Transcript Together is Better

Together is Better
Presentation to the
Third International Conference on
Patient and Family-Centered Care
Seattle, WA
July 30, 2007
Rosemary Gibson
A Glimmer of Hope…

Since the 1999 Institute of Medicine
report, To Err is Human, there has
been unprecedented growth in the
number of patients and families who
are working with health care
professionals to improve quality and
safety

The number is small but growing

What accounts for this growth?

There is urgency for improvement
because people are being harmed

The public and health care
professionals have begun to see the
human face of harm, and it is
creating the will to change

Before we can work together, as
health care professionals we have to
see patients and families in a new
way

First, something so fundamental
about ensuring the dignity of
people…
Down With the Gown
3 Opportunities for Providers and
Patients/Families to Work Together

Ensuring safe and high quality care
for the individual patient

Working to improve quality and
safety at the organizational level

Advocating as citizens for greater
accountability for health system
performance
Opportunities for Providers and
Patients/Families to Work Together
1. Ensuring safe and high
quality care for the individual
patient
Extraordinary Work… The New
Frontier in Health Care

End-of-life family conferences

Family-centered rounds

Direct access to rapid response teams by
patients and families

Shared decision making about treatment
options, e.g. hysterectomy, back pain
Opportunities for Providers and
Patients/Families to Work Together
2. Working to improve quality
and safety at the organizational
level
A Better Way

Patients and families are working with
health care organizations a develop better
ways to respond to adverse outcomes
Progressive Organizations Are
Changing Culture Around Disclosure

University of Illinois interviewed 16 law
firms in Cook County on how they would
handle a case of wrong site surgery

12 of the firms said they could get the
hospital “off the hook”

4 of the firms said the hospital has to tell
the patient; U of I will contract with one of
these 6 law firms.
Progressive Organizations Are
Changing Culture Around Disclosure

They meet with patients, apologize, and
provide a remedy whether patients want to
file a claim or not; they do a root cause
analysis and implement improvements

The centralized billing office puts a hold on
all billing in the case of an error

The first big case was the preventable
death of a kidney donor; within 90 days the
case was settled for $6.7 million
Guiding Principles

When we hurt someone through
unreasonable medical care we need to
make it right

When the care our staff provides is
reasonable, we need to support them

We need to learn something from medical
errors that will help us to improve our care
Progressive Organizations Are
Changing Culture Around Disclosure

Families who have experienced an error or
adverse outcome continue to seek care
there

Malpractice insurance premiums have
declined
Patient and Family Wishes in the
Aftermath of Error

Disclosure/truth telling

Non-abandonment

Non-abandonment of the clinicians
involved in inadvertent errors

Find the root cause and prevent the same
error from happening again
“A (patient) is the most important visitor on
our premises. He is not dependent on us.
We are dependent on him. He is not an
interruption in our work. He is the purpose
of it. He is not an outsider in our business.
He is part of it. We are not doing him a
favor by serving him. He is doing us a
favor by giving us an opportunity to serve
him.” Gandhi
CNO Leadership: Case of a
patient missing in the hospital

Elderly confused woman recently admitted
to the hospital; family present in the unit

Patient was missing during the night

Nurse supervisor informed the CNO
Narrative from a CNO
“… It was a Sunday morning and I was
having breakfast with the night staff. It was
Nurse Recognition Week. A new nurse
supervisor came up to me and said that a
patient had been missing during the night…
Narrative from a CNO
…The family was angry, blaming the
hospital. I said, ‘Let’s go talk with the
family.’ We walked to the patient’s room.
The supervisor was a big guy and he was
very shaken. I was frightened…
Benevolent Gestures
… I went into the room, sat down and
introduced myself and said, ‘I am so, so
sorry. I came to apologize on behalf of the
hospital.’
The daughter started crying and I held her
hand. I realized the family was blaming
themselves in part because they were there
the whole time.
More Benevolent Gestures
…I said, ‘There is not going to be any
blaming in this room.’
…After searching the hospital, we did find
the patient…
More Benevolent Gestures
… We had the patient thoroughly checked
in the Emergency Department; they went
over every inch of her whole body, and the
family saw that we took great care in
making sure their mother was alright. I
stopped in to see the woman and her family
every day…
Restoring Trust
… The family thanked me for coming to see
them -- they were stunned. We restored the
family’s trust in us.
I said to them, ‘If you have lost faith in the
unit where your mother went missing, we
can move her to another unit.’ The family
did not want that – because their trust had
been restored…
Role Modeling for Nursing
Staff
… The nursing staff were in the room and
standing in the hallway as I was talking to
the family and holding the daughters’
hands.
… They had never seen someone take
ownership. I was stunned to hear the next
day how many people knew about this.
People came up to me in the halls and said,
‘I heard about what happened and what you
did…’
Breaking the Cycle
… I remember as a 25-year old nurse being
publicly ridiculed for a mistake. There was
a surgeon I trusted. The patient’s hand was
swelling after surgery. He said to cut the
back of the dressing. I should have asked
more questions. He screamed at me in the
middle of the nursing station.
Breaking the Cycle
… Now, years later in my role at the hospital,
nothing punitive is going to happen if
someone makes an unintentional
mistake….
“Drive out fear so that everyone may work
effectively….”
Deming
How patients and families have influenced
my thinking and action…
A 70-year old female patient

Recent diagnosis of lung cancer

Patient reports no pain; morphine
prescribed

Family reports of respiratory
depression/loss of consciousness
unheeded

Patient dies
A Daughter’s Words
“My mother did have such sparkling
beautiful blue eyes, which always triggers
tears to my eyes when I seem them in
pictures or daily thoughts…
The last time I saw her beautiful blue eyes
staring at me (awakening briefly after
receiving the narcan, albeit too late) was
when I was holding her hand and talking to
her. Her brain had been damaged already
from the medication overdose…
She was just horribly frightened and in
irreversible multiple organ failure from the
overdose that they did not treat until it was
just too late. After the narcan, her beautiful
blue eyes were filled with fear and she cried
out in a baby-like voice, ‘Mama, Daddy, help
me, help me.’ It is a horrific moment and
horrific picture that is burned in my brain
forever…
Only 24-hours earlier she was still my
normal mother. She said, ‘I love you’ and I
said, ‘Me too. Don’t worry, just go to sleep
and I will be here all night right beside you
in this chair…’”
“… I thought of calling 911 from my mother’s
hospital room and regret to this day I didn’t
do it.”
A wise person once said, “Every problem
has a solution.”
Rapid Response Systems

A system to respond to patients whose
condition is deteriorating

As late as the 1990s, the medical literature
documented deaths from failure to rescue
but no solution was proposed…. until…

IHI found the concept of Rapid Response
Teams in the Australian medical literature
Rapid Response Systems

Early evidence suggest the potential to:

Reduce codes and mortality

Create a healthier work environment

Reduce nursing turnover
Driving Out Fear…

A med-surg nurse: “Before, when a patient
was deteriorating, it was like being thrown
to the wolves.”

What changed? A system is set up that
enables nurses to practice with greater
confidence and skill and less fear

What is good for patients is good for the
people who care for them
Together is Better
 Rationale
for allowing patients and
families to call the Rapid Response
Team:
 Dr.
W. Edwards Deming: “Customers
would be eager to work…to reduce
mistakes.”
Opportunities for Providers and
Patients/Families to Work Together
3. Advocating as citizens for a better
and more accountable health care
system
Pop Quiz
Name the part of the Medicare benefit
that was designed by health care
professionals and patients/families
working together.
A Case Example of the Public’s
Push for Improvement

A predominant view has existed that
hospital-acquired infections are inevitable.

In history, noble attempts have been made
to demonstrate that infections are not
inevitable
Joseph Lister
(1827 – 1912)
The 21st Century Brings a New Context

The public is vastly more educated and
has access to information.

The public is learning that infections can
be prevented.

The public has its own sense-making and
belief -- different from many self-sealing
clinical systems.
Data Show Scourge of Hospital Infections
Alarms raised on hospital infections
What the Public is Hearing…

The public is reading about physicians who have
the courage to speak out.

“The number of people needlessly killed by
hospital infections is unbelievable. For years,
we’ve just been quietly bundling the bodies of
patients off to the morgue while infection rates
get higher and higher.”
Dr. Barry Farr
Former President, Society for
Healthcare Epidemiologists of
America
Improvement Work Informs the
Mental Models of the Public

Public is becoming aware of IHI’s work to
reduce infections, and the progress on
MRSA in Sweden, Netherlands

Pronovost’s work with Michigan hospitals
to reduce CLABs by 66% in 3 months

Message: infections are not inevitable
Source of the Public’s Interest

Experience of suffering and death

2 million people acquire infections in
hospitals; 99,000 people die every year

Data persuades, emotion motivates

Every data point is a person
Consumers Union Campaign:
StopHospitalInfections.org

CU launched a campaign in 2003 to pass
state laws requiring that hospitals publicly
report infections

To date, 19 states have passed laws
requiring public disclosure of hospital
infection rates

The campaign has engaged patients and
families who have experienced HAIs
Why Have Infections Captured the Public’s
Attention?

Urgency: 40 deaths from HAIs during our presentation this morning

Universality: rich or poor; black, white or brown; D or R

Specificity: infections are understandable to the public -- in
contrast to broad constructs, e.g. quality

Preventable: belief that most infections can be prevented

Authentic truth, not socially constructed, no spin
 Gifts
 Two
of realization…
kinds of people in the world…
“An object at rest remains at rest until
an external force is applied.”
Isaac Newton
Wall of Silence
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