Author Rosemary Gibson Keynotes MedStar Health’s Quality and Safety Retreat

Author Rosemary Gibson was kind enough to keynote our MedStar Safety and Quality retreat yesterday with her talk entitled, The Patient Perspective in Patient Safety: Can It Make A Difference? With almost 100 MedStar leadership associates in attendance, her message, and her ability to bring the patient’s voice into the auditorium, was the very best way we knew to accelerate what MedStar Health established as rule number one years ago…that is, “The Patient is Always First”. The patient is the very reason caregivers do what they do–and that can sometimes be forgotten in the push to get things done, or in the many details of the day.

As Rosemary spoke, the room was silent. I did not see her compete with even one handheld device in the audience. “Patients make the invisible, visible,” she said, as she shared stories of patient harm, but also gave examples of how far we’ve come in healthcare. To the left is a photo of Diana, a mother who fought a surgical site infection throughout the last months of her pregnancy. Two days after giving birth, Diana’s body could no longer fight the infection and she died. This photo is the only one of mother and daughter together. Diana’s mother is now raising her granddaughter, and understandably was devastated after her own daughter’s death. Rosemary shared how Diana’s grieving mother was able to eventually become a resource to healthcare providers by sharing their families’ story so that others would not experience the same senseless loss. She has used her personal loss to help others by becoming a national leader in infection control awareness. This is the power of welcoming patients into the safety and quality conversation–many have unique insights and ideas that caregivers often lack – they see things we don’t which adds significant opportunity for improvement to any quality and safety mission.

There were many excellent takeaways from yesterday. Rosemary reminding all of us the great value patients add to the caregiving environment, both during excellent provision of care and also at times when things do not go as planned, was most definitely one of the key messages. Her comments, along with the additional thoughts shared by many attendees follow, emphasizing the value of having patients and families on different healthcare teams–something being done more and more throughout the MedStar Health System.

  1. Patients and families can help make care safer by working with care providers in a structured way (Advisory Boards, Panels, Committees)
  2. Patients and families bring a different perspective and new areas of expertise that complements what we do as caregivers
  3. Patients and families are additional eyes present at times caregivers are not. They provide additional data points we don’t necessarily collect but are of great importance to the healthcare team.

When harm does occur, Rosemary shared that her anecdotal research has shown patients do not want to resort to litigation, and that those who seek legal council have done so because they have been blocked by the medical establishment’s Wall of Silence, also the title of her first book. They file claims out of anger…not out of greed because we as caregivers have historically built those walls of silence around us, keeping the truth from them. As Rosemary pointed out, patients and families don’t want to spend 4-6 years of their lives in courtroom battles, depositions, listening to expert witnesses (a.k.a. hired guns), and not being able to move on, or put the harm behind them…always having to relive the event over and over with no sign of closure. Instead, she has found, along with increasing peer-reviewed research performed at the University of Michigan, University of Illinois and others who have adopted an open and honest approach to medical harm, patients just want to know what happened. They want to be absolved of the guilt they feel–that they could have done something to prevent the harm to their loved one. They don’t want to be billed for, or pay, for poor quality care. And they want to know this same event will not happen to another person–that the hospital has learned from the unfortunate event and made the necessary changes that make the care system safer.

There are pockets of greatness occurring across the country. MedStar is one of those bright spots. The organization has had a policy of open and honest communication after patient harm and has been doing it right for over ten years.  After the session, Rosemary shared with me that she saw the eyes of understanding and readiness looking back at her from the audience yesterday, and I could also feel the eagerness to achieve quality and safety greatness in the room.


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