What Do Patients Really Want?

Don't get me wrong, it's huge to see patient safety evolving to be a front-burner issue. After beating the drum for years, The National Patient Safety Foundation (whose annual Congress convenes this week) and other groups are seeing progress, with meaningful use, electronic health records, Pay for Performance, and the patient-centered medical home. Medicare Innovation grants and the Partnership for Patients are chipping away at medical harm and 30-day re-admissions. Empowered patients are test-driving their choices and influence though open notes, shared decision-making, lobbying and partnering. The first strides toward transparency are being taken.

Ken Schwartz

But before we get too focused on metrics or dazzled by our success, here’s another litmus test with which to measure our progress: "What Would Ken Schwartz Think of That?"

Schwartz was a 40-year-old lawyer working in healthcare, married with a young son when he got devastating news: advanced lung cancer. It came from out of the blue: he’d smoked an occasional cigarette in college and law school, but he'd been living a smoke-free, healthy lifestyle since then.

When Schwartz wrote about his care in the Boston Globe, early on in the diagnosis and treatment process, it was about something much more elemental than technology or transparency:

…the nurse was cool and brusque, as if I were just another faceless patient. But once the interview began, and I told her that I had just learned that I probably had advanced lung cancer, she softened, took my hand, and asked how I was doing. We talked about my two-year-old son, Ben, and she mentioned that her nephew was named Ben. By the end of our conversation, she was wiping tears from her eyes and saying that while she normally was not on the surgical floor, she would come see me before the surgery. Sure enough, the following day, while I was waiting to be wheeled into surgery, she came by, held my hand, and, with moist eyes, wished me luck…

This small gesture was powerful; my apprehension gave way to a much-needed moment of calm. Looking back, I realize that in a high-volume setting, the high-pressure atmosphere tends to stifle a caregiver’s inherent compassion and humanity. But the briefest pause in the frenetic pace can bring out the best in a caregiver, and do much for a terrified patient…I cannot emphasize enough how meaningful it was to me when caregivers revealed something about themselves that made a personal connection to my plight. It made me feel much less lonely. The rulebooks, I’m sure, frown on such intimate engagement between caregiver and patient. But maybe it’s time to rewrite them.

Ken Schwartz died of lung cancer in 1995, less than a year after his diagnosis. But his legacy lives on in the foundation he started shortly before his death, the Schwartz Center for Compassionate Healthcare at Massachusetts General Hospital. Dedicated to strengthening the relationships between patients and caregivers, it also stands as a poignant testament to the power of the human touch, and human kindness, in affirming our basic humanity.

The Power of Touch

“The most important innovation in medicine to come in the next 10 years is the power of the human hand,” says physician and author, Abraham Verghese, in his TED Talk, A Doctor’s Touch. During this era of “patient-as-data-point”, Verghese believes in “the old-fashioned physical exam, the bedside chat, the power of informed observation”.

From TED.com:

Before he finished medical school, Abraham Verghese spent a year on the other end of the medical pecking order, as a hospital orderly. Moving unseen through the wards, he saw the patients with new eyes, as human beings rather than collections of illnesses. The experience has informed his work as a doctor -- and as a writer. "Imagining the Patient’s Experience" was the motto of the Center for Medical Humanities & Ethics, which he founded at the University of Texas San Antonio, where he brought a deep-seated empathy. He’s now a professor for the Theory and Practice of Medicine at Stanford, where his old-fashioned weekly rounds have inspired a new initiative, the Stanford 25, teaching 25 fundamental physical exam skills and their diagnostic benefits to interns. He says: “I still find the best way to understand a hospitalized patient is not by staring at the computer screen but by going to see the patient; it's only at the bedside that I can figure out what is important.”  

Here’s the catch-22: sitting at the bedside takes time…time that’s precious, and to be frank, un-billable. In the 18 minutes it would take just to watch Abraham Verghese’s TED talk, a physician could see two patients (and get paid for it). Nurses also are over-worked and time-deprived.

Ken Schwartz would probably nod his head. He was a lawyer, after all. He would get it: tough to make a business case for compassion. But imagine yourself tied to the bed by IV lines, staring at the ceiling tiles and wondering if you’ll live to see another day. 

Respiratory therapist Colleen Murphy Allen posted this online (I’m using it with her permission): 

What makes a difference to the wounded and sick? Yes, good medicine is amazing science and phenomenal minds working hard to cure. However, let us not forget the small things: a warm smile, an ice chip, a warm blanket, a cool washcloth. A pillow flipped to the other side and a boost in bed. Holding a fragile hand while sitting by the bed of the dying in the deep recess of night. Jumping up onto a bed to do CPR…Staying alive, staying alive…Chapstick and a damp mouth swab. A patient comforted, a smile, a deep breath and heartbeat from someone resuscitated. This was a bit of my job over the last few days. We all do this. Every one of us. And this is not even in our job description. 

Maybe the incentives and payment widgets that shape and constrain a clinician’s time—and muddy the imperatives for “high-touch” care-- need some doctoring of their own. Perhaps along with our agendas, laptops and business cards, we can carry this question into every aspect of our patient safety work this year: 

"What Would Ken Think"?

Some of this post is excerpted from Pat Mastors' forthcoming book Design to Survive: 9 Ways an IKEA Approach Can Fix Health Care & Save Lives.

Ilene Corina: “I couldn’t believe it when the doctor said ‘no’.”

Ilene Corina, PULSE of New York

The National Patient Safety Foundation (NPSF) annual Congress will bring some 1400 patient safety champions from around the country to New Orleans May 8-10 2013, to collaborate, brainstorm, teach and learn. As guest blogger for the NPSF Congress, I'm privileged to share the amazing stories of some of the champions of patient safety who'll be attending. This profile will cross-post on the NPSF Congress website this week.

Who: Ilene Corina

What: President, PULSE of New York

Member, NPSF Board of Governors, 7 years 

ICorina@aol.com

www.pulseofny.org, www.patientsafetyconsultants.com  

Ilene Corina has experienced the best and worst in health care. Her first child bled to death after a routine surgery. Her agony intensified after his death, when the surgeon who’d dismissed her concerns about her son's bleeding post-surgery refused to take her phone calls. But it was another event years later that would propel Ilene into a lifetime of patient advocacy. Today she believes that in order to stay on top of health care, there is no substitute for sitting at the bedside of a patient.

Pat Mastors: What brought you to patient safety in the first place?

Ilene Corina: Most people think it was the death of my first child, Michael in 1990, who bled to death from a tonsillectomy, that sent me into the work of patient safety, but that's not true.  I was in too much pain then. The impetus was the feeling of helplessness years later when my youngest child needed surgery.

Matthew was born severely premature at just 23 weeks. His team in the NICU was amazing, and he survived. But when he was three years old, and I needed an anesthesiologist for his surgery in 1996, I was told I couldn't choose the anesthesiologist myself.  Even though my son was born premature, had 24 hour nursing care and lung problems, and I went to meet the anesthesiologists in the weeks before his surgery with his list of medications, lung x-rays and medical records. When the doctor said "no"-- that I would have to wait until the day of surgery and see who would be available-- I was stunned. The system was taking away my right to choose a doctor for Matt, after I'd helped get him over the painful humps so early in his life.  I was determined to change things-- or at least be heard. I knew it was time, right there, to change the rules, were I ever to need to do this again. 

 

The joy in all of this is that Matt not only survived being born so early, he had no disabilities and today is a healthy young man in college. I credit that to the partnership between me and his medical team, back when he was born. I like to think I experienced the worst in healthcare and I experienced the best. I now want people to know what I know.

Pat Mastors: What’s the most encouraging thing that’s happened in the past year in patient safety? The most concerning?

Ilene Corina: The work that I am doing on Long Island is growing.  Our Patient Safety Advisory Council has grown and we have looked at patient safety as it pertains to individuals, not just a society as a whole. Some of the groups I have worked closely with are people with disabilities, adults with low literacy, transgender patients and teen moms.  All our work is at the grassroots level. I learn more than I can teach, and that's exciting!  We are teaching about patient safety, and then learn what it's like to walk in their shoes, what their obstacles are, and how they’re navigating them. Then we develop tools to help them feel more empowered and improve their care.  We hope to help the people who work in the healthcare system understand what we have learned and incorporate our findings into their work. 

  

I think the most concerning thing is still the lack of funding available for our type of work.  There are hundreds of community members representing breast cancer support, HIV/AIDS, Autism, veterans and bullying, but not enough representing patient safety.  It's hard to grasp or show the full scope of the need when there are only a few of us working on the changes.

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

Ilene Corina: I am not presenting at the Congress but I will be looking for collaboration...NPSF is the leader in bringing the patient and families voice to the table.  I like to think that we do the same at PULSE,  bring everyone's voice to the table.

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

Ilene Corina: Two areas. Our Family-Centered Patient Advocacy is growing and our small classes fill up now. I would love to hold classes more often.

I also think that the people who make the big decisions in the hospital setting may be losing track of what goes on at the bedside. I feel obligated to spend a certain amount of hours a year with people I do not know at their bedside so I can watch independently what happens and practice what I preach for others to do. Do they wash their hands or introduce themselves to the patient?  Are they giving out pills in little paper cups and not asking the patient her name?  Is the doctor asking the patient questions and having the patient answer appropriately?  Does the nurse seem stressed?    I need to know what is happening at the bedside.  If problems need addressing, I will write to the hospital and I also blog about my experiences. These are things no one can see regularly unless someone is willing to plant themselves at the patient's bedside…and I am willing! 

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.

Patty Skolnik: In Her Own Words

In the weeks leading up to and during  the National Patient Safety Foundation Congress 2013 May 8-10, I'll be guest-blogging for the NPSF Congress website and cross-posting here. (this post should be on their site as early as tomorrow). I'm excited to be profiling patient safety champions and programs, using their own words to acquaint the broader community with their stories, efforts and successes. There are so many of you out there doing great work; I'd love to know all of you better, and I know the world would be as inspired by your work as I am! Once the Congress is over, I hope to continue with these profiles on this blog. Please share as you see fit to help connect the patient safety universe.

Who: Patty Skolnik

Executive Director, Citizens for Patient Safety, Denver, CO

Member, board of Governors, NPSF since May 2012

CitizensforPatientSafety.org

Patty@CitizensForPatientSafety.org

Twitter: @SkolnikPatty

Pat: What brought you to patient safety in the first place?

Patty: The death of our only child, Michael, in June 2004. Michael was 22 years old and was going to college when he passed out one day. A neurosurgeon looking at test results of Michael’s brain, said a cyst was blocking his cerebral fluid and causing his brain to swell to life-threatening levels. He told us Michael needed surgery within 48 hours.

I checked out the profile of the neurosurgeon on the website of the Colorado Board of Medical Examiners. Nothing unusual came up. What I didn’t have any clue about was that this neurosurgeon was being sued for the death of another patient in Atlanta and had operated on the wrong disc. He had also operated on and disabled another patient in Atlanta.

After my husband David and I had left the hospital for the night, the neurosurgeon got a signature from Michael—who was on heavy medication-- on a consent form to do brain surgery. When we got back to the hospital the next morning, Michael was already in the operating room. The procedure was supposed to take three hours. Michael was wheeled out six and a half hours later.

They didn’t find any cyst. But we soon saw that six hours rooting around in our son’s brain had caused tremendous damage. Michael lost the ability to walk, speak, eat, became partially blind. He was paralyzed except for spastic movement of his right arm and hand. Over months in the ICU he suffered from hallucinations, blood clots and many infections. It was absolute torture for him. Our son died of massive organ failure, 32 months after the surgery. We were devastated. But we had vowed to Michael, who’d been going to nursing school before this all began and had loved the field, that we would leave health care better off than we found it. So we started Citizens for Patient Safety, and I now teach and present to groups around the world. I’m trying to bring that mission to life every day.

Can you share an iconic moment of impact, success or motivation?

Patty: The realization that patients and families like ours had no meaningful access to important information about their doctors made us set out to change the law. We wanted physicians’ malpractice history to be available in a quick online search.

We had to bring some reluctant groups on board…the Colorado Medical Society, the state’s largest malpractice underwriter, and on both sides of the political aisle. But I met with them, said “I’m a mom, could you please watch a short video about our son” (it was a segment from the Today Show). Everyone eventually came on board. We had to do it, to create a resource every family might need one day.

The governor signed The Michael Skolnik Medical Transparency Act in 2007. David and I then lobbied for two subsequent patient safety bills that also passed. Another one is pending. Today I do advocacy training around the world.

Pat: What is the most encouraging thing that’s happened in the past year in patient safety?

Patty: For me, shared decision-making and informed consent are the foundation of patient safety. Patients need to be part of the team, the team that has to live with the outcome. I had been doing consumer training, and still do that. But in the past year the door to the provider world is opening up wider to patient advocates. More and more I’m working hand in hand with medical professionals, even participating in grand rounds in hospitals. In August of last year I presented to the board of the New York State Association of Hospital Trustees, nearly 500 decision-makers in health care. The key to having an impact is in how we as patient advocate leaders present ourselves. Not to “shame and blame” and point a finger, but rather by asking what the problems are, and how we can resolve them together.

Pat: What’s the most concerning thing about patient safety in the past year?

Patty: That people will lose hope. There is so much to do. But as Winston Churchill said, “Never, never, never give up”. We had that quote posted next to Michael’s bed. Progress in patient safety is coming slowly, but we have to keep going. The other thing I worry about is that we veterans who have been working in patient advocacy have a lot of wisdom and experience. We’ve learned how to “play in the sand box” with others. But we have to mentor younger people, to teach them all we’ve learned…to pass the torch to the next generation, so the improvement movement keeps going.

Pat: What unique skill will you bring to the NPSF 2013 Congress?

Patty: I’m a networker. I put the right people together. Sometimes they may seem like strange bedfellows, but there are common passions and complementary skills or capabilities. I’ve been able to do this several times. I think we all have to look for and assist others who can further our mission.

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

Patty: I’d like to see more patient and family representation at conferences that are talking about patient safety. Many advocates who would like to attend don’t have the employer support or financial resources to participate. So I’m hoping there will be ways to work on this. 

Parts of this profile are excerpted from my forthcoming book, Design To Survive: 9 Ways an IKEA Approach Can Fix Health Care & Save Lives.

NOTE: Patty Skolnik is also among a handful of patient safety advocates (including Helen Haskell, Rosemary Gibson and others) whose collaboration with Medstar Health is being featured in the forthcoming documentary film: Breaking the Wall of Silence. Film production funds were just successfully raised on Kickstarter.

Know a patient safety/engagement "Island of Excellence"  that deserves recognition? Please suggest in comments.