Fundamentals of Risk Management & Patient Safety for Community Health Centers

On-site RM Training Seminar – November 2008

Petra S. Berger PhD RN, CPHRM

Healthcare Risk, Quality, and Patient Safety Consultant [email protected]

Phone: 517 –281-7816 1

Learning Objectives

 Demonstrate understanding of

risk issues

inherent in providing community health center services  Explain leadership

tools & methods

related to: 

Proactively identifying risk concerns

, and 

Responding

from the risk control, quality, and patient safety perspective  Recognize the critical role played by

patients and families

regarding high risk aspects of patient care

2

Definitions

Risk Management

&

Liability Coverage



What is

“Risk management”

@ CHCs

 

Dir. & Officers:

 Financial, Contracting Employment Practice, Workers ’ Comp General Liability: Property etc.

Concepts in Professional Liability



Risk identification & reporting

 

Clinical Liability review Risk intervention:

immediate & QI referral

3

VITAL BRIDGE OVER TROUBLED WATERS QUALITY MANAGEMENT Patient Safety = Q. I.

Risk Management

= identify risk – respond – prevent

4

CORE PURPOSE

of

RISK MANAGEMENT



S T O P ADVERSE OUTCOMES

Preventing Patient harm



Protecting Healthcare facility

from  litigation and financial loss  patient and community distrust 

Protecting

involved

Providers 5

QUALITY OUTCOMES & RISK ASPECTS on O N E Quality Management Platform



Patient Satisfaction



complaint management



Clinical Effectiveness



missed diagnosis

  

Policies & Protocols



after hours coverage

Regulatory compliance



informed consent

Efficiency, UR, Cost control 6

Risk & Quality Leadership Roles

     A

culture of safety

in which individuals can draw attention to potential or real

hazards, barriers, gaps, or failures without fear Non – punitive reporting

Strategic Risk & Quality planning based on

Prioritization

Implementation of practice guidelines and procedures through Monitoring and Q. I. “Knowledge transfer”

of patient safety practices 7

Health Center Trends and Issues

FTCA CLAIMS DATA     

Claims Occurrence

Error in Diagnosis 30% Treatment related 21% Medication related 10% OB Related 22% Surgical Procedures 6%

Claims Location

Health Center 65% Hospital 35% 8

Liability Question: Allegation of NEGLIGENCE

Duty –

based on

existing provider-patient relationship

To exercise

degree of care

that a

reasonable & competent provider

would exercise under

same or similar circumstances Breach

of Duty Plaintiff must show that defendants failed to exercise

‘reasonable’ care,

and

adherence to

established

clinical standard

(expert testimony)

Injury

proximately

CAUSED

by breach

(foreseeable)

9

Case:

Incomplete Medication History

 58-year-old male patient was scheduled for a major diagnostic procedure at the hospital where a certified registered nurse anesthetist (CRNA) provided conscious sedation.   A required copy of the clinic medical record was sent preoperatively. No mention was made of the patient’s

medication

.

seizure 10

Case:

Seizure & Respiratory arrest

   No recent

blood level

had been obtained related to the patient’s seizure medication

.

Patient

compliance

with the medication was unknown.

The patient underwent scheduled procedure

 Patient experienced

a grand mal seizure

during the procedure and had a

respiratory arrest. Intubation was delayed

and the patient suffered

permanent brain damage.

11

Immediate RISK INTERVENTION



PATIENT STATUS?



Medical Record As Core Evidence



Privileged & protected information



Fact-based investigation

  

No premature conclusions Timelines and event analysis (RCA) Sequestering evidence 12

Alleged Negligence: Duty? Breach?

A.

Clinical standards of care

= ‘duty’ 

Monitoring, patient medication & document



Test result reported & signed off by provider



Treatment plan updated, w/

or

w/out change



Reliable medical record system @ hand off with external medical providers and hospital B.

[CRNA &

hospital

standards of care]

13

P o l i c y & P r o c e d u r e s: Standards by which Care is judged



Difficult to defend

policy & procedure:  If not based on

evidence-based guidelines

 If

no allowance is made for clinical judgment to vary from protocol

 If

local practice not the same as policies

 If

not monitored for adherence 14

RISK IDENTIFICATION



Generic screens:

waiting times, no show rate

 Incident (or occurrence) reporting    (1 - 30%) Omitted or delayed

diagnostic reporting

Adverse medication event –

outcome /process

Patient or family complaint; Feedback 

Staff feedback & surveys

 

Risk reporting marathons Electronic information system 15

Procedures of

Incident reporting

 

H o w to complete incident report



Fact based, objective, w/ timeline

 

No speculation, opinion, blaming not:

“gave wrong med” 

Persons notified: RM, provider, family

No copy – no staples –

no

mention, MR placement



Medical record documentation

  

Date & time, provider actions Patient’s clinical status; quotes

not

NO PERSONAL NOTE KEEPING

adjectives 16

Risk vs. Quality measures: need both

       

Sample RISK MEASURES Patient complaints Misfiled and non initialed test results Missed diagnosis: Cancer Insulin medication error and patient harm Adherence to Anticoagulation guidelines Sample QUALITY MEASURES Medical record documentation audits /criteria Diabetic HgbA1C baseline & improvement Pediatric Immunization rates 17

TJC: National Pt Safety Goals

       P atient identification Verbal orders Hand off @ transition Medication reconciliation Critical lab value reporting Patient involvement in care Suicide assessment

18

Risk aspect #1 : Risk aspect #2:

Patient communication Provider Team Communication



PATIENT COMMUNICATION



Patient interview & Treatment planning



Health instruction –

literacy – interpreters 

Patient feedback & complaints



PROVIDER TEAM COMMUNICATION



Hand off @ transition points



Inter-provider relations

&

teamwork 19

Risk aspects #3:

The Medical Record

Risk aspects #4:

Clinic Operation & Flow

The Medical Record

 Chart c

ontent &

What To Document  Legal aspects: alterations, legibility, etc.



Confidentiality & Release of information Clinic Operation & Flow

  

Continuum of care

(62% claims) vs. fragmentation

Diagnostic test tracking After hours coverage; telephone triage 20

Risk aspects #5 : Risk aspects # 6

:    

Clinical Practice Medical Mis-Diagnosis

Patient assessment & monitoring Treatment & Use of Practice Guidelines Medication prescription practice Complications,

preventable



OB, Surgical procedures, Emergency visit

   

Most frequent Mis-Diagnosis

Inadequate medical history & physical exam Insufficient diagnostic work-up Incorrect interpretation of diagnostic tests Incomplete follow-up

21

   

Risk aspect # 7: Risk aspect # 8

:

Medication Safety

EQUIPMENT – EOC – EMERGENCY

Adverse Medication events

related to phases:

Product labeling

, packaging, nomenclature

Prescribing:

Indications, interaction, off label

Dispensing:

compounding, distribution error

Administration

: wrong drug/ dose/ route    

Emergency Preparedness Crash cart (incl. pediatrics) & checks Behavioral Building /weather 22

Risk aspect #9

: Risk aspect #10:

Clinic Staff performance

Medical Provider Quality



Staff qualification & orientation

   

Clear directives & protocols Orientation and Training Staffing levels Material resources

  

Medical Provider Quality & Peer review Review mechanism –

why, who and how

Data sources and Measures



Quality indicators



Risk indicators and events 23

Risk Aspects of Clinic Services I

24

High Risk Clinic Service Aspects – I

        Diagnostic ordering and test tracking Patient & Family Communication Informed consent and refusal Telephone triage, After hours, No shows Patient satisfaction & complaints Health Literacy Non compliance Termination of Care

25

Risk aspect #4:

Diagnostic test tracking & QC audits

     

Test ordered

by med. provider & log Request form created copy retained Test completed - patient compliance?

Results received & logged in / ck log Results reported to provider

(same day for abnormal /critical results)

Patient notification documented 26

Risk aspect #1:

Patient communication



Patient assessment & interview

 

Treatment planning

  &

consent

Conflict resolution; Non compliance Termination of care

Health instruction –

literacy – interpreters  Explain back / read back 

Patient feedback & satisfaction

 Complaint management

27

Medication compliance

PATIENT COMMUNICATION 

Medical literacy & English proficiency



Lay language



Validated understanding



Hearing, vision limitations ?



50% non-adherence to prescribed meds

 8.4 mio not taking hypertension meds

28

Why Do People Sue?

 Study of law suits against a large medical center indicated

Problematic Relationships:

 Perceived

desertion

of the patient 

Devaluing

patient and/or family views 

Poorly delivering

health information  Failing to

understand the perspective

patient and/or family of

29

Informed Consent

 

Used whenever an invasive procedure is proposed that carries a material risk of harm

Need to have a discussion of the    

Procedure and benefits

(P)

Risks

of the procedure ( R)

Alternatives

to the procedure (A) Questions asked (Q) 

What should be documented?

 Consent process, any questions answered

30

Informed

Refusal -

signed



Should be obtained whenever refusal to have a test or procedure done may have adverse results

– related to index of suspicion



Examples

 Mammograms   Chest or other x-rays Cardiac work-ups  Lumbar punctures

31

Telephone triage

&

Legible

Documentation      Using protocols adopted by medical staff,

or

direct consultation w/ med. provider

Name of Caller & purpose of call Advice & orders given (prescription refills) Follow-up instructions Date, time, AND initial of provider Review through Q.I. process



Based on criteria of clinical protocols 32

Telephone communication

 Document phone calls incl.

AFTER HOURS

calls,

in the medical record

if the following was discussed:   

medical symptoms, new or continued abnormal test results reported medical advice offered

 

questions about medical treatment prescriptions provided 33

Missed appointments

–

No Shows

 

Tracking high-risk patients scheduled appointment who miss



Pending diagnostic results?

Documenting all notification attempts



Include medical implication appointments of missing



If worsened outcome possible record , a certified letter is sent, with copy & receipt in medical 34

Risk ID through Patient Complaint

 Categorize

types

of complaints  Prioritize by

severity & risk level

 Establish

who is responsible for responding

to the complaints 

Log and trend

complaints & resolution 

Address systems issues

through

P.I.

35

           Risk-related Inventory Reasons for Care Termination

Group A

1. Repeatedly missing appointments w/out prior notification 2. Disagreement over treatment recommendations 3. Non-adherence /non-cooperation w/ treatment plan

Group B

1. Verbally disruptive and hostile behavior toward medical provider and/or staff [by patient or family /caregiver] 2. Threatening behavior toward medical provider / staff

Group C

1. Noncompliance with office policy re: prescriptions

Group D

1. Delinquency on bill payments

36

Termination of Care

Solution of

‘last resort’

 Patient given notice  of termination Evidence of certified letter in chart  Patient given reasonable amount of time which to obtain alternative care  Usually thirty days in  Patient given assistance in obtaining alternative care  e.g., a list of appropriate potential providers

37

Perhaps not now

-- Termination of Care      During treatment for an imminent or unstable medical condition  

Mental health disability if yet untreated in process of medical workup for diagnosis

Pregnant patient, approx. last trimester 

Pregnant patient approx. last 2 trimesters if high risk

Patient in immediate postoperative stage

Precaution w/discrimination issues, e.g. HIV

Remote area and lack of alternate providers

38

Risk Aspects of Clinic Services II

39

High Risk Clinic Service Aspects – II

 Staff communication & Human Factors  Credentialing, Privileging, Peer review  Clinical risk factors in Perinatal, Surgical, Behavioral Health, and Dental Services  Emergency Response

40

Provider Team Communication

 Half of communication breakdowns occurred as patients were HANDED OFF @ TRANSITION POINTS between providers (verbal & written)  2/3 of serious medical errors occur @ transition points (TJC reports) 

Inter-provider relations

&

teamwork 41

Risk aspect #9:

STAFF PERFORMANCE



Staff qualification & orientation

 Clear directives/protocols & Training  Staffing levels & Material resources  Human factor remedies

:

distraction, memory overload, fatigue, confirmation bias  Provide Performance feedback

42

Human Factor: Patient safety

Ownership & Just Culture

  

Imperfect behaviors, lapses, oversight

 Inadequate realization of risk, poor risk awareness , inadequate diligence – systems barriers & gaps?

At-risk behaviors --

e.g. shortcuts  Intentional conduct that

unintentionally

increases risk of harm: policy non compliance re: double checks

Reckless behavior /

questionable moral judgment 

Recognition

of high risk, BUT risk is

disregarded;

commission of intentionally hazardous acts -- cause violation of trust; e.g. alteration of medical records

43

Quality & Peer review:

Clinical Practice Pattern

  

Medical evaluation & Treatment



Complex medical condition:

Cancer, Co-morbidities  

Medication therapy Pre-natal risk factors



Pre-, intra- & post-surgical Tx & evaluation Use of Practice Guidelines: decrease variability



Asthma, Anticoagulants, Stroke, Pediatric Fever Complications,

preventable



OB, Surgical procedures, Emergency

Sample protocols can be accessed at http://www.guideline.gov/

44

Clinical Protocols w/ Risk Focus

      Pre natal risk assessment & OB practice Fever in Children (ACEP) Stroke Chest pain Abdominal pain Anticoagulant Management  Sample protocols can be accessed at http://www.guideline.gov/

45

Pain assessment :

a diagnostic Key



Assessment

(Pain & Headache)

& DOCUMENT

 

Location and Radiation (All locations) Onset – Duration - Frequency

    

Severity (per scale 1 – 10) Pain Quality or Type (pressure, cramps etc.) Last dose of Pain medication / frequency Recent Health history, events, procedures Other S & S: weakness, numbness, neck pain, stiffness, photophobia, diaphoresis, N-V, SOB (LMP) 46

Confirmation Bias

Paris in the the Spring

Once we decide that we “know” what something is, we tend to exclude or neglect information that may be

contrary to our original perceptions 47

Pre-natal risk assessment



PRE NATAL ASSESSMENT per protocol

(standardized)

 

Consistent documentation, prenatal visits Prompt high risk referral

 

PRE NATAL MED. RECORD TO HOSPITAL @ 36 wks Maternal conditions: hypertension – prior PE

–

diabetes – drug & alcohol – antepartum hemorrhage – cardiac risk factors

http://www.rmf.harvard.edu/ ; AAFP standards / ACOG standards

48

SURGICAL PROCEDURES  Scope of Privileges  Patient assessment,

pre procedure

  History & Physical

Prev. complications

related to procedures  Informed

Consent

and

Refusal

 Patient education / Health literacy  Post procedure follow up:  Complication? Infection? Pain?

49

BEHAVIORAL HEALTHCARE

    

Initial Assessment & Treatment Plan



Suicide assessment and Safety precautions

Case management

Medication therapy

(?informed consent) 

Monitoring of effects and compliance



Patient /family education: purpose /side effects

On-going

acuity assessment & referrals Documentation standards & confidentiality 50

Suicide assessment

-

Document

      Concurrent Dx :

depression \bi-polar \psychosis Family history



Previous patient attempts Lack of social support



Recent significant loss Alcohol /drug intoxication Terminal or chronic debilitating disease Abrupt withdrawal from normal routine

 John Hopkins Health Information, 1998.

Spotting the Warning Signs of Suicide

51

Incidental Assessment of Abuse or Neglect

   

Domestic violence

: child – dep. adult – partner Mandatory reporting laws :

suspect, not

prove

How to assess:

 Ask about abuse in private w/ respect, non blame  Feel safe? What stress? Should I be concerned?

   Emergency plans? Resources: friends, family?

Contusions, abrasions (head, chest, abd); fractures Abuse during pregnancy

DOCUMENT in detail

a n d

objectively 52



Human Performance Factor for Medical Providers

Clinical /technical

judgment & knowledge



Diagnostic

practice pattern & experience 

Medication knowledge

– indications, interaction, off label use, etc.

  

Understanding Patient needs

: dialogue, health education & clinical monitoring

Communication skills:

providers, patients

Documentation skills 53

Credentialing Focus

Initial credentialing varies from re- credentialing 

INITIAL

:

Licensure verification,

References

re:

privileges

Qualifying education &

experience

, NPDB



RE-CREDENTIALING

:

Quality & Risk data required

   Which value-added measures to select How to obtain the data efficiently What to do with quality information

54

Credentialing process:

I n i t i a l  Responsibility of

medical staff

and

board

 Include all

mid level providers & residents

 Documented process to

grant privileges



Reference letters address privileges sought

 Qualifying

education

& experience - criteria 

NPDB

query, all states w/ previous practice   Initial criminal background check Check all staff & volunteers, pertinent states

55

Re-credentialing & Quality indicators

    Patient assessment & monitoring (MR)   Diagnostic services and follow up Unclear /inconsistent documentation Medication prescription pattern Guideline adherence: e.g. Anticoagulant Tx Communication – team & patient relations

56

California Dept. Managed Health Care (DMHC) Fines Kaiser Health Plan for

Lack of Quality Oversight

(7/07) DMHC observed that of 228 peer-review files, one third were deficient, such as    Not handling quality concerns promptly Not fully considering a physician’s complaint history in evaluating peer review matters .

Not carrying out corrective actions HRC Alerts at http://www.ecri.org

57

Credentialing Files: Risk & Quality section

  Credentialing files organized into 2 sections Separate

Quality file

per practitioner  Sect. A: Guideline adherence; Documentation   Sect. B: P.C.E. = Potentially compensable event Adverse event review Peer review result

Top Confidential,

keep secured

58

Risk aspect #8: EQUIPMENT – EOC – EMERGENCY RESPONSE

Emergency protocols implemented and monitored



Medical emergency

    1 BLS trained staff on-site at all times

Crash cart (incl. pediatrics) & checks Behavioral Building /weather (power outage; fire) 59

Pediatric office emergencies

  

“…occur more commonly than perceived by family physicians; most offices not well prepared Obtaining training in pediatric emergencies, performing mock ‘codes’ to assure office readiness can improve actual handling of pediatric emergencies Common airway emergencies include foreign body aspiration and croup.”

Source: Wheeler, Kiefer and Poss. American Family Physician,

Pediatric Emergency Preparedness in the Office,

June 1, 2000.

60

EQUIPMENT LIABILITY

How to protect against risk    

THE EQUIPMENT WAS:

used in reasonable manner (vs. ‘user error’) inspected for obvious defects prior to use on regular preventative maintenance schedule

All staff using the equipment were trained Procedures developed & staff trained on how to respond in case of equipment failure 61

Environment of Care Infection control & Hazardous Material  

Develop, implement and monitor an Infection control (I.C.) plan pertinent to the facility Involve I.C. professional



Trend I.C. issues & take corrective action



Protect staff, providers, patients, and visitors from hazardous material 62

Behavioral Emergencies



OSHA cites healthcare facilities under general duty clause for failure to prevent patient violence against healthcare workers

 Medical providers & staff

exposed

to

potentially dangerous confrontations incl. ill-intended trespassers

 

Security audits needed to reveal problems

Address aspects of potential risk of violence Source: ECRI, HRC Risk Analysis – Overview: Managing Risks in Physician Practices , July 2003.

63

Risk Aspects, Clinic Services III

64

High Risk Clinic Service Aspects – III



Medical Record Documentation



Medication Management

65

Risk aspects #3:

T

he Medical Record -

Content

 Medical history,

comprehensive &

in ink

  Diagnosis

& Current medical problem list

Double check @ each visit before chart returned



Lab work, other diagnostic results

 

All results initialed by medical provider : QC

Patient notification documented

: QC



Current

  medication log

in ink

(

herbals, OTC) Double check @ each visit before chart returned Cross off old info w/single line, explain i. e. D/C

66

Personal Health Record (PHR)

 

Manual or electronic version



Portable / Paper / web based / CD ROM

Content

       Updated medication list incl. OTC Allergies & immunizations w/ dates Significant recent diagnostic test results Medical history incl. procedures Special diet and other health measures Health insurance information Living will

67

What

To Document

–

Concurrent



Referrals & consultations



Patient notification

 Instruction to patient /family,

in writing

    Questions addressed

Patient's failure to keep appointments Informed consent / refusal DISCUSSION

All entries

timed, dated & signed

/initialed

68

Guess that Prescription

 Handwritten prescriptions are often misread   In the prescription above, the drug name

“Avandia”

was incorrectly interpreted as Coumadin.

  http://www.medscape.com/viewarticle/557740?src=mp From American Journal of Health-System Pharmacy

69

Risk & litigation aspects

MEDICAL RECORD DOCUMENTATION

       

?Treatment rationale; ?Diagnostic Follow Up Omissions \ delays Contradictions; confusion between provider Finger pointing, subjective statements Corrections: Write overs & White out Illegibility & error prone abbreviations Altered Medical Records; “Late entries” Do not : mention ‘incident report completed’ 70

Alteration

of Medical Records

    A recent case in Ohio involved a physician who “whited out” the following phrase:

“I do not feel that a biopsy is necessary at this time”

And replaced it with:

“The patient does not want a biopsy at this time” Jury returned a verdict for $3 Million in an otherwise defensible case !

Destruction of records is equally detrimental 71

Policy development

Confidentiality & Release of information Release of information

 

verify request authenticity Incapacitated adults; Minors

  

Families of deceased patients Law enforcement officials /agencies Employers and other third parties Protecting Confidentiality



Leaving message on answering machine /at work



Sign in sheet at front desk & privacy

 

Privacy re: staff conversation /phone calls, reception area Faxing protocols 72

Faxing documents & Confidentiality

 What not to fax: HIV results, mental health records  Avoid sending to general locations, e.g. mailrooms  Request that the recipient acknowledge receipt  Include confidentiality statement on fax cover sheet  If intended recipient does not receive fax because of incorrect dialing, fax request using incorrect fax number & request return or destruction of material

73

Medication Safety

Adverse Medication events related to phases:



Product labeling

, packaging, nomenclature 

Prescribing: Indications, interaction, off label



Antibiotics, anticoagulants, narcotics,

cardiovascular, steroids; serum levels



Dispensing:

compounding, distribution error 

Administration

: wrong drug/ dose/ route Source: National Coordinating Council on Medication Error Reporting and Prevention –www.nccmerp.org

74

PROVIDER COMMUNICATION

& MEDS

PHARMACIST function    

Legible

prescriptions for Pharmacist Including

indications / purpose

diagnosis and/or Include all of the following components in order:

dose – strength – units/metric – route – frequency

Guarding against

LASA drugs

: 

Restoril ordered, Remoran

(Antidepressant)

dispensed



Patient also taking another anti-depressant 75

PROVIDER COMMUNICATION

& MEDS

NURSES and Verbal Orders  Restricting Verbal Orders –

Limit to Emergencies

 Speaking slowly & deliberately    Specific

indications /purpose

provided for all medication, including for “as needed” P.R.N. “Read back”

verification

, with

spelling

of drug name as necessary  Caution w/

sound alike and high alert drugs

Nurses to ask for

clarification of illegible or unclear

orders;

eliminating

second guessing

76

Clinical Protocols

Documenting MEDICATION MONITORING



Cholesterol

– liver panel, lipids 

Anticonvulsants

– drug levels, liver, CBC  Chronic

anti-inflammatory

/arthritis meds  kidney function, esp. geriatric patients 

Anticoagulant

 Warfarin / Coumadin – INR, PT, PTT

77

Anti Coagulant Monitoring

heparin – warfarin – other anticoagulants

 Warfarin dispensed by pharmacy per Patient 

Clinical pharmacist resource support



Education

about anticoagulants for

prescribers, nurses and pharmacists



Patient /caregiver education

   includes

reasons and benefits of therapy follow-up monitoring /compliance dietary restriction; potential drug interaction 78

ABBREVIATIONS “Do Not Use” list

    - NOT: U (unit) or IU (international unit) - NOT: Q.D., Q.O.D.

- NOT: MS, MSO4, MgSO4 - NOT: Trailing zero (X.0 mg)-

write

X mg  -

DO

use leading zero (NOT .X mg)

instead

 Do

write 0.X mg 79

Sample drugs & Medication security

  Manage controlled substances

Manage sample drugs

 

Storing & securing (authorized access; log in & out) No prescription pads in exam rooms

  

Monitoring expiration dates Dispensing function



log in & out; lot # Recall function 80

Protocol: Prescription refills

 

Medical records reviewed

prior to renewals for  

Needed labs, Most recent & next appointment (missed appt?) Medication renewals limited to patients previously seen by medical provider in clinic

 

Pain med renewal ONLY by Medical provider

Document:



Medication name, dose, amount, date of last appointment, completed labs as applicable 81

Medication Reconciliation

 RN/ MA intake interview: takes time  Interview skills   Medication knowledge Pt. brings in all current medications & OTC  Establish / update 

Medication Inventory

Keep in visible location on pt. chart   Patient keeps copy and updates Patient uses Medication inventory daily  Update medication supply

@ each visit to reduce refill requests

between visits

82

• Make change permanent (standardize) or • Continue the PDCA cycle • Collect data • Analyze data • Determine the

effectiveness of the change 83

•

Select

problem process •

Understand

the process • Decide on

process steps to improve

• Data collection • Data analysis •

Implement the change /

pilot