“ The Role of the Patient in Safety” Six Recommendations Dan Ford The Seventh Annual Quality Colloquium – Harvard Universi...
OVERVIEW <ul><li>The Ford family medical error story puts a face on unexpected outcomes </li></ul><ul><li>Highlights  of i...
RECOMMENDATIONS <ul><li>1)  Let’s be responsible providers of information </li></ul><ul><li>2)  Let’s ask questions and sp...
LET’S BE RESPONSIBLE PROVIDERS OF INFORMATION <ul><li>As patients, let’s know, document and update our medical history, ac...
LET’S BE RESPONSIBLE PROVIDERS OF INFORMATION  <ul><li>Active participation implies sharing information and opinions, join...
LET’S ASK QUESTIONS AND SPEAK UP <ul><li>“Speak Up” program.  Joint Commission suggests that patients self-educate about  ...
LET’S ASK QUESTIONS AND SPEAK UP  <ul><li>Don’t be intimidated.  </li></ul><ul><ul><li>“Doctor, did you wash your hands?” ...
LET’S ASK QUESTIONS AND SPEAK UP  <ul><li>When visiting a doctor or hospital, invite a family member, friend, patient advo...
LET’S ASK QUESTIONS AND SPEAK UP  <ul><li>Find out how infections occur, early symptoms and avoiding, treatment and preven...
LET’S ASK QUESTIONS AND SPEAK UP  <ul><li>Don’t be afraid to beg and be persistent.  (Dale Micalizzi, New York) </li></ul>...
LET’S BE EXPECTANT AND PRESUMPTUOUS <ul><li>The patient is the center of the health care team.  </li></ul><ul><li>We are a...
LET’S BE EXPECTANT AND PRESUMPTUOUS  <ul><li>.…Respect for our  values, preferences and expressed needs, information and e...
LET’S BE EXPECTANT AND PRESUMPTUOUS  <ul><li>Expect our privacy and confidentiality be honored at all times </li></ul><ul>...
LET’S BE EXPECTANT AND PRESUMPTUOUS  <ul><li>OUTRAGED by too many continuing medical errors – let’s work with providers to...
LET’S BE EXPECTANT AND PRESUMPTUOUS  <ul><li>Accountability by providers to patients may help to balance the unequal distr...
LET’S BE EXPECTANT AND PRESUMPTUOUS  <ul><li>Hurting patients are not interested in hearing about hospitals protecting ass...
LET’S BE ENCOURAGING AND SUPPORTIVE  <ul><li>Let’s encourage providers to become  patient  centric, rather than  physician...
LET’S BE ENCOURAGING AND SUPPORTIVE  <ul><li>Patient and Family Advisory Councils are being formed -- I chaired the “Patie...
LET’S BE ENCOURAGING AND SUPPORTIVE  <ul><li>The bedside nurse can still be the patient’s best advocate.  </li></ul><ul><u...
LET’S BE ENCOURAGING AND SUPPORTIVE  <ul><li>Lucian Leape from Harvard suggests:  “Let’s help the clinician do the right t...
LET’S BE ENCOURAGING AND SUPPORTIVE  <ul><li>Providers also go through “Deer in the Headlights” syndrome, when experiencin...
LET’S BE ENCOURAGING AND SUPPORTIVE  <ul><li>Let’s encourage providers to never forget the HUMAN side.  </li></ul><ul><ul>...
LET’S BE ENCOURAGING AND SUPPORTIVE  <ul><li>ARROGANCE, parental attitudes, turf battles by some clinicians continue – sty...
LET’S BE ENCOURAGING AND SUPPORTIVE  <ul><li>Empathize with providers that involving patients and families is not easy.  T...
LET’S PARTICIPATE WITH PROVIDERS AND BECOME INVOLVED  <ul><li>Let’s volunteer to participate on provider patient safety, q...
LET’S PARTICIPATE WITH PROVIDERS AND BECOME INVOLVED  <ul><li>In my committee work, I remind providers that I am not a cli...
LET’S PARTICIPATE WITH PROVIDERS AND BECOME INVOLVED  <ul><li>Patients and family members worldwide are becoming involved ...
LET’S PARTICIPATE WITH PROVIDERS AND BECOME INVOLVED  <ul><li>May, 2006, “Patients for Patient Safety” Workshop in San Fra...
LET’S PARTICIPATE WITH PROVIDERS AND BECOME INVOLVED  <ul><li>STORYTELLING by patients and families – presentations, perso...
LET’S PARTICIPATE WITH PROVIDERS AND BECOME INVOLVED  <ul><li>Let’s help the healing process, for all – patients, families...
LET’S ENCOURAGE AN OPENNESS TO OTHER NEW IDEAS <ul><li>Medical records – assure that patients and families have access to ...
LET’S ENCOURAGE AN OPENNESS TO OTHER NEW IDEAS  <ul><li>Partnership in the healing process is absolutely essential.  </li>...
LET’S ENCOURAGE AN OPENNESS TO OTHER NEW IDEAS  <ul><li>Sarah Lawrence College in New York offers a master’s degree in pat...
LET’S ENCOURAGE AN OPENNESS TO OTHER NEW IDEAS  <ul><li>RETICENCE – legal considerations, tradition, change, peer review, ...
LET’S ENCOURAGE AN OPENNESS TO OTHER NEW IDEAS  <ul><li>Instead of a divisive spirit, with on-going care and when unexpect...
This is why I do what I do… Grandpop and Jadyn – April 2008
Dan Ford Biography <ul><li>Spouse suffered permanent brain damage/short-term memory loss because of medical errors in an I...
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“The Role of the Patient in Safety”

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“The Role of the Patient in Safety”

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

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