This document summarizes a presentation about using patient experiences to drive improvements in healthcare. It discusses:
1) The potential for learning from negative patient experiences and using them as catalysts for positive change.
2) The emergence of "patient advocates" who partner with healthcare professionals to improve safety and outcomes.
3) Examples of how open communication, transparency, and inclusion of patients can help align culture and expectations to better ensure safe, high-quality care.
5 Clinician-Patient Communication Gaps Compromising Your Hospital’s Outcomes,...Wellbe
Stephen Wilkins, MPH, is a thought leader, researcher, entrepreneur and blogger at Mind the Gap whose areas of expertise include patient engagement and physician-patient communications. He has over 20+ years experience as a hospital marketing executive, consumer health behavior and patient-centered communications expertise.
Wilkins shared with attendees a definition of patient-centered communications, provided practical examples of patient-centered communication skills in a hospital setting, contrasted a patient-centered style of communications with the more traditional physician-directed or paternalistic communication style and shared evidence demonstrating the benefits of clinician adoption of a patient-centered communication style and skills.
Wilkins identified the top 5 clinician-patient communication gaps found in most hospitals, including examples along with how these clinician-patient communication gaps impact the patients, clinicians and the organization. The webinar also provided strategies for closing the identified clinician-patient communication gaps.
5 Clinician-Patient Communication Gaps Compromising Your Hospital’s Outcomes,...Wellbe
Stephen Wilkins, MPH, is a thought leader, researcher, entrepreneur and blogger at Mind the Gap whose areas of expertise include patient engagement and physician-patient communications. He has over 20+ years experience as a hospital marketing executive, consumer health behavior and patient-centered communications expertise.
Wilkins shared with attendees a definition of patient-centered communications, provided practical examples of patient-centered communication skills in a hospital setting, contrasted a patient-centered style of communications with the more traditional physician-directed or paternalistic communication style and shared evidence demonstrating the benefits of clinician adoption of a patient-centered communication style and skills.
Wilkins identified the top 5 clinician-patient communication gaps found in most hospitals, including examples along with how these clinician-patient communication gaps impact the patients, clinicians and the organization. The webinar also provided strategies for closing the identified clinician-patient communication gaps.
Study and survey results indicate that digital can best be deployed by healthcare and life sciences/pharmaceuticals practitioners and companies to offer "warm" treatment that encourages and empowers patients in order to yield excellent health outcomes and operational efficiencies.
Krames Patient Education is the only choice for enterprise-wide patient education. In this presentation, practices will learn who Krames Patient Education is and What we can do for you.
We will review Patient-Centered Care and Patient Education; The Case for a Patient Education Investment, The Krames Differencet; Return on Investment; and Krames Solutions.
Indiana University Health University Hospital Palliative Care ServicesMike Aref
Introduction
In the past three years, Indiana University Health (IUH) University Hospital Palliative Care Services has expanded its size and scope. Our mission remains to treat the suffering of patients with chronic, progressive illnesses, their families, and their providers through symptom optimization and the search for meaning. While continuing to work with patients near the end-of-life and transitioning to hospice we have increasingly been involved with complex patients whose deaths are not imminent or even expected.
Our Team
The team has transitioned from a part-time to a full-time physician, a new full-time nurse practitioner, a new position in a nurse clinical coordinator, increased time for out part-time social worker, and continued part-time chaplain.
New Opportunities for Palliative Care
IUH University Hospital sees some of the sickest of the sick including advanced liver failure, advanced pulmonary disease, and transplant patients. Our service has become involved in alleviating suffering in pancreatic, liver, renal, and multivisceral transplant patients. Our expertise in opiates has placed us in a unique position to assist with patients having pain due to opioid-hyperalgesia and narcotic bowel syndrome. In addition we have started seeing more hepatology, oncology, hematology, and pulmonary patients earlier in their disease.
Out-Patient Services
We have expanded our service to now include out-patient, currently by embedding within other clinics at University Hospital including seeing patient in the multidisciplinary oncology clinic, hematology, digestive and liver disease clinic, and surgical out-patient clinic. In the near future we hope to have dedicated clinic space within the geriatrics clinic.
Ethics at the End of Life and Introduction to Hospice and Palliative Care for Medical Students. Exploration of feeding tubes, code status, when to stop chemo. Discusses cases and the ethical principles and values that are the basis for disagreement in care and what to do when there is a conflict in ethical principles themselves. Also provides an introduction to decisions of last resort including physician aid in dying, palliative sedation and voluntary refusal of nutrition and hydration.
Scoring Suffering to Address Patient Needs in Palliative Care: The "Maslow Sc...Mike Aref
Introduction
Palliative care patients have been scored by their symptom burden and performance but there is little standardization of their multidimensional suffering, needs, and wants. Maslow’s Hierarchy of Needs is a model for describing these needs as physiological, safety, love/ belonging, esteem, and self-actualization. The functional pain score is a validated method of scoring pain based on patient report and provider assessment. Using these two frameworks, the “Maslow Score” seeks to use Maslow’s Hierarchy to score the current patient situation based on symptom burden, plan, network, and meaning.
Methods
The scores are four-digit codes describing the patient situation at a given time base on team consensus. Each digit is a score from most secure, 0, to most vulnerable, 5. Both written examples and an algorithmic approach have been provided to obtain each score.
Results
Morning huddle has been expedited by utilizing scores recorded the previous day. Also if sudden changes have been reported they can be compared rapidly against a team standard. This triaging helps direct team resources as to whether patients should be reassessed by the entire team or specific members. The discussion has improved assessment of patients from an interdisciplinary perspective. In general, patients cannot improve their network and meaning scores until symptom and planning scores have been optimized.
Discussion
The “Maslow Score” appears to have improved the quality of care that our service delivers by improving efficiency. Further development and study is needed to standardize and validate our method.
Watch LIVE 8/13/13 on Google +
http://bit.ly/1aLt5XU
Medical Improv in Healthcare: Exploring Learning Experiences that Promote Safe Care, Patient Satisfaction, & Rewarding Careers
Description
Improv or “Medical Improv”* builds skills that promote the emergent behaviors we need for collaborative practice and cultures. In this 75 min presentation, you’ll learn how the principles of improv can be applied to critical skills, thinking, and relationship-building among healthcare professionals. You’ll meet pioneers in the “Medical Improv” field, explore opportunities for utilizing current strategies, learn about upcoming applications, and participate in Q and A. Join Organizational Development, Consultant Beth Boynton, RN, MS with Co-presenter Stephanie Frederick, RN, M.Ed and and Sponsor, Judy White, SPHR, GPHR in an invitation to learn more about cutting-edge applications of Improv in healthcare settings.
* “Medical Improv”, is a term coined by Professor Katie Watson, JD of Northwestern University Feinberg School of Medicine in her curriculum for medical students.
www.bethboynton.com
Presented at Kansas City University of Osteopathic Medicine 10/27/15 in Lecture Series in Bioethics. See live presentation here: https://www.youtube.com/watch?v=Dr3g3PeVKeo
A care partner is a family member or friend of the patient who is made part of the care team and shares responsibilities in the care of the patient.
The initiative eventually improves in reducing the feeling of isolation and anxiety of the patient throughout the patient journey, and prepares the family member to take better care of the patient as he/she transitions from hospital to home. This positively affects the outcomes (eg. Patient returning to ER within 72hrs)
Perfecting the art of medical hypnosis as an alternative to traditional anesthesia, learnings from Sodexo's International Leaders' Survey, addressing the challenges and opportunities created by the multi-generational workforce in hospitals, improving transport services to increase efficiency, news around the world.
Improving the Family Experience at the End of Life in Organ DonationAndi Chatburn, DO, MA
Communication skills strategies for improving family experience at the end of life for patients who die in the ICU after determination of brain death or after removing mechanical life support. Audience: Organ Procurement Organization staff and hospital administration
Caritas in Action (launch): How Caring Science Informs and Inspires the Nursi...Kaiser Permanente
Kaiser Permanente, Northern California - Patient Care Services developed a Caritas in Action campaign to encourage caregivers to reflect authentic expressions of Jean Watson's Caring Science in their daily practice and within their medical center.
Study and survey results indicate that digital can best be deployed by healthcare and life sciences/pharmaceuticals practitioners and companies to offer "warm" treatment that encourages and empowers patients in order to yield excellent health outcomes and operational efficiencies.
Krames Patient Education is the only choice for enterprise-wide patient education. In this presentation, practices will learn who Krames Patient Education is and What we can do for you.
We will review Patient-Centered Care and Patient Education; The Case for a Patient Education Investment, The Krames Differencet; Return on Investment; and Krames Solutions.
Indiana University Health University Hospital Palliative Care ServicesMike Aref
Introduction
In the past three years, Indiana University Health (IUH) University Hospital Palliative Care Services has expanded its size and scope. Our mission remains to treat the suffering of patients with chronic, progressive illnesses, their families, and their providers through symptom optimization and the search for meaning. While continuing to work with patients near the end-of-life and transitioning to hospice we have increasingly been involved with complex patients whose deaths are not imminent or even expected.
Our Team
The team has transitioned from a part-time to a full-time physician, a new full-time nurse practitioner, a new position in a nurse clinical coordinator, increased time for out part-time social worker, and continued part-time chaplain.
New Opportunities for Palliative Care
IUH University Hospital sees some of the sickest of the sick including advanced liver failure, advanced pulmonary disease, and transplant patients. Our service has become involved in alleviating suffering in pancreatic, liver, renal, and multivisceral transplant patients. Our expertise in opiates has placed us in a unique position to assist with patients having pain due to opioid-hyperalgesia and narcotic bowel syndrome. In addition we have started seeing more hepatology, oncology, hematology, and pulmonary patients earlier in their disease.
Out-Patient Services
We have expanded our service to now include out-patient, currently by embedding within other clinics at University Hospital including seeing patient in the multidisciplinary oncology clinic, hematology, digestive and liver disease clinic, and surgical out-patient clinic. In the near future we hope to have dedicated clinic space within the geriatrics clinic.
Ethics at the End of Life and Introduction to Hospice and Palliative Care for Medical Students. Exploration of feeding tubes, code status, when to stop chemo. Discusses cases and the ethical principles and values that are the basis for disagreement in care and what to do when there is a conflict in ethical principles themselves. Also provides an introduction to decisions of last resort including physician aid in dying, palliative sedation and voluntary refusal of nutrition and hydration.
Scoring Suffering to Address Patient Needs in Palliative Care: The "Maslow Sc...Mike Aref
Introduction
Palliative care patients have been scored by their symptom burden and performance but there is little standardization of their multidimensional suffering, needs, and wants. Maslow’s Hierarchy of Needs is a model for describing these needs as physiological, safety, love/ belonging, esteem, and self-actualization. The functional pain score is a validated method of scoring pain based on patient report and provider assessment. Using these two frameworks, the “Maslow Score” seeks to use Maslow’s Hierarchy to score the current patient situation based on symptom burden, plan, network, and meaning.
Methods
The scores are four-digit codes describing the patient situation at a given time base on team consensus. Each digit is a score from most secure, 0, to most vulnerable, 5. Both written examples and an algorithmic approach have been provided to obtain each score.
Results
Morning huddle has been expedited by utilizing scores recorded the previous day. Also if sudden changes have been reported they can be compared rapidly against a team standard. This triaging helps direct team resources as to whether patients should be reassessed by the entire team or specific members. The discussion has improved assessment of patients from an interdisciplinary perspective. In general, patients cannot improve their network and meaning scores until symptom and planning scores have been optimized.
Discussion
The “Maslow Score” appears to have improved the quality of care that our service delivers by improving efficiency. Further development and study is needed to standardize and validate our method.
Watch LIVE 8/13/13 on Google +
http://bit.ly/1aLt5XU
Medical Improv in Healthcare: Exploring Learning Experiences that Promote Safe Care, Patient Satisfaction, & Rewarding Careers
Description
Improv or “Medical Improv”* builds skills that promote the emergent behaviors we need for collaborative practice and cultures. In this 75 min presentation, you’ll learn how the principles of improv can be applied to critical skills, thinking, and relationship-building among healthcare professionals. You’ll meet pioneers in the “Medical Improv” field, explore opportunities for utilizing current strategies, learn about upcoming applications, and participate in Q and A. Join Organizational Development, Consultant Beth Boynton, RN, MS with Co-presenter Stephanie Frederick, RN, M.Ed and and Sponsor, Judy White, SPHR, GPHR in an invitation to learn more about cutting-edge applications of Improv in healthcare settings.
* “Medical Improv”, is a term coined by Professor Katie Watson, JD of Northwestern University Feinberg School of Medicine in her curriculum for medical students.
www.bethboynton.com
Presented at Kansas City University of Osteopathic Medicine 10/27/15 in Lecture Series in Bioethics. See live presentation here: https://www.youtube.com/watch?v=Dr3g3PeVKeo
A care partner is a family member or friend of the patient who is made part of the care team and shares responsibilities in the care of the patient.
The initiative eventually improves in reducing the feeling of isolation and anxiety of the patient throughout the patient journey, and prepares the family member to take better care of the patient as he/she transitions from hospital to home. This positively affects the outcomes (eg. Patient returning to ER within 72hrs)
Perfecting the art of medical hypnosis as an alternative to traditional anesthesia, learnings from Sodexo's International Leaders' Survey, addressing the challenges and opportunities created by the multi-generational workforce in hospitals, improving transport services to increase efficiency, news around the world.
Improving the Family Experience at the End of Life in Organ DonationAndi Chatburn, DO, MA
Communication skills strategies for improving family experience at the end of life for patients who die in the ICU after determination of brain death or after removing mechanical life support. Audience: Organ Procurement Organization staff and hospital administration
Caritas in Action (launch): How Caring Science Informs and Inspires the Nursi...Kaiser Permanente
Kaiser Permanente, Northern California - Patient Care Services developed a Caritas in Action campaign to encourage caregivers to reflect authentic expressions of Jean Watson's Caring Science in their daily practice and within their medical center.
"Quality in action...for every patient, every time" by Derek FeeleyNHSScotlandEvent
n this opening plenary session of the NHSScotland Event 2011, Derek Feely talks about progress on quality. Along with Jason Leitch, Derek reflects on some of the challenges facing the service and how NHSScotland would respond. He also celebrates some of the successes over the last year across NHSScotland.
Patients for patient safety. Margaret Murphy. III International Conference on Patient Safety: "Patients for Patient Safety" (Madrid, Ministry of Health and Consumer Affairs, 2007)
Resident Performance from the Patient's View: Richard Wardrop, MD, PhD, FAAPPicker Institute, Inc.
Principal investigator: Richard M. Wardrop III, MD, PhD, FAAP, FACP, WakeMed Faculty Physicians, Internal Medicine and Pediatrics, Assistant Professor at Virginia Tech Cailion School of Medicine and the University of North Carolina School of Medicine
The Resident Performance project intended to adapt an existing attendant-based evaluation into a patient-centered prototype tool that is concise, valid and reliable, and that enables patients to accurately assess resident performance on 4/6 ACGME competencies. Performance with regard to ACGME core competencies of residents who receive feedback and coaching using the patient-centered tool was compared to that of those who received attending-only feedback.
Learning the Lessons from Winterbourne View: An insider perspective.DMALtd
Learning the lessons from Winterbourne View An insider perspective on developing the conditions for person centred care.To share lessons learned and to understand the critical factors that increase organisational risk.
This presentation was delivered to the National Conference 'Improving Health, Improving Lives, December 2012.
20131210 Electronic Health Records - Is the NHS ready? What about patientsamirhannan
On 12th December 2013, Dr Hannan (GP / family physician) along with Marilyn Gollom (patient) presented this talk to Health 2.0 Manchester. You can watch the talk by going to http://www.htmc.co.uk/pages/pv.asp?p=htmc0519.
As patients and families impacted by harm, we imagine progressive approaches in responding to patient safety incidents – focused on restoring health and repairing trust.
We can change how we respond to healthcare harm by shifting the focus away from what happened, towards who has been affected and in what way. This is your opportunity to hear about innovative approaches in Canada, New Zealand, and the United States that appreciate these human impacts.
This interactive webinar is hosted by Patients for Patient Safety Canada, the patient-led program of the Canadian Patient Safety Institute and the Canadian arm of the World Health Organization Patients for Patient Safety Global Network.
This interactive webinar is part of the world tour series designed by the World Health Organization's Patients for Patient Safety (PFPS) Global Network and hosted by Patients for Patient Safety Canada, the patient-led program of the Canadian Patient Safety Institute, a WHO Collaborating Centre on Patient Safety and Patient Engagement.
The goal of this virtual discussion is to explore practical solutions for keeping seniors safe. The ideas are drawn from real life experiences noting how COVID-19 impacted seniors, their loved ones as well as healthcare workers and leaders.
The focus of the discussion is on identifying safety risks together with practical solutions for seniors who live at home, in residences and long-term care facilities.
After hearing the perspectives of patients, providers and leaders from Indigenous communities on how they perceive safety and what solutions are/ can be implemented, we will leave the session with at least one practical idea for engaging all patients, families and/or the public in improving patient safety.
Healthcare providers and leaders will address three types of silences in healthcare: organizational silence, patient-related silence, and provider to provider silence.
Read More: www.conquersilence.ca
Healthcare providers and leaders will address three types of silences in healthcare: organizational silence, patient-related silence, and provider to provider silence.
Read More: www.conquersilence.ca
Enhanced Recovery After Surgery (ERAS®) is the Enhanced Recovery After Surgery (ERAS®) is the implementation of patient-focused, standardized, evidencefocused, standardized, evidencefocused, standardized, evidencefocused, standardized, evidencefocused, standardized, evidencefocused, standardized, evidence-based, interdisciplinary perioperative guidelines.
Learn more about Enhanced Recovery Canada:
http://ow.ly/hR3j30jsnjR
Dr. Dee Mangin, Professor of Family Medicine and the Associate Chair and Director, Research, at McMaster University, will join practicing pharmacist, and Vice President, Pharmacy Affairs, Sandra Hanna of the Neighbourhood Pharmacy Association of Canada to discuss medication risks, deprescribing and the dangers of polypharmacy in this one hour webinar. Learn more at www.asklistentalk.ca
Joshua Myers, Terry Brock - Fraser Health (BC) - We Want to Hear from You: Fraser Health Real-Time Experience Survey
Leading organizations in Canada invite, listen and act on feedback from patients in their care to improve the safety and quality of care. Explore the three award-winning practices linked below then join us in a conversation to learn more about each approach and reflect on how you may apply it in your organization. This webinar promises practical ideas to help you engage patients in making care safer.
Leading organizations in Canada invite, listen and act on feedback from patients in their care to improve the safety and quality of care. Explore the three award-winning practices linked below then join us in a conversation to learn more about each approach and reflect on how you may apply it in your organization. This webinar promises practical ideas to help you engage patients in making care safer.
Cathy Masuda, Leslie Louie - BC Children's Hospital, an Agency of the Provincial Health Services Authority -Patient's View: Engaging Patients and Families in Patient Safety Incident Reporting
Leading organizations in Canada invite, listen and act on feedback from patients in their care to improve the safety and quality of care. Explore the three award-winning practices linked below then join us in a conversation to learn more about each approach and reflect on how you may apply it in your organization. This webinar promises practical ideas to help you engage patients in making care safer.
Alberta Health Services: Family Volunteers or Advisors Gathering Real-time Patient Experiences
Leading organizations in Canada invite, listen and act on feedback from patients in their care to improve the safety and quality of care. Explore the three award-winning practices linked below then join us in a conversation to learn more about each approach and reflect on how you may apply it in your organization. This webinar promises practical ideas to help you engage patients in making care safer.
This final webinar will emphasise the importance of understanding the problem before brainstorming solutions to better ensure a match between barriers and the solutions.
MORE INFO: http://bit.ly/2KctiLH
The fourth webinar picks-up directly from the third session, focusing on the next key step to inform implementation initiatives: identifying barriers and enablers to implementation.
READ MORE: http://bit.ly/2kIxtQo
The fifth webinar continues the momentum of the series as it focuses on providing concrete approaches for identifying barriers and enablers, emphasising behaviour change approaches.
READ MORE: http://bit.ly/2LOwbj0
Please join CPSI as we conclude our Human Factors webinar series with our final presentation Collaborative "Spaces" and Health Information Technology Design
Professor Benedetta Allegranzi,World Health Organisation
Dr. Benedetta Allegranzi is a specialist in infectious diseases, tropical medicine, infection prevention and control and hospital epidemiology. She currently works at the World Health Organization HQ (Service Delivery and Safety department), leading the "Clean Care is Safer Care" programme. Since 2013, Dr Allegranzi has gathered the title of professor of infectious diseases in the official Italian professorship list and is adjunct professor attached to the Institute of Global Health at the Faculty of Medicine, University of Geneva, Switzerland. She closely collaborates with the team at the IPC and WHO Collaborating Center on Patient Safety, University of Geneva Hospitals (Geneva, Switzerland), as well as with the Armstrong Institute for Patient Safety and Quality, John Hopkins University, (Baltimore, USA) for clinical research projects. She is currently involved in the leadership on the WHO Ebola Response in the field of IPC and supervises IPC activities in Sierra Leone and Guinea. She has experience in clinical management of infectious diseases and tropical medicine, and clinical research in healthcare settings in both developing and developed countries. She has thorough skills and experience in training and education.
She is also the author or coauthor of more than 150 scientific publications, including articles published in high-profile medical journal such as the Lancet, Lancet Infectious Diseases, New England Journal of Medicine and the WHO Bulletin, and six book chapters.
Lori Moore joined GOJO Industries in 2013 as a Clinical Application Specialist. In this position, she provided leadership and support to healthcare organizations as they implemented electronic compliance monitoring (ECM) to more accurately measure hand hygiene performance. She has been a trusted partner to hospital key stakeholders in the development, design and implementation of hand hygiene improvement efforts. Areas of expertise include root cause analysis with targeted solutions, just-in-time coaching and ECM software data analytics. In January 2017, she transitioned to the position of Clinical Educator for Healthcare.
She began her professional career in healthcare in 2010 as a registered nurse in the medical intensive care unit at the Cleveland Clinic Foundation (where she continues to work on the weekends). Her passion for patient safety and quality of care sparked her interest in infection prevention, and she worked as an infection preventionist prior to joining GOJO.
Lori has a well-rounded academic background which includes a Bachelor’s of Arts in Management from Malone College, a Bachelor’s of Science in Nursing from the University of Akron, and a Master’s degree in Public Health from the University of Akron. She is a member of the Association for Professionals in Infection Control and Epidemiology, American Society of Professionals in Patient Safety, and the American Medical Writers Association. She has also earned the credential of Certified Health Education Specialist (CHES) and Certified Professional in Patient Safety (CPPS).
The third interactive webinar in the series builds on the second session by focusing on the question: once we have evidence to justify implementing a new patient safety initiative, what next?
This second interactive webinar in the series will draw upon Dr. Ian Graham's Knowledge to Action cycle and focus specifically on the central role of developing and synthesising evidence of what to implement and which knowledge translation and implementation strategies are most effective for promoting implementation, and developing the knowledge infrastructure to make best use of evidence.
1. Patients for
Patient Safety
Margaret Murphy, Patient Advocate
External Lead Advisor
Patients for Patient Safety Programme
WHO Patient Safety
Canada’s Forum
On
Patient Safety & Quality Improvement
- CPSI Turns Ten -
29th October, 2014
The Patient Experience as a Catalyst for Change
2. INTRODUCTION
Addressing the heart of the matter – the patient and
family experience of care
Recognising the potential of patient experience to
drive improvement in all aspects of care
Ensuring structures which learn from the raison
d’etre of healthcare and provide truly patient-centred
care
Need for reflection on important issues at a time of
celebration – leadership, partnership, medication
safety, responding to the deteriorating patient and
considering frontline staff
Courage – being prepared to put our heads above the
parapet
3. DEMONSTRATING COURAGE
“There is one thing worse than being blind
and that is having sight but no vision”
Helen Keller
Motivations to strive for healthcare
improvement, e.g. (i) a negative experience of
care (the patient); (ii) awareness of the gaps
between the safety measures that are possible
and those actually being experienced by patients
(the healthcare professional)
4. Patients For Patient Safety (PFPS)
The emergence of the ‘Patient
Advocate’
The nature of advocacy – volunteers
committed to collaborative
partnership in the co-production of
safe care
The advocate's motivation – seeing
experiences as catalysts for change –
using the past to inform the present
and influence the future
A brand of partnership that
facilitates empowerment of patients
by enablers within the system
5. Addressing the Challenges
Ensuring productive engagement
Balancing the different commitments
Role of leadership to provide a robust culture together
with systems and supports to enable staffs and empower
patients
In honour of
those who have died,
those who have been left disabled,
our loved ones today,
we will strive for excellence,
so that all people receiving healthcare
are as safe as possible,
as soon as possible.
This is our pledge of partnership
6. FRAMEWORK AND PROCESS
COMMITMENT
Proactive engagement of patients in own
care
Capturing lessons learned from the patient
experience
Embedding patient and family in every
aspect of healthcareDELIVERABLE
Knowledgeable Patients receiving safe & effective
care from skilled professionals
in appropriate environments
with assessed outcomes
7. ACHIEVING THE GOAL
“No one is ever hesitant to speak up regarding the well being of a
patient and everyone has a high degree of confidence that their
concern will be heard respectfully and acted upon”
- Michael Leonard, Physician Leader for PS at Kaiser Permanente
Synchronising Culture and Expectation
“Around the world, healthcare organisations that are most
successful in improving patient safety are those that encourage
close cooperation with patients and families”
- Safety First, 2006
88% of Survey Respondents trust their doctor to tell the truth
- Irish Medical Council 2012
8. Disclosure = ?
Blame vs Integrity and Professionalism
Learning?
Preventing recurrence?
The need to understand and resolve the
disconnect between humanity, compassion and
inappropriate responses in the aftermath of
events
THE ACID TEST
DISCLOSURE and the LIVED EXPERIENCE
9. A Personal Experience
Using a negative experience as a learning tool
Awareness raising and providing insight and
motivation for reflective learning
Appreciating and owning the gift of being a healthcare
professional
Accepting engagement as a requirement for safe care
which enhances staff safety and satisfaction
"Making the status quo uncomfortable, while making the
future attractive “ J. Conway, IHI
“The time is NOW. If health an/or healthare are on the
table, then the consumer must be at the table, every table
– NOW! “– Lucien Leape
10. Tell me a fact
...and I’ll learn
Tell me a truth
…and I’ll believe
Tell me a story
…and it will live in my heart forever
(Indian Proverb)
To experience Openness, Transparency and Inclusion
To see evidence of Professionalism and
Trustworthiness
What Patients Want....
11. The Effectiveness of the Story
Examples of Feedback
“Facts do not change
feelings and feelings are
what influence behaviours.
The accuracy, the clarity
with which we absorb
information has little effect
on us; it is how we feel
about the information that
determines whether we will
use it or not”.
- Vera Keane, 1967
20. Peer Review
Research 96% Success; 1% Complication Rates
“All the evidence indicates that the
patient was suffering from a solitary
parathyroid adenoma at the time,
removal would have been curative with
a normal life expectancy”
“The combination of bone pain, renal
failure and hypercalcaemia in a
young patient points either to a
diagnosis of primary
hyperparathroidism or metastatic
malignancy and these ominious
results should have been
investigated as a matter of urgency”.
“Kevin would have had surgery to
remove the over-active parathyroid
gland. He would have been cured
and would still have been alive
today.”
23. The Shortcomings
Inability to recognise seriousness of Kevin’s condition
Appropriate interventions not taken
Selective and incomplete transmission of information.
Non receipting of vital information
Absence of integrated pathways
Link between behaviour and test results not made
Developing neurological problems ignored
No evidence of tracking of his deteriorating condition
ABSENCE OF DIRECT COMMUNICATION
WITH THE PATIENT
24. Shortcomings Contd…
Treatment at Registrar level
The team dynamic
The impact of a weekend admission
Patient asked to accommodate system
Expectations of a Tertiary Training Hospital
25. The Response
Defensive
‘Loyalty to colleagues’
Muddying the waters – dissembling
- e.g. Claims of inability to understand ‘layspeak’
Attempts to shift responsibility
Confidence in any hope of ascertaining truth
shattered
Excuses offered were unsustainable
Expectation of professional and honourable
conduct betrayed
27. Legal Route to Finding Answers
System favours defendants
Disempowerment of plaintiff
Plaintiff takes huge personal risks
“David and Goliath” experience
Wearing-down process
Lack of compassion
28. “It is very clear to me that Kevin
Murphy should not have died.”
Judge Roderick Murphy at High Court Ruling
May 2004
Court Ruling
30. A Wish List : Do it Right!
Observe existing guidelines, best practice and SOP’s.
Be prepared to challenge each other in that regard
Following adverse outcomes undertake “root cause analysis” "system
failure analysis"/"critical incident investigation”.
Communicate effectively within the medical community
and with patients
Keep impeccable records and refer constantly to those records
Listen to and respect patients and families
Know your personal limitations
Replicate what is good and be always vigilant for opportunities to
improve.
ACKNOWLEDGE ERROR AND ALLOW LEARNING TO OCCUR
31. A Wish List Contd
Learn and disseminate that learning
Practice dialogue and collaboration – meaningful
engagement with patients and families
Create a coalition of healthcare professionals
and patients
Be honest and open and seize the opportunity to give some
meaning to tragedy
It could not happen here
– 5 most dangerous words
ACKNOWLEDGE ERROR
AND ALLOW LEARNING TO OCCUR
32. The Way Forward
- Barriers to Progress -
Inappropriate responses and their role in relation to
fuelling confrontation?
Inaccessibility of partnership and collaborative
opportunities to ordinary patients and families
The culture of medical practice - a perception of
infallibility and faultless performance
Fears relating to litigation and loss of reputation.
Excluding the patient and family from the change
process.
Neglecting to learn from industry
33. The Swiss
Cheese Model
A Better Way
Sir Liam Donaldson, Chair, WHO World Alliance for Patient Safety
35. More than anything,
what distinguishes
the great from the mediocre,
is not so much that they fail less,
it is that they rescue more.
- Atul Gawande
“To err is human,
to cover up is unforgivable
but to fail to learn is inexcusable.”
-Sir Liam Donaldson,Chair, WHO Patient Safety
Responding to the Deteriorating Patient
- A Resolution Going Forward -