Missouri and Patient Safety

I just returned from Missouri where I had the opportunity to address the Missouri Center for Patient Safety Conference participants. I have said it before and I will say it again; any organization that invites me to speak about patient safety must really be serious. After all, I care about the patient – and only the patient. Don’t get me wrong. Its not that I don’t care about the others in the medical team; nurses, doctors, lab techs and patient transporters, but my concern is openly about the care the patient and their family receive while in the hospital.

The support system that is available to the medical team, to do their job right, was in this audience. Missouri is doing some great things for patient’s safety. Their patient safety organization is supported by the hospitals and health systems of Missouri, a sure sign they mean business.

It is exciting to speak with this group and hope that there will be some take-a-ways on how to communicate with the patient or family, how to teach about patient safety in the community or the importance of recognizing that everyone who they know and love may someday be a patient within their own health system.

I also had an opportunity to learn from some of the “great” people of patient safety. Many of us at a table shared stories; I heard some of their best practices and programs that are running in some of the hospitals. It’s frustrating that after attending so many conferences and learning so much, there is no place local I can use this information.

Wouldn’t you think someone at a New York hospital might say “come help us implement some of these programs?”

Unfortunately, hospitals are still not opening doors. They still do not, in many cases want the patient to have access. If they did, there would be patients and their families on every committee, in the board room and participating in programs about quality and safety. But, in New York, we still aren’t there yet.

Compassionate Communication and Patient Safety

PULSE of NY just completed day 2 of our workshop on apology and compassionate communication. The workshop was facilitated by Leslie Farrington MD, PULSE of NY newest board member. The idea was to learn if an apology can be delivered without saying the words “I’m sorry”. To some, the words I’m sorry have to do with “my” responsibility. It is a play on words but as we learned in these two, two hour sessions, words matter.

14 people participated; a perfect amount for a small focus group. There were 3 physicians, 2 in quality /risk, 2 nurses, 4 patient and / or family members and 3 observers / community members.

After introductions last week we watched the video ‘Beyond Blame” about a little boy who died during surgery in the mid 90’s. The film had us sympathize with the medical staff and learn some of their turmoil when something goes wrong. We also needed to remember the family and the pain they endured. The film set the mood.

We looked at the ‘disclosure” process from a registered nurse who is also a risk manager and very familiar with the disclosure and apology process throughout the country. She explained how physicians and hospital staff are being trained in disclosing bad outcomes to the patient and / or family. We then had a presentation about compassionate communication, how it is used to connect and listen and a discussion followed.

We ended on a good note last week to come back again and learn more.

Tonight we introduced ourselves again and reflected about last week. Many shared that they view compassionate communication as important but lacking in their training as medical professionals and in the patient’s experience in the healthcare setting. Someone suggested that they didn’t realize how just listening is so important.

Anne, a compassionate communication facilitator read a story about a medical injury and how compassionate communication helped the young girl who previously awoke during a painful procedure, through her next surgery.

Tonight we did some exercises practicing listening and reflecting and then Leslie did a role play with a woman who had a medical injury many years ago, Much of compassionate communication is about listening. We are accustomed to asking questions, giving advice or filling in blanks. Tonight we are introducing the skill of just listening, connecting with some feelings and the needs which are universal such as trust, sympathy and respect.

Leslie, a physician for over 25 years, listened as the woman shared her experience of years ago in the hospital. Leslie reflected back her feelings of anger betrayal and as someone said later, disrespect in not feeling heard. One of the people in the room commented on how it is so common to want to give advice. It came naturally for the people who worked in health care. The patient didn’t need advice, she needed to be heard. And Leslie offered her that.

One physician commented that doctors don’t get paid for “listening” there is no time. But we were assured that in Leslie’s practice, she encourages the patient to make a second appointment. Or, as Anne explained, the listening can come from anyone.

Our listening process took less than 10 minutes and the patient felt heard, respected and empowered.

The healing and connection that a patient experiences after being heard, helps the healthcare provider to gather important information, make the patient more compliant and trusting and will make the whole experience for all parties more productive and timely.

We then heard from Steve, also a board member of PULSE who is a nurse by training but a mediator for 7 years. He described how mediation can be for patients and families who have had a bad outcome. The discussion that followed showed me that we seem to all have a different view on mediation. For financial compensation, healing, closure, answers? With no exact mutual definition or even a reason for using mediation, it’s even harder to figure out what people want. I still say we can offer mediation as a third party who comes to the table with 2 parties willing to discuss what happened. Reporting the outcome to the National Practitioners Data Bank was a concern for a physician in the room. Not sure if that should matter. If the parties agree, it should be made available. Some people felt mediation is already being done through the disclosure process in hospitals. Others said that it is the patient representative who is there for the patient and / or family. Others commented that mediation is a tool for those who get turned down from the legal system because of the lack of financial compensation.

Mediation, as a form of communication would help parties come to an agreement following an unplanned outcome. We have a long way to go.

This 2 part workshop was just an introduction. We have so much more to explore and to learn. I would like to see an all day workshop. I would also like to raise the money to make this a paper that can be expanded on. Someone suggested this be offered in medical or nursing schools. At PULSE we have begun teaching forms of compassionate communication as part of our family advocacy training . Listening, connecting and really hearing the patient’s needs and feelings is as important as hearing what the healthcare provider is suggesting.

It was good to hear the differences which helped me see some of the obstacles. I won’t always agree but as Steve explained about mediation when we hear the word conflict, it has a negative tone. Conflict does not have to be negative. Disagreements are OK. It is how we resolve the conflict that matters. It can be done with compassion, with connection.

The 2009 National Physician of the Year Awards

Imagine my surprise when my phone rang late last week and a woman on the phone asked if I were Ilene Corina. She had John Connolly on the phone and he wanted to speak to me. What could John Connolly, President and CEO of Castle Connolly Ltd want with me?

He was inviting me, and the PULSE volunteers to The 2009 National Physician of the Year Awards Ceremony. Held at the historic Hudson Theater at the Millennium Hotel, New York City.

Seven of us went and it was a lovely evening with speeches and recognition and fine food. But what was important is that we, or at least I, can recognize the great work that physicians do as they save lives, connect with patients and generally love their work. It does not take away, for a minute, the pain someone suffers when things go wrong or, an outcome in care is not what was expected.

I am glad to have the opportunities to celebrate healthcare as well as know the pain of the unpredicted. I wish everyone had that opportunity.

Surgery

How do we choose where to have surgery? There is no easy answer. In most cases, we go where our doctor works or, if there is a choice, the hospital that we think has the best reputation. We can look up information on their infection rates or ask a nurse we know who works there, but none of these guarantee a “good” outcome to our surgery.

I had the opportunity to speak at a hospital in NY yesterday during Patient Safety Awareness Week and was very impressed with the attendance and audience participation. I was doubly impressed when I was greeted by the nurse in charge of surgery – before surgery, during surgery and after surgery, is how he explained what he is responsible for.

He told me about their “time out” which is done before a procedure so the medical team can check if they have the correct patient, if they are doing the correct procedure and if other safety measures are in place.

I was given a sign titled “Universal Protocol Time Out” with a script to be utilized before each procedure. It has the patient’s name, type of surgery or procedure and side or extremity with other check list information.

Any “no” answer it reads, stops the process. Not unlike a pilot in the cockpit, this sort of teamwork can really make patient feel confident and when done correctly, will make this part of the procedure a success 100% of the time.

I was given a Time Out pen that is given to patients to be sure the site of surgery is marked. I want terribly to open the seemingly sterile wrapper but instead, will keep it a souvenir.

The Time Out and marking the site of surgery are just a very few of the Joint Commission standards and basic safety tips. But, when a facility takes it seriously enough to put resources behind it, to be sure the medical teams have everything needed to make it fool proof, they should be recognized for taking patient safety seriously.

Was one person to slip, and forget to follow the standard procedures, the system may not work and patients, and their families may suffer. This is how I believe we should be choosing a hospital to have surgery but too bad we are usually not given this information. Maybe for Patient Safety Awareness Week next year this hospital will tell their patients how safety conscious they are so the patients can be that much more involved in choosing a hospital.

Patient Safety Awareness Week, Reflections

It’s Patient Safety Awareness Week and as it comes to an end, I want to reflect back what this week has been like as a patient safety advocate. I am so grateful that the National Patient Safety Foundation recognizes the importance of patients and families having a voice in patient safety. But, at a national level, that’s often all it is, a voice. What is being done, at a local level to include the patient and the community in patient safety? In my opinion it is still a big fat nothing (at least in New York).

I had the honor of sitting in at a presentation at a NY City health system for their leadership and another on Long Island for their whole health system. In both cases, they talked about patient safety, told stories of injuries or death and shared statistics. The IOM report was mentioned that as many as 98,000 people die in hospitals each year from preventable medical errors. I can’t imagine that 10 years after that report, there is anyone in senior leadership who isn’t aware of it. And, if newer staff aren’t aware of the report, why aren’t the medical and nursing schools teaching it?

To hear these presentations are bittersweet, I know we need to talk about patient safety to make patient safety happen. Talking is the start. But there should be more than talk.

I really believe that with my own presentations, and I am doing quit a few of them the last few weeks, I am offering more to hospitals and medical staff on what can be done to reduce errors than what I hear at these presentations. What is needed now is what the Institute for Healthcare Improvement offers; best practices. I am offering best practices and ways to include the patient and family. But by inviting me in to speak, am I leaving them with anything to “do”? I think I am. Are they doing it? I may never know.

I know that medical staff are told what to do to reduce the rate of injury or death, and Patient Safety Awareness Week is a time to (maybe) celebrate all they are doing. It would give me greater satisfaction if they used this time to include the patient and their family in this work. The hospitals and health systems should be practicing safe care all year, they could celebrate any time. But for Patient Safety Awareness Week it could be better spent by informing patients, and the community about what their role is in partnering in their care.

Patient Advocate

I spent 4 days at the bedside of a patient (and dear friend) which gave me another opportunity to practice and learn advocacy skills. There was nothing earth shattering about our stay but it sure was interesting.

I arrived before 8:00 each morning and stayed until after 9 PM. The registered nurses each had 4 patients with a certified nurse’s assistant having 10 patients. There was a “floater” nurse who helped when needed.

The hospital staff were unusually friendly. They smiled in the hallway and greeted each other as well as the patients. It was more like a hotel atmosphere than a hospital. This friendliness did not always lead into the patient’s room. Even though in most cases the nurse and nurse assistants were very friendly and kind, there were some who were not as patient or caring.

Kindness, I learned long ago is not a synonym for quality and being nice does not make for patient’s safety. Being kind and caring does open the door for a dialogue that can help avoid a bad outcome. For instance, when the night nurse gave the patient a new medication, the patient stopped him and asked why she was getting that and if there had been some mistake.

Years ago, I remember the nurses might say that “the doctor ordered it” so it was OK but in this case the nurse stopped and said he would check on it. He was pleasant and very willing to confirm the medication was correct, leaving the patient to believe it was OK to question.

Upon his return, the nurse explained why the patient was given the new medication. He continued, following his explanation to say that there are many medication errors made so it was good that the new medication was questioned. He was empowering the patient to speak up again in the future.

Another nurse came back the next day after doing a full search on why the patient’s mediation was different when questioned. This absolutely impressed the patient.

When a doctor came in to see the patient he chatted for awhile and then went over to examine her. As he took out his stethoscope I asked him to please wash before the examination. He explained “I did wash but will be happy to do it again” He left the room and returned drying his hands telling us “don’t ever hesitate to ask anyone to wash their hands, we all should be doing it” He too really empowered the patient to speak up and be involved.

The small things like treating the patient with dignity, covering them up for privacy and pulling the curtain were there for the nurses but not for the physical therapist. The PT continually compared the patient I was with to the patient in the next bed “she walked today so you can too” or telling us what she did with the patient in the next bed the day before. The patient in the next bed had the same procedure done a day earlier so the two women got along well and shared their pain and concerns but it was not for the PT to continually talk about the other patient – within hearing distance. This was both disappointing and wrong.

What was disappointing was the lack of information available to patients letting them know it’s OK to ask, question and speak up about their care. The empty walls in the hospital could have had patient safety posters, hand washing notices or friendly reminders about checking wrist bands, checking medications or letting us know who is I charge. It was also disappointing that the nurse was rarely available on some shifts and when the patient had questions, the nurse would scoot in and out without answering questions. The patient was not terribly sickly, so these areas are just cosmetic on what seemed to be a good, sound health system.

HRET Patient Safety Leadership Fellowship

I had the absolute honor of addressing the HRET American Hospital Association and National Patient Safety Foundation Patient Safety Leadership Fellowship last week. I myself have submitted an application to work along side the most committed group of people in this country when it comes to patient safety.

My presentation was almost 3 hours if you consider the 45 minutes my colleague Ken discussed compassionate communication. Being a small group, there was plenty of interactive discussion and sharing. They mostly shared their commitment to their patients and their patient’s safety, but when I returned home, I received heartfelt e-mails about their own experience with medical injury to themselves or their families. It really does support my claim that it isn’t “if” you or someone in your family has experienced harm, it is “when”.

I hope my presentation reached some of them to consider patient safety as a lifestyle, not just a job. I was pleased that NY City Health and Hospital Corporation played such a big role as participants in this program as they met in NY City as part of their year long commitment to the program.

Unfortunately, no one from any of the many Long Island hospitals participated in this years Patient Safety Leadership Fellowship. This may just be a reason I can worry using the hospitals in my own community.

Remembering the Medical Injury

Have you ever wondered why people who have experienced medical injury seem to remember for many years later the conversations with healthcare providers following the incident? A 60 Minutes program about the medication called Proprandol that can block painful memories for post traumatic stress also mentioned how post traumatic stress or PTS happens. Another article on the same subject has just surfaced.

Adrenaline is released when an incident happens that makes you angry and emotional and this adrenaline actually makes you remember better.

Those who experience medical injury remember the details of the incident itself. However, it is often the conversations that follow the incident, with the medical personnel in which answers are not honest and forthright, that the patient and their family remember and focus on. I call this “he said she said”. Although it is better to focus on facts so others can learn from the incident, it is the conversations that follow that get the most focus.

Example: a patient may have had a delayed diagnosis because no one called about her test results. This alone is very traumatic and has a lesson - we should always call to get our own test results if we do not hear from the doctor’s office. But, the conversation may continue, “I asked the doctor why they didn’t call and he said he would look into it.” This may seem a reasonable answer, but this answer may be what has actually traumatized the patient long after she received her treatment, even with good results, because this conversation is what caused the adrenalin to be released. Additional conversations are also remembered in detail and are as painful.

Although there is no proof, it does seem like something worth knowing. Studies have shown repeatedly that honest disclosure and upfront compensation or an apology reduces the chance of a lawsuit. It may be another reason that patients experiencing medical injury should be treated fairly and with honesty from the beginning. Maybe treated with respect and honesty will keep that adrenilin from flowing.

The Bus Driver and the "System"

I just read a story about a 7 year old boy left behind on a school bus. What surprised me was that the driver and matron were arrested and charged with a misdemeanor.

You may be wondering what this has to do with patient safety but just this week I heard about a child who died because someone who is not permitted to distribute medication in a hospital, did and it was a massive overdose. This careless act caused a child her life. There were no misdemeanor charges. This is a ‘systems” failure the medical industry calls it. No one is to blame because the system was set up for failure. This mother called to ask about getting policies changed within the hospital that caused her child’s death. I had to tell here there are policies, but once again they were not being followed.

If these are system errors, shouldn’t we say that maybe the bus driver was part of the bus companies system? In the case of the 7 year old boy he, and his family may be traumatized but he’s not dead – unlike in the medication case.

It may just be that the bus company doesn’t have a big enough “system” to fight this charge.

The Flight

A pilot lands a plane in the Hudson and all the passengers are safe. The pilot is hailed a hero and the public is made aware of how dangerous it could be if the pilot is not experienced and the plane is hit with birds. Still, flying is considered the safest form of travel. Thank goodness. Because I still fly.

What is not revealed is that these passengers were taught ahead of time what to do if they have to land in water. They are told where the life jackets are and where the emergency exit doors are. I noticed that they were wearing their life jackets coming out of the plane and someone opened the door quickly to help everyone out. This was a well orchestrated evacuation because flight crews teach the passengers what to do before it ever is needed.

When I flew last week I looked for the exit doors and realized I missed the presentation about where my life jacket was. I asked the man next to me "where did she say the life jacket is?" It never mattered before.

Imagine if patients and their families were taught before they went to the hospital how to stay "safe" since so much more can go wrong in hospitals than in the sky.

Ask if the surgeons use the surgery checklist , ask who will mark the site of surgery and when, ask if the hospital has around the clock pharmacists or what the nurse patient ratio is. Ask what the infection rate is or see if the hand gels are filled and working in the hospital.

Why wait until after something happens to become educated. Imagine if those passengers didn't know where the emergency exit was.