Transcript ford_1

“The Role of the Patient in
Safety”
Six Recommendations
Dan Ford
The Seventh Annual Quality
Colloquium – Harvard
University
August 19, 2008
OVERVIEW
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The Ford family medical error story puts a face
on unexpected outcomes
Highlights of ideas and recommendations, from
the Ford family and others’ experiences
We are all consumers as patients and family
members – encourage thinking as consumers
We should all be active patient safety
advocates, as providers of services and
products, as well as consumers
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RECOMMENDATIONS
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1) Let’s be responsible providers of information
2) Let’s ask questions and speak up
3) Let’s be expectant and presumptuous
4) Let’s be encouraging and supportive
5) Let’s participate with providers and become
involved
6) Let’s encourage an openness to other new
ideas
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LET’S BE RESPONSIBLE PROVIDERS
OF INFORMATION
As patients, let’s know, document and
update our medical history, active
medications and our allergies.
 Understand that medication improper
usage, over-use, misuse and hand-off’s
are huge source of medication errors
worldwide.
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LET’S BE RESPONSIBLE PROVIDERS
OF INFORMATION
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Active participation implies sharing information
and opinions, joint problem solving and joint
responsibility. (Patrice Spath)
Bring literacy issues to attention of providers. In
the U.S., over 90 million have literacy
challenges.
Patients provide a second set of eyes. (Merrilyn
Walton, Australia)
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LET’S ASK QUESTIONS AND SPEAK
UP
“Speak Up” program. Joint Commission
suggests that patients self-educate about
diagnosis, medical tests, treatment plans.
 Find out who we can talk with regarding
anxieties, concerns about our care. Tell
someone to stop if it doesn’t feel right.
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LET’S ASK QUESTIONS AND SPEAK
UP
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Don’t be intimidated.
“Doctor, did you wash your hands?”
 Ask about anesthesia, IV drips, special tests,
x-rays with dyes, etc.
 Insist on full disclosure. We have a right to
know exactly what happens to our body.
“Nothing about me without me.”
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LET’S ASK QUESTIONS AND SPEAK
UP
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When visiting a doctor or hospital, invite a
family member, friend, patient advocate,
navigator or vigilant partner to help.
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Help those who have no such advocate.
Ask for medication sheets, help
caregivers cross-check medications,
receive tips about safe medication
practices.
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LET’S ASK QUESTIONS AND SPEAK
UP
Find out how infections occur, early
symptoms and avoiding, treatment and
prevention plans.
 We can monitor for compliance with safe
practices, including medication
administration, AFTER our patient
identification is verified.
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LET’S ASK QUESTIONS AND SPEAK
UP
Don’t be afraid to beg and be persistent.
(Dale Micalizzi, New York)
 We can be too easily intimidated by
providers from actively participating in
our own care -- encourage and work on
our right to question and to challenge.
 Again….speak up!
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LET’S BE EXPECTANT AND
PRESUMPTUOUS
The patient is the center of the health
care team.
 We are all consumers, as patients or
family members, at some point.
 Picker Institute Europe suggests that
patients desire respect ….
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LET’S BE EXPECTANT AND
PRESUMPTUOUS
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.…Respect for our values, preferences and
expressed needs, information and education,
access to care, emotional support, involvement
of family and friends, continuity and for
transition, physical comfort and coordination.
We should expect these to be honored, at all
times.
“Patients can become the first line of defense,
against misadventures and unsafe situations.”
(Merrilyn Walton, Australia)
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LET’S BE EXPECTANT AND
PRESUMPTUOUS
Expect our privacy and confidentiality be
honored at all times
 Expect current, evidenced-based
medicine, unless logical and convincing
reasons for other approaches
 If a mistake happens without our
knowledge, even without harm, we should
be told -- ethical thing to do.
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LET’S BE EXPECTANT AND
PRESUMPTUOUS
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OUTRAGED by too many continuing medical
errors – let’s work with providers to eliminate
them.
Expect candor, honesty, disclosure and
transparency to be the norm.
No longer accept being treated as numbers,
statistics, nameless.
We are people with families, victims, survivors
and change agents
Let’s expect listening to be the norm – when
missing, is at the heart of many problems.
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LET’S BE EXPECTANT AND
PRESUMPTUOUS
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Accountability by providers to patients
may help to balance the unequal
distribution of power between a physician
and injured patient. (Nancy Berlinger)
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Accountability is the lynchpin in the relationship.
Expect and encourage providers to do the
right thing, when things go wrong including taking responsibility for their
own actions.
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LET’S BE EXPECTANT AND
PRESUMPTUOUS
Hurting patients are not interested in
hearing about hospitals protecting assets.
Lack of respect.
 We have a need to be heard. There is a
need for closure – including an honest
and candid understanding of what
happened, apologies, what is being done
for prevention in the future.
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LET’S BE ENCOURAGING AND
SUPPORTIVE
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Let’s encourage providers to become patient
centric, rather than physician centric.
Providers can better plan and deliver care, and
we can achieve better outcomes
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by truly partnering with patients and families
by involving us in decisions about our own care
by gaining the benefit of our help and insights
By having in-depth conversations with patients, from
the beginning of the relationship and in the hospital
Hospitals can also improve staff satisfaction.
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LET’S BE ENCOURAGING AND
SUPPORTIVE
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Patient and Family Advisory Councils are being formed
-- I chaired the “Patient Role in Safety” Sub-Committee
of AzHHA Patient Safety Steering Committee.
Encourage providers to tell the truth, when unexpected
outcomes happen, and to apologize.
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Culture has to start at the top of every hospital.
Needs to be the right spirit and “a fire in our belly” for telling the
truth.
Even when telling the truth and being candid takes us out of our
comfort zone.
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LET’S BE ENCOURAGING AND
SUPPORTIVE
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The bedside nurse can still be the
patient’s best advocate.
Patient loads, stress and human frailties get
in the way,
 Let’s remember and enhance the nurse
advocacy and partnering role.
 Let’s assure this is taught in training – patient
centered language and behavior
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LET’S BE ENCOURAGING AND
SUPPORTIVE
Lucian Leape from Harvard suggests:
“Let’s help the clinician do the right thing,
rather than chastising them for not.”
 Encourage providers to understand the
“Deer in the Headlights Syndrome” when
unexpected outcomes happen.
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Patients and families are suffering terribly
following these events,
 We are in shock – devastated in many ways.
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LET’S BE ENCOURAGING AND
SUPPORTIVE
 Providers
also go through “Deer in the
Headlights” syndrome, when
experiencing unexpected outcomes.
 Physicians
and nurses and others did
not wake up this morning, with the intent
or anticipation of hurting someone today.
 They are also often in shock or grief.
 Need support for all.
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LET’S BE ENCOURAGING AND
SUPPORTIVE
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Let’s encourage providers to never forget the
HUMAN side.
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Role model that as patients and family members.
Every patient experience requires COMPASSION
and empathy.
Significant efforts are being made to deal with
the clinical and system pieces. But….we find
the human part to be awkward.
Let’s encourage, support providers to be team
players – that all be good wingmen
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LET’S BE ENCOURAGING AND
SUPPORTIVE
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ARROGANCE, parental attitudes, turf battles by
some clinicians continue – stymies progress
and change in delivering care
All are human beings, w/human needs –
patients, family members and staff – respect
everyone’s dignity and roles.
Cold and unfeeling attitudes build barriers.
Genuine listening will help break them down.
It’s about mutual respect – communications and
teamwork – need to rebuild trust.
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LET’S BE ENCOURAGING AND
SUPPORTIVE
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Empathize with providers that involving patients
and families is not easy. This is a journey in a
new direction.
Understand that engagement is key, as well as
a new learning experience.
Humbled, supportive and complimentary of all
of the good progress being made, even as
providers weary from all now on their plates.
Respect and encourage champions who work
tirelessly for change – many are here today
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LET’S PARTICIPATE WITH
PROVIDERS AND BECOME
INVOLVED
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Let’s volunteer to participate on provider patient
safety, quality and patient-centered care boards
and committees, as well as self help groups –
such as MITSS here in Boston (Linda Kenney)
Dana Farber Cancer Institute in Boston involves
patients and family members on virtually every
committee and board in the hospital.
Our voices, as patients and consumers, can be
heard in many venues.
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LET’S PARTICIPATE WITH
PROVIDERS AND BECOME
INVOLVED
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In my committee work, I remind providers that I
am not a clinician. Typical response: “We have
enough clinical experts around the table. We
want to hear your voice and ideas, as a
consumer. Question us, ask us, encourage us.”
Many people like me – would love to be positive
and constructive committee and advisory board
members – eager to serve, learn and be good
ambassadors.
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LET’S PARTICIPATE WITH
PROVIDERS AND BECOME
INVOLVED
Patients and family members worldwide
are becoming involved in consumer and
patient advocate organizations.
 Desire is to PARTNER – to work
cooperatively/constructively with providers
regarding patient and family-centered
care, as well as patient safety and the
aftermath of medical errors.
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LET’S PARTICIPATE WITH
PROVIDERS AND BECOME
INVOLVED
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May, 2006, “Patients for Patient Safety”
Workshop in San Francisco, sponsored by
WHO/PAHO.
54 participants from South America, Mexico,
Canada and United States – profound
experience – followed the inaugural WHO
workshop in London in December, 2005, with
24 participants.
Similar Workshop in Chicago in June, 2008 –
consumers and providers – Chicago area focus.
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LET’S PARTICIPATE WITH
PROVIDERS AND BECOME
INVOLVED
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STORYTELLING by patients and families –
presentations, personal contact, in writing.
Important to help leadership spawn change.
Injured patients and those who have lost loved
ones to medical errors can share their stories
Providers need to hear – are inviting these
stories – catalyst for causing change.
Providers may weary of the stories. WE HOPE
NOT!
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LET’S PARTICIPATE WITH
PROVIDERS AND BECOME
INVOLVED
Let’s help the healing process, for all –
patients, families and providers.
 Rounding – some organizations are now
inviting patients and families to take part
in multi-disciplinary rounds and asking for
their comments.
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LET’S ENCOURAGE AN OPENNESS
TO OTHER NEW IDEAS
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Medical records – assure that patients and
families have access to the entire medical
record – spirit of information availability and
transparency.
Incorporate and invite input from patients and
families directly into medical and health
records.
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Not to change what is written by providers, but….
To supplement. We should be able to provide our
own notes in the record.
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LET’S ENCOURAGE AN OPENNESS
TO OTHER NEW IDEAS
Partnership in the healing process is
absolutely essential.
 Dr. Saul Weingart and colleagues at Dana
Farber and Harvard University – as well
as others nationally, are conducting
substantive studies on patient and family
involvement.
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LET’S ENCOURAGE AN OPENNESS
TO OTHER NEW IDEAS
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Sarah Lawrence College in New York offers a
master’s degree in patient advocacy.
RCA’s – involve patients/family when debriefing
unexpected outcomes and problem solving.
Invite patients and families to participate in
RCA’s, and other clinical investigations – not all
will want to participate, nor should be.
Do away with classical CYA attitudes.
Offensive to be left out of discussions about
what really happened – it is our body.
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LET’S ENCOURAGE AN OPENNESS
TO OTHER NEW IDEAS
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RETICENCE – legal considerations, tradition,
change, peer review, role behaviors, ego’s and
other human behaviors.
Telling the TRUTH is the right thing to do.
Openness will enhance learning all around –
will decrease, rather than increase, litigation.
Continued tension between the fear of litigation
and transparency/telling the truth.
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LET’S ENCOURAGE AN OPENNESS
TO OTHER NEW IDEAS
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Instead of a divisive spirit, with on-going care
and when unexpected outcomes happen, let’s
be PEACEMAKERS.
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“But the wisdom that comes from heaven is first of all
pure; then peace-loving, considerate, submissive, full
of mercy and good fruit, impartial and sincere.
Peacemakers who sow in peace raise a harvest of
righteousness.”
James 3:17-18
We are each human beings – need each other.
Know the Bible is not the source of everyone’s
faith, but the spirit of this is universal.
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This is why I do what I do…
Grandpop and Jadyn – April 2008
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Dan Ford Biography
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Spouse suffered permanent brain
damage/short-term memory loss because of
medical errors in an Illinois hospital – a patient
and patient safety advocate.
Health Care Executive Search Consultant with
Furst Group, Phoenix, Arizona – concerned
about how all provider executive candidates
view the patient experience.
www.furstgroup.com
[email protected]
520.548.3339 (cell)
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