Task Force on Resolution of Adverse Healthcare Incidents Meeting Minutes March 10, 2021 | 2:30 – 4:00 p.m. | Virtual Meeting

Attendees

Present Virtual Absent

Task Force Members Rob Beatty-Walters (Trial Lawyer) ☐ ☒ ☐ Bob Dannenhoffer (Practicing Physician) ☐ ☒ ☐ Jeff Goldenberg (Practicing Physician) ☐ ☒ ☐ Michelle Graham (Hospital Health System) ☐ ☒ ☐ Anthony Jackson (Public Member) ☐ ☒ ☐ Bob Joondeph (Public Member) ☐ ☒ ☐ Richard Lane (Trial Lawyer) ☐ ☒ ☐ Saleen Manternach (Practicing Physician) ☐ ☐ ☒ John Moorhead (Practicing Physician) ☐ ☒ ☐ Tina Stupasky (Trial Lawyer) ☐ ☒ ☐ Rep. Ron Noble (Legislative Member) ☐ ☒ ☐ Rep. Rachel Prusak (Legislative Member) ☐ ☐ ☒

OPSC Staff Heidi Steeves Valerie Harmon Beth Kaye Linda Lancaster Sydney Edlund

Guests Roxy Mayer, Office of Rep. Prusak

Agenda Items

Welcome and Introductions

This meeting of the Task Force on Resolution of Adverse Healthcare Incidents (Task Force) was called to order by John Moorhead at 2:33 p.m. A quorum was present. Task Force members, guests, and OPSC staff introduced themselves.

Review and Approve Minutes

December 9, 2020 Minutes

• Motion: Jeff Goldenberg moved to approve the minutes of the December 9, 2020 meeting. Michelle Graham seconded.

• Vote: Rob Beatty-Walters, Bob Dannenhoffer, Jeff Goldenberg, Michelle Graham, Anthony Jackson, Bob Joondeph, Richard Lane,

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John Moorhead, and Tina Stupasky voted in favor. The motion was approved unanimously.

The Patient at the Center

Dr. John Moorhead shared the story of his mother who died unexpectedly

the day after she had sought care at the emergency department for

stomach pain. After his mother’s death, Dr. Moorhead found information in

her medical record that would warrant further evaluation, as it may

indicate a heart attack; however, there was no evidence that the medical

team had followed up on these indicators. He tried to speak with the

hospital about what happened but was never able to receive any additional

information about what had happened.

Many years later, the cause of Dr. Moorhead’s mother’s death remains

unresolved. Additionally, the hospital missed an opportunity to learn from

what happened. He observed that most people want to understand what

happened when patient harm occurs to make sure that it does not happen

again.

Task Force members thanked Dr. Moorhead for sharing the story of his

mother.

EDR Updates from OPSC

Heidi Steeves presented the EDR updates.

Legislative Update on Senate Bill 110 to Remove the EDR Sunset Clause

• The SB 110 has been voted out of the Senate Health Committee. No concerns or opposition were noted at the public hearing or in the work session. Thank you to everyone who testified or submitted testimony.

• Following the third reading on March 17, Chair Patterson will bring the bill to the Senate floor for a vote. Then it will head to the House, where Rep. Prusak and Rep. Noble will have more line of sight to its progress.

• OPSC is not certain if there will be a need for more testimony but will reach out to Task Force members if the need arises.

Update on Task Force Membership

• Task Force appointments are anticipated in the near future. (OPSC Board appointments were finalized earlier this week.)

• Thank you to Richard Lane and Bob Dannenhoffer for their continued contributions to the Task Force.

Update on Collaborative for Accountability and Improvement (CAI) CAI is hosting a series of free monthly webinars that Task Force members are encouraged to attend. The full list of upcoming webinars is available on the Training Opportunities page on the CAI website.

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EDR Data Snapshots Heidi Steeves presented the EDR Data Snapshots as a follow-up to the Task Force’s request to share measures based on data OPSC currently collects. The snapshots, along with analysis, are included in the EDR annual report. Discussion themes included:

Outreach

• Increasing awareness about EDR

• Increasing facility and provider proactive use of EDR: o Voluntary nature of EDR versus a mandatory approach o How to make the business case for a transparent approach o Anthony Jackson noted that diversity and inclusion

programs were not embraced by businesses until a persuasive business case was presented.

• Heidi agreed that a strategic outreach plan will be important. She also took the opportunity to share that OPSC is in the process of updating its website, with a focus on providing clear, actionable information for anyone interested in EDR. The website will be a valuable tool in understanding how future outreach initiatives are working.

• Heidi noted the importance of demonstrating the value of EDR participation to patients, providers, and healthcare organizations.

• Task Force members offered suggestions for potential future targeted outreach (e.g., historically underserved communities, groups that have frequent interactions with the healthcare system).

• OPSC will work with their board when planning their outreach strategy to allocate resources for both outreach and program administration responsibilities.

Understanding the Data

• Organizations with internal communications and resolution processes may not choose to use EDR.

• Responses to voluntary Resolution Reports from the facility, the patient or patient representative, and any named providers do not always align. For example, patient and provider may not agree on whether an apology was offered, or resolution reached. One potential contributor may be that different respondents interpret questions differently. Literature suggests providers have an opportunity to improve their understanding of what their patients are looking for during a conversation, as well as after a harm event.

• Task Force members asked if OPSC had noticed if a single facility or health system could skew the data. While OPSC cannot publicly share information about individual facilities or that may compromise the confidentiality of any facility that either participates or chooses not to participate in EDR, OPSC does consider this in our evaluation.

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Task Force Data Review

• Goal: To help answer the Task Force’s questions about EDR. Bob Dannenhoffer suggested: “How can we improve customer experience in the medical system?”

• Frequency: It was agreed that reviewing most of the data annually, in the context of preparing the EDR annual report, is adequate. Data that signals a significant shift should be brought forward sooner.

EDR Evaluation: Continuous Improvement

Heidi Steeves continued the conversation from the September and December 2020 meetings regarding the information Task Force members would like to effectively evaluate the EDR program. This conversation focused on data collection opportunities.

Reasons OPSC Collects EDR Data

• Satisfy legislative mandates, including the Task Force’s evaluation and reporting mandate and the mandate to share best practices.

• Understand the current environment for communication and resolution in Oregon.

• Inform continuous improvement of EDR internal and external processes.

Current Data Collection Process Data is collected at four primary points in the EDR process:

• Intake conversation (optional)

• Request for Conversation form

• EDR Online System

• Resolution Report

Continuous Improvement OPSC has been examining what it could see from the current data collection process that would help drive better practices. Staff saw opportunities to improve how we ask, when we ask, and from whom we collect data.

OPSC wants to engage a professional evaluator to help with its review of the process and its redesign of the tool.

Review of OPSC’s EDR Data Collection Process OPSC staff propose to start the review near the end of the EDR process, because it is the critical time to gather participant feedback. Currently, OPSC uses the Resolution Report.

Opportunities for Improvement:

• Understand more by user category (e.g., patient, provider, facility).

• Revise the language for clarity.

• Gain a better understanding of the experiences of those involved by examining what other factors had an impact on the conversation.

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• Identify better practices OPSC and the Task Force could highlight(e.g., how to help patients and providers better prepare forconversations).

Upon request, Beth Kaye provided more details about the current Resolution Report, including:

• Number of meetings had

• Who attended the meetings

• What was discussed

• Whether resolution was reached

• Elements of any resolution. There is also a free text box for anyother information that the submitted wishes to provide. A linkto the form is emailed to participants, and a hard copy of theform is mailed to participants who do not have email access.

John Moorhead questioned the incentive to respond to a paper or electronic survey and suggested that a personal communication might yield more responses and a broader set of data on the user experience. He suggested considering an alternate method to collect (e.g., phone interviews). Other members of the Task Force supported this idea.

The Task Force expressed support for OPSC’s proposal.

Patient Demographic Data Heidi noted that there is pending legislation that may set a new standard and provide a new tool for gathering information about patient demographics. If the REAL-D bill does not pass, OPSC will consider other options for expanding its patient demographic data set.

OPSC’s Next Steps

• Explore different ways to deliver the request for feedback.

• Engage a professional evaluator to review EDR data collection toolsand processes and provide recommendations for improvement.

• Share data with the Task Force that will provide insight into EDRimplementation and effectiveness.

• Research data collection practices of other programs in the CAIcollaborative and of programs in other states that have CANDOR-type legislation.

Outreach Task Force members provided thoughts on strategies for EDR awareness.

• Providers: Emphasize the business case for EDR.

• Patients: Focus on outreach patient groups who may be at anincreased risk to experience medical harm or who may beunderserved.

Anthony Jackson suggested OPSC compile a list of organizations serving historically underserved and marginalized communities that could distribute information about EDR to their members.

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Heidi agreed to look into outreach strategies and noted that it would be important to measure its impact.

Action Item: Task Force members are invited to send Beth Kaye a list of organizations, including the name of a contact person and their contact information, that OPSC could reach out to about the distribution of EDR information.

Public Comment No written public comments were submitted.

Upcoming Task Force Meetings

The next Task Force meeting is scheduled for June 14, 2021 (unless otherwise noted). The meeting schedule will be available on the Task Force Meeting page of the OPSC website.

Task Force members are invited to contact OPSC staff or the co-chairs if they would like to give the Patient at the Center story or add items to the upcoming Task Force agenda.

Evaluation Reminder and Adjourn

John Moorhead adjourned the meeting at 3:54 p.m. Task Force members will receive an email with the link to take an electronic meeting evaluation.

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