National Academy of Medicine

More Hospitals Begin to Apply Lessons from Seven Pillars Process

By Carolyn M. Clancy
August 24, 2012 | Commentary

When the family of Michelle Malizzo Ballog found out that their daughter’s 2008 death had been caused by a preventable medical error, one question trumped all others: How could this have happened?

To the family’s surprise and relief, officials at the University of Illinois Hospital and Health Sciences System (UIHHSS) in Chicago did not defer that question to their lawyers. Instead, they investigated their suspicion that a fatal error occurred during Ms. Ballog’s surgery, confirmed that information with the patient’s family once it was established, apologized, and provided a financial settlement for Ms. Ballog’s young children. Importantly, the hospital made changes in their anesthesia processes to ensure that the same error would not happen again.

The Seven Pillars Process

This approach, known as the “Seven Pillars,” was adopted by UIHHSS in 2006. It is a notable exception in our nation’s health care system, which still relies heavily on the medical liability system to sort out the myriad issues involved in investigating, addressing, and preventing patient safety events. (A full-disclosure policy that was adopted in 2001 by the University of Michigan Health System is credited with reducing costs per claim by 50 percent and earning approval of 98 percent of the system’s faculty physicians.)

 

Note

Disclaimer: The views expressed in this paper are those of the authors and not necessarily of the authors’ organizations, the National Academy of Medicine (NAM), or the National Academies of Sciences, Engineering, and Medicine (the National Academies). The paper is intended to help inform and stimulate discussion. It is not a report of the NAM or the National Academies. Copyright by the National Academy of Sciences. All rights reserved.