Rick Boothman: "The Dogmas of the Past Are Inadequate"

It's the kind of story you hear too often from medical insiders: the elderly patient should never have had major surgery in the first place. The poor medical care she received that caused her suffering and death was bad enough. Worse for lawyer Rick Boothman was when he found out out the surgeon who'd operated on her had been sued three dozen times before. But the tipping point for Boothman came when the hospital CEO angrily told him to just do what he'd been hired to do-- defend the hospital in the family's wrongful death claim. 

In this week's post leading up to the National Patient Safety Foundation Congress 2013 May 8-10, Boothman shares the story of his unlikely career change, what drives him to champion transparency and disclosure, and how he's inspired by the words of Abraham Lincoln. 

 

Who:  Richard C. Boothman, Chief Risk Officer, University of Michigan Health System

How many years attended Congress?  6 years (he's on the Board of Governors)

boothman@med.umich.edu

 

Pat Mastors: What brought you to patient safety in the first place? Can you share one iconic personal moment of impact/success/motivation? 

Rick Boothman: I actually “backed into” patient safety and for that reason, I probably see things differently than many.  In my former professional life, I was a trial lawyer representing Michigan and Ohio hospitals and doctors in malpractice litigation – I did that for 22 years and loved my work.  But during my entire time as a trial lawyer, two observations increasingly plagued me:  one, the enormous human cost of patient injuries not only to patients, but to caregivers I represented as well.  The damage to patients – at least some of the damage to patients, is often obvious – seriously altered and lost lives, etc., but the impact to our caregivers is something we don’t talk about very much, something we often don’t even acknowledge, and something I do not believe we understand very well. Litigation of course, exacerbates the tragedy for everyone concerned.  I was always struck by the magnitude of this problem across the board and the heartbreaking impact it had on those involved.  Second, not once in 22 years did any of my clients ever ask me what they should have learned from the cases I handled.  In fact, on several occasions, I DID raise lessons learned after cases were completed and every time, it was clear that in their view, my job was to defend cases, not wade into hospital business. 

The experience that tipped the scales for me occurred just before I left private practice.  I was representing a small community hospital in a wrongful death case that arose from bilateral [double] knee replacement surgeries on a seriously medically compromised 85-year-old woman who got septic [developed a serious infection] and lingered miserably for months until her death.  Doing even ONE knee replacement on this patient demonstrated highly questionable judgment-- she had problems more serious than knee pain-- the decision to do two replacements was completely indefensible.  When I checked the court records, I discovered that the orthopedic surgeon involved had been sued 32 times!  He was uninsured and had settled a recent case with some real estate from Northern Michigan.  In my opening letter to my client I urged the hospital to trigger the peer review provisions in its medical staff bylaws because this surgeon seemed both incompetent and reckless to me.  I received an angry call from the hospital CEO who told me that the surgeon “single-handedly kept the orthopedic service afloat”; he reminded me that I was hired to handle the medical malpractice claim, not create other issues. 

For years I saw how counterproductive litigation was-- that the “deny and defend” culture effectively inhibited the kind of accountability that was essential to improving patient safety.  Honesty isn’t just an ethical imperative-- as a practical matter, you can’t fix a problem until you first acknowledge a problem exists and you accept ownership of it. 

Having represented the University of Michigan for more than 20 years, having seen its vulnerable underside and inner workings, I knew it to be an organization with impeccable ethics filled with amazingly skilled and dedicated caregivers of all stripes.  When an opening arose in the legal office in 2001, I saw an opportunity to make a difference across a whole community of caregivers. I wanted to do something that would logically ameliorate some of the pain I saw in both patients and caregivers, and move the focus from responding defensively to patient injuries to a proactive effort to improve safety as THE gold standard for addressing the malpractice problem that plagued the community of patients and the people who care for them.  My original plan was to take two years, put the architecture in place and return to my work as a lawyer.  So much for planning, eh? 

We are all in this together.  We will only fix these problems together.  Litigation by its nature is counterproductive to that reality and I was determined to do my best to shift the focus to make sure we learn from our patients’ experiences. 

Pat Mastors: What is the most encouraging thing that’s happened in the past year in Patient Safety? The most concerning?

Rick Boothman: The most encouraging thing that I’ve observed is the decided shift and attention to these issues across the board.  Groundbreaking people like Lucian Leape and Don Berwick and Bob Wachter and Peter Pronovost and a host of others have been at it such a long time-- such a stunningly long time-- and it’s encouraging to see now much more openness, and even a sense of urgency to patient safety.  The other encouraging development is the increased attention being paid to the very fabric of our patient/provider relationships.  We must move to more of a partnership with our patients.  I hate the concept of informed consent for instance, because in most places, informed consent simply means getting a form signed.  Even when it’s done well, informed consent is consigned to special events like having a procedure or surgery done.  The quality of the conversation between caregiver and provider should be uniformly high and tailored to the patient’s needs and situation-- not relegated to a conversation to be had only when a patient is scheduled to have surgery.  I’m encouraged by the dialogue that is growing around this.  Lastly, I am encouraged by growing attention to the well-being of our health care workers of all stripes.  I believe the evidence clearly demonstrates that healthy and happy workers, people who find joy and meaning in their work, actually provide more thoughtful and safe care to our patients.  I believe we have taken our health care providers for granted for far too long and again, if we’re all in this together, we need to pay closer attention to their well-being, physical and emotional well-being. 

The most concerning thing to me is our health care community’s seeming addiction to quality and safety thresholds dictated by outside agencies.  I deeply respect the work that the Joint Commission does for instance, but at some level, don’t you think we all should be embarrassed by the fact that organizations like the Joint Commission [TJC] even exist?  We need greater ownership of these safety and quality issues.  I’m aware that for many hospitals, simply getting through their surveys is considered an accomplishment.  Thresholds set by outside agencies should represent the floor, not the goal.  I sit on the board of the Michigan Hospital Association Keystone Center’s Patient Safety Organization and reportedly, there are hospitals in Michigan that acknowledge no sentinel events [an unanticipated death or serious physical or psychological injury to a patient not related to the natural course of the patient's illness] year after year.  Amazing, isn’t it?  I suppose we should be knocking their doors down to understand and replicate what they’re doing, eh?  Accountability remains a challenge. 

Pat Mastors: What will you uniquely bring to the discussion at the Congress?

Rick Boothman: Being not grounded in the old status quo, I think I can bring a fresh set of eyes and a perspective that others might not have.  I can question why we do what we do easier than someone whose very identity is tied to their roles as established in the status quo.  One of the most important quotes that resonates with me are Abraham Lincoln’s words to the Congress in 1862 when he said, "The dogmas of the quiet past, are inadequate to the stormy present. The occasion is piled high with difficulty, and we must rise-- with the occasion.  As our case is new, so we must think anew, and act anew.  We must disenthrall ourselves, and then we shall save our country.“   I am impressed constantly by the level to which we are too invested in the status quo.  As Lincoln said so eloquently, we MUST disenthrall ourselves and think anew and act anew because our challenges are new. 

Patience is NOT a virtue when people’s lives are at stake.  We are far too patient with ourselves.  We are far too embedded in the old ways.  We need a greater sense of urgency around efforts to improve.  

Pat Mastors: Where would you like to see more energy focused?

Rick Boothman: I would like to see greater efforts to understand how we create perverse incentives that operate at cross-purposes to our overall goals.  Fee-for-service reimbursement predictably favors care delivery systems and medical judgment that is wasteful, for instance.  Certain professional compensation models foreseeably encourage some caregivers to cut corners.  I would guess, for instance, that no hospital root cause analysis would be robust enough to consider listing the manner in which we compensate surgeons as THE root cause for why some surgeons think it’s acceptable to have two cases proceeding at the same time in two different operating rooms.  We need to be more thoughtful about how incentives drive behaviors that put patients at risk or use valuable resources in meaningless ways.  I would also love to see far greater emphasis on the huge component of our population whose health care needs are not served at all, or are grossly underserved.  It’s immoral that in a country as wealthy and gifted as ours we have kids who never see a pediatrician. 

The University of Michigan Health System's open and honest approach to patient injuries, patient safety and claims has been featured on National Public Radio's Weekend Edition with Scott Simon, All Things Considered, and Marketplace, the New England Journal of Medicine, CBS News, CNN, MSNBC, the New York Times, the Wall Street Journal and many other media outlets. In 2005, Boothman advised then-Senators Clinton and Obama in the formulation and introduction of their MEDiC Act.