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An Essay on Patient Safety by Dan Ford, Vice President of the Furst Group in Phoenix, Arizona The following is a (rather long) summary I prepared for several people who asked me for feedback. I participated in a two hour conference call Friday afternoon at 5 p.m., from Orlando, with the AzHHA Patient Safety Steering Committee. I am also a member of the Quality Committee of an Arizona hospital system.
My on-going personal goal is to
reach/influence my provider colleagues, nudging/pushing while
understanding/compassionate at the same time. I am probably the only
health care search consultant with a genuine passion for patient
safety. Some are not appreciative of my forthright efforts, and that
has gotten in the way of my search business. Am more than willing to
take that risk. The goal is worthy.
Several people asked me to share
ideas from the Annual NPSF (National Patient Safety
Foundation) Congress in Orlando this past week, am reflecting this
Saturday a.m., returning to Tucson later today, Sarah
(daughter) joining me on my flight from DFW as she arrives from
Nashville.
Random order listing. You may
also wish to print it out. Please share these if/as you may
choose. Summarizing and sharing this Mother's Day weekend while
I am still on a high, and before getting back to the reality of my
day job, health care executive search.
1) Patient safety is a human rights
issue.
2) The words I heard most often that
seemed to trickle throughout, that had the most impact with me, had
to do with the need for leadership and the need for trust and
recognizing that patient safety is a human rights issue.
3) Senior leadership has to get it,
set the standard, model, lead/guide, in addition to financial
stewardship. If not, others should make it happen and cause senior
leadership to get it. Board members need to also get it and to
cause the CEO to make it happen.
4) One of the most remarkable
speakers was Dr. Mamphela Ramphele, a South African national,
Chair of Circle Capital Ventures, a Cape Town base company
focusing on growing companies and investing in people, former
Managing Director of the World Bank and responsible for focusing
the institution's human development activities in the areas of
education, health, nutrition, population and social protection.
She talked about the change from Apartheid to Post-Apartheid
South Africa, and the analogies to the transformation changes
needed in health care.
She noted there can be no
excellence without equity, the need for vision and understanding
of human rights, leadership, empowered teamwork and the
empowerment of the patient. She noted that South Africans were
not used to power and/or leadership and in the transformation
this was a real learning experience: "Groups with well
established power were reluctant to cede power to newcomers.
The similarity to health care, where physicians often perceive
that their power and authority is challenged by efforts to
improve safety and involve a wider array of clinicians, support
staff and patients and families in the identification of
problems, the search for solutions, and the efforts to implement
change."
Dr. David Lawrence (retired
Chair/CEO of Kaiser Permanent in Oakland), one of the co-chairs
of the Annual NPSF Congress this year and last, had invited Dr.
Ramphele to speak. It was sheer genius on his part.
Dr. Ramphele has a book entitled
"Across Boundaries," available on Amazon.
5) Importance of IT,
training/education, systems improvement, need for
underlying trust. Trust is not an option.
6) Understand/deal with role
conflicts.
7) Importance of data
collection, including near misses.
8) Patients should not be
treated as, nor called, visitors, rather as a key part of the
hospital team.
9) Increasing number of
hospital patients and family advisory councils.
10) Need for empowered teamwork.
Critical linkage of cultural leadership and teamwork (aviation and
space industry good role models.)
11) Empowerment of the patient.
12) Increased
use of Rapid Response teams.
13) Disclosure, candor, honesty
are good business.
14) Increased involvement by
patients/families. Dana Farber has patient safety clinician
champions as well as patient/family safety liaisons. Used on
patient rounds, among other.
15) Some hospitals are involving
patients/families in the root cause analysis process (one of my
personal push-points). This came out in a breakout session on the
consumer, introduced by Dennis O'Leary (JCAHO), and chaired by Chuck
Denham (M.D., Texas Institute of Technology and I believe the chair
of LeapFrog). Chuck is producing a film featuring patient/family
stories. Had hoped to have it finished by this week but it was
not.
Several of us were asked to speak
about our personal/family medical error vignettes in this session.
I talked briefly about ours, including the lack of closure,
arrogance, wall of silence, my forgiveness/lack of justice. I said
I was not a clinician, that my interest/expertise is the human
piece. I highlighted the need for communications, the need for
human support of the patients/families, and for nurses, physicians
and others.
I suggested involving
patients/families in the root cause analysis process, noting I had
received pushback on this when recommending this. Several people
spoke up and said they are already doing that.
16) Key provider leadership
characteristics, per one of the key speakers: honesty, clear code
of ethics, trust, courage, willingness to change, willingness to
take risks, wise, passionate, ability to deal with adversity,
persistent, hopeful, and open to bigger ideas.
17) Literacy challenges. 90 million
Americans have limited literacy, clearly impacting patient safety.
(A real eye opener.)
18) "Understanding is a two way
street." Eleanor Roosevelt.
19) Support systems for traumatized
physicians, nurses and others following unexpected outcomes.
20) Forgiveness. Reconciliation
should not be punitive.
21) The opening session talked
about realities regarding the most common excuses that rapidly
defeat rapid improvement in patient safety: 1) The business case,
2) Evidence for action, 3) Capacity/resources,
4) Leadership, 5) Power and 6) Disclosure/autonomy.
The panel included moderator, Chuck
Denham, and nationally known speakers Jim Bagian, Jennifer Daley,
Lillee Gelinas, Dennis O'Leary, Sue Sheridan, and Bob Wachter. It
was very, very well organized and presented, and set a high energy
level for the meeting.
Sue Sheridan (Eagle, SD) lost her
husband and her son has a permanent lifetime disability,
both because of medical errors. She talked about the metaphor of a
hit and run accident. I believe it was Sue who also said that
honesty is not an option. (I can personally relate to this metaphor
and feelings.)
22) Beverly Johnson, President/CEO,
Institute for Family-Centered Care, Bethesda, MD, is working with
AHA in promoting the creation of effective partnerships with
patients and families. She emphasizes four principles:
respect/dignity, information, participation and collaboration. (She
and I co-presented at the Patient Safety Fellowship in Tucson last
fall.)
23) The importance of story-telling.
24) The importance of every single
person in the hospital.
25) Cultural
transformation/education has to start in medical school for
physicians. (This was brought up by several physicians in the room
at the consumer break-out session, and elsewhere.)
26) There were many speakers and
break-out sessions on the clinical, medications, systems, IT parts
of patient safety and are good resources. I did not attend these as
these are not my areas of expertise. These are clearly important to
clinicians/leaders wanting to cause change.
27) The legal piece of this
continues a major problem, including the attorneys and insurance
companies.
28) We are all consumers. Medical
error/unexpected outcome is a level playing field.
The following are Dan Ford thoughts,
emphasized in this conference, rattling around my head and important
to me for a long time, and increasingly important in my recruitment
of outstanding leadership for a variety of provider executive
positions:
-- The wall of silence has no place
in health care
-- Providers need to quit being
threatened by talking with each other and with patients/families
about troublesome health care/patient safety issues
-- Role conflicts need to be
recognized and dealt with
-- Trust and candor and
communications and disclosure are principles that need to be
embraced
-- Patients and families are part of
the team (That sounds as simplistic as the need to legislate "I'm
Sorry" by providers, but is part of the culture of our
industry/society.)
-- Senior leadership simply has to
get it.
-- Likewise, board members and
physician leaders
-- We have got to do away with the
arrogance and condescending attitudes and deal with each other
straight, human being to human being.
-- Senior leadership compensation
programs need to have quality/safety responsibility/results/progress
as a direct piece of the program.
-- We have to be sensitive to and
compassionate about the human needs of providers, just as with
patients and families.
-- Virtually every single one of the
patients/families who are involved in this movement that I have met,
including myself (several of us are health care professionals), are
involved because we want to help cause positive change because we
care deeply about the heatlh care industry and about providers.
Some of us still and may always have anger, but we have compassion
for providers and wish to help deal with the barriers. We don't
have to be right, rather preferring to be heard. In a way we
are modeling candor and directness and honesty through
communications with providers. Putting it in plain terms we need to
love and support and understand each other.
One of my MD/JD friends recently
suggested "my problem" was that I was a spiritual person and led
with my feelings. Sorry, no apologies.
That is me. I am also a realist and
understand and have consider empathy for
the issues/barriers/agendas/politics/fears of my provider executive
friends and colleagues. I truly have much compassion for each of
you, along with my nudging.
Patient safety is as important as
financial stewardship, and should be intertwined. Every health care
provider executive that I now interview as a position candidate I
ask about their perspective about the patient experience, including
CFO candidates and others.
I am very willing to get in the face
of litigation/defense attorneys and insurance companies, in
forthright and constructive ways, as relate to all of these issues.
Door openers and ideas are invited and appreciated. We are all
consumers. I understand many, though not all of their realities. I
am offended by what our family has experienced with the legal system
and insurance companies involved, knowing our feelings are not
unique and are shared by many providers. Making/saving money at the
expense of a brain damaged patient and a poor quality life is
simply unacceptable.
As an industry insider I will
continue to do all I can to help to cause constructive change, as a
health care search consultant and through my voluntary, personal
patient safety journey.
My interest is not to live in the
past, but to recognize that my first wife's permanent brain
damage/short term memory loss/poor quality of life will last all of
her lifetime as will the impact on our family (and the providers
involved?), to accept and appreciate the spirit of those providers
who continue to encourage me on this personal and voluntary journey,
and to help cause change from where the industry is today.
Much good is being done. I applaud
and have compassion for all who are so very committed to making this
a better industry. Much, much more is needed.
Thanks for reading.
Many blessings --
Dan
Vice President
Furst Group
Phoenix, Arizona www.furstgroup.com |
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