate resources, such as connection to support services and oversite and quality of care organizations.

Task Force members inquired as to the possibility of comparing state data to see if EDR is having an impact on tort litigation. Melissa shared that the new e-court system will make more data available about Oregon lawsuits that have been filed after it has been fully implemented statewide in Summer 2016. It may still be very difficult to track the impact, as we do not know how many serious adverse events occur, and as the claims that may be filed will not all state the same cause of action, e.g. medical negligence.

Maintenance of Certification Multi-Specialty Portfolio Program

Task Force member John Moorhead gave an overview of the American Board of Medical Specialties’ (ABS) Multi-Specialty Portfolio Program (MSPP). Dr. Moorhead explained that physicians struggle to keep up with certification requirements, and that the current certification process is seen as cumbersome and duplicative. Physicians may meet the requirement through programs offered by an established healthcare organization (e.g., Mayo Clinic, Michigan System of

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Hospitals, etc.) that has been MSPP certified. When an organization is pre-credited by the ABS as a program sponsor, the physicians who participate in these programs receive credit. MSPP aligns the requirements and streamlines the process. If OPSC became a MSPP sponsor, it could offer credit to physicians who participate in EDR.

Beth Kaye reviewed the requirements for OPSC to become a Portfolio Sponsor, including application process and fees. Beth identified some issues that might arise and suggested how they might be addressed (e.g. fee for service). Dr. Moorhead added that the goal is to give providers credit for something they are already doing and to provide value for participation in EDR. The director of ABMS has a background in patient safety and is eager to work with OPSC. Task Force members suggested that the opportunity to earn credit be made available both to medical professionals responding to an actual adverse event and to those who would like the training. Trained people will be better prepared to use EDR, and perhaps more willing. Task Force members expressed concern about whether EDR had sufficient staff and resources to take on MSPP sponsorship. Gayle Evans suggested that staff develop a business case before moving forward, and consider whether there are opportunities to partner with other organizations already designated as portfolio sponsors. The EDR team agreed to provide further details at the next Task Force meeting, and Bethany shared plans to bring the concept to the OPSC board of directors as well. Member of the public, Jeff Merrick, suggested that OPSC could develop a curriculum and standards and then provide it to an already certified Portfolio Sponsor to administer. Staff agreed to explore whether any other organization was situated to take this on.

Communications Refined Messaging Melissa shared that OPSC has refined its basic EDR messaging, incorporating input from the last Task Force meeting, as well as from a stakeholder group. The Task Force approved the messaging. OPSC will now move forward with integrating the new language into our materials and website.

Strategic Communications Plan Melissa gave a brief overview of the EDR strategic communications plan, covering the period from now to June 2017. In the interest of time, she invited Task Force members to review and communicate any input regarding the plan to her after the meeting.

Oregon Collaboration on Communication and Resolution Programs (OCCRP)

As approved by the Task Force at the November 2015 meeting, OPSC has moved ahead with the formation of the Oregon Collaborative on Communication and Resolution Programs (OCCRP), a 12-month breakthrough series collaborative to accelerate the adoption of robust CRPs in Oregon by engaging leading healthcare organizations to learn, test, and refine national best practices. OPSC’s partners are the Oregon Association of Hospitals and Health Systems (OAHHS), the Oregon Medical Association (OMA), and the Osteopathic Physicians and Surgeons of Oregon (OPSO).

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Because only two organizations (Providence St. Vincent and PeaceHealth Sacred Heart – Riverbend) were ready to go by the January 15, 2016 deadline, the recruitment plan has been revised. OPSC and the OCCRP Advisory Committee are actively recruiting hospitals, medical group practices and long-term care facilities, by contacting organizations that had previously expressed interest in the collaborative, and reaching out to other additional organizations. There will be a webinar for prospective applicants on April 13, 2016. The new OCCRP launch date is September 2016.

The Task Force suggested targeting leading participants from the 2015 Patient Safety Reporting Program as potential applicants.

As planned, OPSC sponsored teams from the two current collaborative members to attend the 2-day Collaborative for Accountability and Improvement (CAI) CRP Leader Retreat in Stanford in February. Melissa and Beth also attended the retreat, and shared that the experience was very effective and highly interactive. CAI plans to repeat the 2-day training on the east coast in the fall, and as a one day event at the National Patient Safety Foundation annual congress in May, so there is still the potential for applicants to attend the training and receive the same foundational education in preparation for collaborative participation.

Public Comment Members of the public had no comment.

Adjournment The meeting was adjourned at 3:58 p.m. The next Task Force meeting will be June 8, 2:30 p.m. to 4:00 p.m., at the Ride Connection Conference Room, 9955 NE Glisan St, Portland OR 97220. The meeting schedule is available on the Task Force page of the Early Discussion and Resolution website.