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)
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.
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