Thursday, April 29, 2010

Hand Wahing and Patient Safety

Oh No, Another Hand Washing Story.......

Well, I'm pretty sure offended another medical professional. I hate when that happens. I am generally a nice person and would never purposely hurt someone’s feelings – even if I didn’t like them. But when this nurse came through like a whirlwind and took the patient’s temperature I couldn’t stop her.

When she reached for the tools to do a throat culture, I jumped into action……..

“Excuse me, you will wash your hands first right”? Saying anything else, delaying the words “wash your hands”, and she would have torn through the huge q-tip wrapper to be used for a throat culture and, as far as I’m concerned, possibly contaminate it.

“I washed before I came into the room”.

“You touched the pen and the clip board. I’m sure they weren’t washed”. I felt the tension rising and saw her body tighten as she put down the still wrapped tools.

As she walked over to use the antibacterial lotion, she told me in a tense voice “I’ve worked in the emergency room for 30 years and never got anyone sick and never got sick”.

I wanted to say she didn’t know that but realized she was defending her action of not washing - so I let it go.

“I’m sorry if I offended you” I told her.

She said she wasn’t offended. "It takes a lot to offend me".

She has been doing this a long time. Still, I could tell that she was upset.

When she completed her task, and left the room I got a “high five” from my young buddy that turned out to have a pretty bad infection which ended him up in this after hour’s clinic.

When the doctor arrived to do the complete exam, I told her “Before you even start, I am going to ask you to wash your hands before you examine him, even though I’m sure you did.” She looked at me oddly. “But” I went on “ I think I offended your nurse so I am giving you advance warning”. The doctor walked over to the sink and scrubbed up – no offense taken.

Tuesday, April 20, 2010

President Obama Nominates Dr. Don Berwick

Don Berwick's Nomination

President Obama has nominated Dr. Donald Berwick president and chief executive of the Institute for Healthcare Improvement to head up Medicare and Medicaid programs. CMS, with a budget in the trillions, it is the largest U.S. healthcare agency and will undergo major changes following the healthcare system Obama recently signed into law.

Medicare and Medicaid are the federal medical programs for elderly and low income Americans and pending senates confirmation, will extend coverage to millions more Americans with Obama’s healthcare plan.

Dr. Berwick, a professor of pediatrics and health policy at Harvard, a leader in patient safety, led the nation in the 100k Lives Campaign which was aimed at giving hospitals and medical professionals the tools to improve outcomes by using proven methods that work.

There is no doubt that patient safety advocate’s, like myself are excited about this nomination. Even with just the nomination, patient safety is on the radar again. Every chance to discuss the importance of safety and quality in healthcare is important. This has started the conversations going again.

But, I do have concerns if Dr. Berwick took this position. Will he be able to keep safety and quality as the center of his work? I am afraid not. He will be taking on a big job and working for the government. If he worked for the government as a Patient Safety Officer I would say he would and could do great things for us. But he won’t. He will have many departments, a huge budget and many people to answer to. He will, in fact have to dilute his work in patient safety to cover other areas.

As I look for my own work in patient safety (yes, I still need a job), I am careful not to forfeit my values. There are diseases and people who don’t have healthcare but does that mean they don’t deserve safe care or quality care? If we ever get to a place that we are glad we have medical care but we don’t need to monitor their work or demand safe, quality care, hospitals will become an even more dangerous place to be.

I am mixed on my excitement on Dr. Berwick’s possible move. I am excited over this recognition for him but I fear if he takes this position, we may have to start looking for another Don Berwick to keep us safe.

Saturday, April 17, 2010

Patient Centered Care

Patient Centered Care; Born With the Knowledge or Learned?

As I sat next to the elderly patient, who was being prepared for surgery, I watched doctor after doctor come in to speak with her. Alone, if not for my presence, I realized how overwhelming it is to be bombarded by questions by many different strangers, especially when she left her hearing aids at home, as she was told to do.

The surgeon, a physician’s assistant student, the registered nurse, a surgery resident, the anesthesiologist all came through with their own list of questions.

“When did you last eat?”

“What are your past surgeries?”

“What are your allergies?”

“What are your medications?”

The list went on and on. When it seemed to come to an end, the PA student lingered. She chatted with the patient about the patient’s family, travel and life. The surgery resident soon came over to listen and also engage in conversation. Though extremely tired from tests and procedures earlier that morning, the patient was happy to tell stories of her very full life.

I had the opportunity to ask the young medical staff, still in training, if they have ever heard the term Patient Centered Care. They both shook their head and replied “no”.

They asked what that was and I explained that it is treating the patient, not as a disease or illness, but as a whole person. Actually, there are many definitions, that’s the one I chose to use at the time. It is being practiced and talked about in the “patient safety world” I told them.

An article in Family Practice Management explains Patient Centered Care as “treating patients as partners, involving them in planning their health care and encouraging them to take responsibility for their own health” While an article written for Robert Wood Johnson Foundation describes it as “speaking with your patients in their preferred language—at least during critical moments”

By listening to the patient for the extra 5 minutes, these doctors were learning more about the patient’s life and lifestyle. This may be a big part of how the patient will heal after surgery and how she will be cared for. The better the outcome for the patient, the better reputation the doctor will have.

These young people in medicine are learning about the body and how it works, how it fails us and how they can, with their incredibly difficult and long hours of training, can help fix it. I credit them for their skill, their commitment to healing and helping.

I hope that when they realize that their listening skills, empathy and compassion is not just a trait they were born with but also presently a taught skill in patient safety, often not taught until much later in their career, they will continue this practice of Patient Centered Care. I am just surprised this lesson was coming from me.

Wednesday, April 7, 2010

Collaborative Law

Collaborative Law and Patient Safety

Patient safety isn’t just for medical professionals anymore. My entry on March 24 was about my invitation by a medical malpractice law firm to hear Dr. Paul Gluck speak to a room full of almost all lawyers. Besides a few administrators for healthcare and a small handful of doctors, that audience of about 100 people were all lawyers.

Today I spent the day in California at a symposium organized by Kathleen Clarke, who over the years has become a good friend from long distance and a great colleague in the patient safety movement. Kathy practices Collaborative Law. Although she has always talked about it and written about it, I never really understood it. So, when I found out I could come out to California and support her work as well as learn about collaborative law, I counted my pennies and hopped on a plane.

Dr. Mark Graber Chief of Medicine of the LI VA Hospital was a speaker. He started his presentation talking about the day we met 10 years ago at a National Patient Safety Foundation conference in Missouri. He said that it was our conversation there that got him interested in patient safety. I didn’t realize that. He told the audience of about 80 people, mostly lawyers, that he said to me after I spoke at that conference, that I must have been glad that the lawsuit about my son was over. I said it was never over. I then told him it wasn’t about the money and he said he never knew that that was how patients and families felt. But, in most cases it’s never about the money. I didn’t need the money. No more birthdays or no college for my son who no longer was alive. What I needed was answers, acknowledgment and possibly a conversation with the doctor who, just days earlier, I trusted with my son’s life. I needed to feel trust again.

Dr. Graber talked about disclosure and how important it is to talk to patients and / or their family immediately following a bad outcome. Organizations practice open disclosure in many states. It makes them obligated to investigate the problem he told us. Only about 5% of hospitals actually practice disclosure.

Actor James Woods was live with his lawyer on video feed to talk about the settlement of his case against Kent County Hospital. The CEO of Kent, Sandy Coletta opened the discussion telling the story of how Michael Woods died in the Rhode Island Hospital that she herself said was in really bad shape when she took over the job as CEO following the death of Michael Woods. A sincere apology, not taking the advice of the hospital lawyers and instead, showing genuine empathy and remorse for the untimely death of the 49 year old father of two, is what was needed by James Woods to end this long drawn out lawsuit. That, and the development of the Michael J. Woods Institute at Kent teaching patient centeredness.

I wiped my eyes more than once while listening to Sandy Coletta tell her story. Partly jealousy that this family had acknowledgment from the hospital while others never get that. I also felt relief that we have moved so far ahead that this hospital administrator actually was open and honest I also realized that we treat these people like heroes because they are being honest about what happened to a patient.

Any way you look at it, collaborative law needs to be our future. Put in the room all interested parties; lawyers, doctors, patients, families and have a conversation. Put all interests up front, gather all the information, develop the options and negotiate a resolution. Everyone is needed at this table and needs to be a “collaboration”. How have we forgotten this part after all these years.