Collateral Damage: Take Two

“Doctors love to patronize and dominate. Their arrogance and indifference to the philosophy of informed consent is widely known. Surprisingly, most residents and doctors in teaching public hospitals tacitly endorse such reservations against information sharing. To most of them getting informed consent is a needless nuisance, to be delegated to a raw resident whose sole responsibility is to get the patient’s signature on the dotted line.”
Issues in Medical Ethics Volume 8, Number 4, October-December 2000…and Chapter One, Page 1 of Dan Walter’s book titled Collateral Damage

Walt Kelly, 1970

Walt Kelly, 1970

It has only been a few weeks since reading Dan’s book – yet I felt compelled to go back this weekend and read sections of it again. Since medical school, I rarely read something–even the Sunday paper–without a yellow highlighter in my hand, a side effect of the competitive paranoia instilled in me during medical school. I went back this weekend to the sections I had highlighted in Dan’s book, and found the quote above, right up front – Chapter One, Page One. I understand and appreciate why Dan purposely chose that quote to open his book.  I also knew why I had highlighted it a few weeks ago…long before I had finished reading Pam’s story and all the research Dan so eloquently presents  on the “cardiac ablation business”.

I had highlighted this section because that opening paragraph took me back to last summer, and our Telluride Patient Safety Roundtable and Resident Physician Summer Camp. Resident physician leaders from across the country spend one week immersed in patient safety with a major focus on open and honest communication. Over a three-week period during the summer, almost 100 residents and health science students join us in Telluride, CO to learn about important concepts related to patient safety and transparency. Here is a short video clip about the student summer camp, which has organically grown from a roundtable discussion of patient safety diehards and patient advocates over the last nine years into what is now an Educate the Young patient safety summer school. Patients help teach all sessions at the summer camp.

A three-hour session on informed consent/shared decision-making is part of the week-long curriculum in Telluride. At the end of this session last year, Paul Levy (@PaulFLevy, Not Running a Hospital) asked the residents how much informed consent training they had received during medical school and residency. With a show of hands, every resident acknowledged the three-hour session on informed consent/shared decision-making at the Telluride Summer Camp was more training than they received during their entire medical school and residency combined. We all agreed this was a sad commentary on the current state of medical education as it relates to patient centered care. One of our Telluride residents went even further when he posted this reflection on the day’s educational session:

I don’t think that I’ve ever thought so much about informed consent as I did today. A discussion about informed consent to the level of detail that we had today needs to be part of all residency training in the first days of orientation and as refresher training later on in training. All physicians can, and should, do much better in providing informed consent.

Over the years, I have come to know many patients and families who have been harmed from care. It seems almost every story that was shared had a serious breakdown in informed consent, or more appropriately, shared decision-making.  The families of Lewis Blackman and Michael Skolnik, and many others, might have chosen much different treatment courses if all the risks and procedural outcomes were shared with them.

We need to get this right. It is fundamental to ever achieving high quality, safe care.  If we don’t, we will continue to see unnecessary harm, more books like Collateral Damage and more films like The Faces of Medical Error…From Tears to Transparency. As Pogo says “We have met the Enemy…and he is us.”

The Future of Health Is Social

I recently came across an old blog post by Lee Aase, Director, Mayo Clinic Center for Social Media, Move over Dr. Google, the future of health is social. Aase, a long-time communicator in the political arena, has seemingly picked up the new tools of the trade with a flair all his own for healthcare. This particular post from 2011, alludes to the fact that Google may not have been hitting at the core of how individuals will utilize health information in the future. His post significantly precedes Google folding their health business for good in January of this year.

Already a student and believer of the power of social media to change the way we experience health and illness myself, it’s always nice to have other expert communicators confirm those beliefs. For me, healthcare social media use (or #hcsm on Twitter) is less about the social support that traditional social media tools offer–such as people sharing the same illness connecting–which has tremendous value in and of itself. It is more about the reach, and the following opportunities, social media can provide healthcare stakeholders on the whole. For example, social media tools offer:

For Patients:

  • The ability to gather information in a relaxed setting
  • Access to, and information on, research studies
  • Connections to new resources (peers, providers, educators)
  • Access to answers 24/7
  • Greater transparency to the care they are seeking
  • Behavior change options (see ETY post, The Power of Social Networks to Change Health Behavior)

For Providers:

  • Inspiration
  • Training/Education
  • Support networks of their own
  • Ability to meet patients where they are and stay connected
  • Disease and outbreak tracking

It was, however, the following video in Aase’s old post that was my muse for this post. I can’t help but applaud the growing value of YouTube as a tool for patient education and provider inspiration.

In February 2013, Aase posted an article on Mayo Clinic’s Social Media Health Network, The “Right” Length for Health Videos, which summarizes a Google chat facilitated by Kathi Browne, a healthcare social media consultant. This is a timely discussion, as we are currently at work developing videos that convey patient safety information to associates without overwhelming their already overflowing inboxes. With so much competition for the attention of healthcare associates, what is the best way to get your message heard? We have chosen to go with short, sweet and humorous videos for internal education when possible. What successful strategies and tactics have you employed, beyond the traditional healthcare communication Tool Kits or inservices? Please share!

Here are some related tips gleaned from experience and reading of late!

  • Know your audience!
    According to Aase patients, will pay attention to longer videos, especially if it’s about a rare disease, as there is likely little information available. Overloaded associates will not have time to digest lengthy content. Give them meaningful highlights that both engage and educate.
  • Humor works!
    Make ’em laugh, or make ’em cry…
  • Tell a story that touches the heart!
    People will remember a story told from the heart much longer than slides from a PowerPoint deck. Talk to patients and providers about their experiences in healthcare and share those stories when appropriate.

For Boston

Bostrong sign-1

As a longtime runner and marathoner, I often find myself using running analogies on this blog to share similarities between distance running and patient safety (see previous ETY post The Healthcare Safety and Quality Marathon). Training for a marathon takes hard work and sacrifice, as does changing a healthcare culture. Similar to running a marathon, there are times it feels like we hit the same “Wall” in healthcare that runners can hit at mile 18-20. It is only through perseverance and determination that we push pass that wall and achieve the goals set many months before.

The Boston Marathon is the ultimate marathon for runners. It is athleticism and celebration at its finest for those fortunate enough to quality. Being an average runner, I have always lacked the times required to qualify for Boston…. but like many, have always wondered what it would be like to be running the streets of Boston that Monday afternoon each April.

Last Monday, it felt to many of us that we as a country may have hit the “Wall”. But watching the light in our collective hearts overcome unimaginable darkness, we pushed through that wall in Boston and across the country–continuing to rise above yet another emotional challenge put before us as a nation. As a city united, Boston made us proud. Their EMT’s, police and firefighters responded with amazing courage, determination and expertise. So did their medical community. According to all accounts, they were amazing – many of whom were marathon runners themselves, and who immediately changed into scrubs and worked the next 48-60 hours helping those harmed by this senseless violence.  Runners immediately went to hospitals after the race and donated blood.

Similar compassion and support is also occurring across our country…people are running to raise money to help those harmed in Boston. Having had family members waiting for me near many race finish lines, my thoughts this past week have been fixated on those family and friends less fortunate. They came in hopes of celebrating with their loved ones – now they need our support.  The links below share ways that this support can be provided.

Donations have poured in for Boston Marathon bombing victims, with more than $2 million collected via online “crowdfunding.” Hundreds of thousands of dollars have been given for injured mother and daughter Celeste and Sydney Corcoran, Jeff Bauman (who first helped identify the bombers) and newlyweds Patrick and Jessica Downes, who each lost a leg, among others. This flood of generosity has raised concerns over fraud, since critics say the speed some crowdfunding sites allow for opening and collecting funds makes them vulnerable to abuse. But donors give anyway, and the biggest sites, such as Kickstarter, GoFundMe and GiveForward say their vetting and self-policing minimizes the risks. People wanting to contribute to a general Boston fund, as opposed to individuals, are encouraged to go through The One Fund Boston Inc. []

While I know I won’t be able to qualify, I do know where I will be next April 21st – in Boston on Exeter Street near the finish line.

Are You QI Cool?

By Michael Kantrowitz, DO (Guest Author and Chief Resident, Maimonides Medical Center)

It seems that there is a growing number of residents out there who are.

This past weekend, the Committee of Interns and Residents (CIR) hosted an event called “What’s Your QI IQ? Resident Physicians as Quality Improvement Leaders” in New York City. The program was developed as a partnership between the CIR Policy and Education Initiative and the Healthcare Transformation Project of Cornell University.

The day kicked off with introductions by Dr. Svjetlana Lozo, an ob/gyn resident from Maimonides Medical Center in Brooklyn and Dr. Rick Gustave, an emergency medicine resident at Lincoln Hospital in the Bronx. They described the push towards improved quality, safety, and transparency in medical practice and the central role that residents are beginning to play in leading that charge. Next up was Dr. James Pelegano who is an assistant professor and director of the master’s program in healthcare quality and safety at the Jefferson School of Population Health. Dr. Pelegano discussed his own experience in quality improvement in practice as a neonatologist. He then led us in a root cause analysis exercise using the recent death of Rory Staunton, a pediatric patient who succumbed to sepsis as case example.

Breaking into small groups, we were asked to take on various roles of the multidisciplinary team members who were involved to try to identify the contributing factors that led to the delayed recognition of Rory’s ultimately fatal illness. Many residents had never participated in a root cause analysis before, which sparked much discussion over the clinical and communication issues that could be improved. Dr. Pelegano challenged us to think like a hospital’s administration and find a process improvement that could be implemented within two days. He also discussed tools such as flow charts, Ishikawa diagrams, and PDSA cycles which we could add to our arsenal.

We then heard from three residents at CIR represented hospitals who discussed projects they have worked on at their institutions.

  • Dr. Constance Liu, an ob/gyn resident at Boston Medical Center, discussed efforts to improve resident education and adverse event reporting. Residents at her hospital have received a grant for this work.
  • Dr. Sepideh Sedgh, a pulmonary/critical care fellow, described the work that residents at Maimonides Medical Center have done as part of a joint quality partnership between CIR and the administration. Residents, including myself, took on the task of significantly improving the medication reconciliation process to make patient discharges safer
  • Finally Dr. Say Salomon an internal medicine resident from Woodhull Medical Center explained how their House Staff Safety Council has been enhancing patient care. One project he talked about was a resident-led program to reduce heart failure readmissions through better patient education.

The day ended with an interactive discussion run by Jennifer Weiss, a public health consultant with SAE & Associates. She led a workshop on developing and writing quality improvement and patient safety grant proposals using our own ideas for projects. I plan on using these skills as I look to find funding for future projects of my own.

It’s safe to say that we all left with a boost to our QI IQ and I’m looking forward to more events like this, which will train and challenge our generation of physicians to improve quality and safety.

Collateral Damage

I once heard Don Berwick say, shortly after taking over as Director for CMS, that he originally thought quality and safety where the biggest challenges facing healthcare today. But after spending time in the district, he quickly came to realize he was wrong. It was fraud that was the biggest challenge.

Collateral DamageHis message came to mind after recently reading a book given to me by Rosemary Gibson, entitled “Collateral Damage”, written by Dan Walter. I can honestly say that after reading the book, I felt embarrassed to be working in healthcare.

In the book, Mr. Walter shares the story of his wife, Pam, who underwent a cardiac catheter ablation procedure for an abnormal heart rhythm known as atrial fibrillation. He describes what went wrong during Pam’s procedure, and then details the pain, suffering, lack of transparency and denial of accountability that followed for both he and his wife. The procedure was performed at what is considered to be one of the best hospitals in the country, which makes the reader wonder what is going on at the “not so great” hospitals across the country, as well as who is defining what makes a hospital “great”. His aim in writing the book was to, “accurately portray what happened to my wife…without detracting from the skill, kindness and compassion of the majority of the people who work there…and to prove to Pam that she does matter, and to tell her that despite what the leadership of that hospital says, her life is important – and her story is important – and it deserves to be honestly told”.

The book is Mr. Walter’s account of the facts related to his wife’s care, so it is only his side of the story. However, it is remarkably well written, and gives a deeply researched account of the cardiac catheter ablation “business”. He includes information:

  • Taken from numerous publicly available FDA transcripts and testimonies on how unsafe these catheters were thought to be.
  • Promotional materials from companies making these catheters who were trying to get them through the FDA approval process hyping the wonderful results being seen in patients who were the first to be “experimented” on.
  • Transcripts from advisory panels and cardiology meetings where leading experts acknowledged the lack of evidence that these catheters even worked.
  • Conclusions from peer-reviewed journals showing complication rates much higher than what was being shared with patients.
  • Medical records highlighting a lack of real informed consent related to the risks and benefits of these procedures.

Mr. Walter also shares numerous other patient stories and holds nothing back. Not only does he name names, but he includes pictures of physicians and others who he and Pam encountered along their journey.

In one section of the book, the author shares thoughts on the difference between a “witness” and an “accomplice”, a witness being one who sees wrong and reports it.  He raises the question that if we as caregivers witness something wrong and don’t report it, aren’t we really accomplices to the wrong when we turn our back and walk away?  His statement caused me to reflect back on my career. As an anesthesiologist, I remember days when I was assigned to provide anesthesia for a catheter ablation case. Although I spoke with the patient about anesthesia related risks and benefits – I never thought of questioning the merits of the procedure I was to be a witness to. It was challenging enough keeping up with all the new findings in my specialty let alone comprehend everything being published in the numerous specialties anesthesiologists support. But after reading Pam’s story, I felt that I too may have been an “accomplice” to possible wrong doing.

I applaud Mr. Walter for sharing Pam’s story. I also struggle to understand why this book has not received similar attention, or the same hype experienced by authors of recent books published on medical error. Collateral Damage goes much deeper in highlighting problems facing healthcare today…a reason why I believe this book should be required reading for all resident physicians and health science students entering the field.

As quality and safety leaders and educators, our daily efforts are built around things like standard work processes, shared best practices, care bundles, checklists and universal protocols–“things” we do in the best interest of our patients. The bigger picture, as Don Berwick alluded to, requires that we overcome the personal, political, legal and financial agendas inherent within many high-level stakeholders. Otherwise, I sometimes feel we are just moving chairs around the deck of the Titanic.

For those interested, Dan’s book is available free on Amazon Kindle as of June 12th

John Wooden’s Spirit Alive and Well at MedStar Health

This week I again had the pleasure to hear Paul Levy (Not Running A Hospital) speak at a MedStar Health Quality & Safety retreat. Paul’s gentle reminder–that transparency in healthcare is something all of us have to own, not necessarily because someone is watching, but because we hold ourselves accountable to higher standards–was motivating. He quoted John Wooden–the great UCLA men’s basketball coach, reminding healthcare leaders in the room that, “If they haven’t learned it, you haven’t taught it.” As an athlete and coach myself, Coach Wooden has long been a virtual mentor for me. Wooden’s gentle giant approach and his unwillingness to settle for anything but the best effort everyday is an example of excellence in and of itself, but he was also a committed teacher and knew that if his students/players didn’t “get it”, his job was far from done.

Paul’s talk this week also reminded me that leading culture change in healthcare isn’t easy, and requires all of us to recommit to the principles we value–like transparency–even when it’s not necessarily the popular or easy choice. Wooden is a wonderfully invoked example of a leader whose commitment to his own foundational values of hard work, friendship, loyalty, cooperation and enthusiasm, led to unmatched success on the collegiate basketball hardwood.

What is our pyramid of success for healthcare, and can we stand firm–gently, calmly, confidently–because we know it’s the best way to achieve the safest, most cost-effective care for our patients?

And finally, here is a link to a previous Transparent Health blog invoking John Wooden’s spirit–this time around a Telluride Educational Roundtable discussion on the lack of training in informed consent and shared decision-making for resident physicians.

Resilience Engineering: A Novel Approach to Keeping Patients Safe

Resilience ConferenceFollowing is information on another excellent educational opportunity offering a novel approach to keeping patients safe, coming up in June!

Terry Fairbanks MD, Director of the National Center for Human Factors in Healthcare and Neil Weissman MD, Director of the Health Research Institute, both at MedStar Health, are hosting a two-day, innovative and workshop-style conference to share knowledge, spark innovative ideas, and inspire new collaborations and partnerships to apply resilience engineering in healthcare.

The conference, entitled Ideas to Innovation: Stimulating Collaborations in the Application of Resilience Engineering to Healthcare,” will be held on June 13-14, 2013 at the Keck Center of the National Academies in Washington, DC. Additional information and registration can be found at

What is Resilience Engineering and how is it used in Healthcare?  Simply put, it is how individuals, teams and organizations monitor, adapt to, and act on failures in high-risk situations. In greater detail:

Resilience engineering is an emerging field of study that focuses on the fundamental systemic characteristics that enable safe and efficient performance in expected (and unexpected) conditions. It is a paradigm for safety in complex socio-technical systems, and its application to healthcare is very limited. During this two-day workshop, leading researchers and practitioners in resilience engineering and resilient health care will present a set of principles,  practices and desired outcomes and products.  After these presentations, attendees will be asked to initiate discussions that will lead  to the development of  an effective roadmap to catalyze the idea to innovation process – the ultimate goal is to help health care organizations and other interested parties  improve quality and safety.

“Ideas to Innovation: Simulating Collaborations in the Application of Resilience Engineering to Healthcare” is hosted by the MedStar Health Research Institute and the University-Industry Demonstration Partnership (UIDP) as the first conference in UIDP’s Ideas to Innovation series.

Upcoming Quality & Safety Educational Opportunities

Following are two exciting, upcoming educational opportunities focused on quality and safety that we would like to share with our ETY readers. Please feel free to share the information with colleagues!

This year, the Committee of Interns and Residents has partnered with the Healthcare Transformation Project of Cornell University to present a series of conferences in the New York metropolitan area providing education around physician leadership in quality improvement and patient safety. The first conference, entitled What is your QI IQ? Resident Physicians as Quality Improvement Leaders, will be held on April 13 in Manhattan. The one day leadership conference focused on residents and medical students has been organized and led by residents, including many from last year’s Telluride Patient Safety Summer Camp.

The conference will feature:

  • Interactive didactic sessions led by Dr. James Pelegano, Program Director for the Jefferson School’s Master’s Program for Healthcare Quality and Safety, and an innovator in the field of Patient Safety and Quality.
  • Small-group breakout sessions that will allow participants to practice and refine the methods they have learned.
  • A panel discussion with resident physicians who are currently leading QI projects in their hospitals.
  • A hands-on workshop on the formulation and writing of QI/Patient Safety project proposals.
  • Where: Executive Conference Centers 1601 Broadway, New York, NY
  • When: Saturday, April 13, 2013, 9:45 am – 4:00 pm (breakfast at 9AM, lunch provided)

The second exciting educational event coming up in June is the fifth annual AAMC Integrating Quality Meeting once again held in Chicago. This year’s meeting, Improving Value and Educating for Quality, is a highly interactive, interprofessional program that brings together healthcare leaders, faculty, educators, trainees and students from teaching hospitals, medical schools, health professions schools, and other healthcare organizations to share strategies for enhancing the culture of quality in clinical care and health professions education.

The program will feature:

  • A number of plenary sessions, interactive workshops, and posters on topics related to aligning organizational goals and strategies around quality and value
  • QI and patient safety education across the continuum
  • Team-based and interprofessional approaches to quality improvement
  • A plenary session by Peter Pronovost, M.D., Ph.D., FCCM, senior vice president for patient safety and quality and director of the Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine
  • A plenary session by Gary Kaplan, MD, Chairman and CEO of the Virginia Mason Health System
  • Where: Intercontinental Chicago O’Hare Hotel Rosemont, IL
  • When: June 6-7, 2013

The Real Movie Stars of Patient Safety

By Michael Kantrowitz DO (Guest Author, and Chief Resident at Maimonides Medical Center)

It was exciting to be part of the filming of “Breaking the Wall of Silence” a few weeks ago as the filmmakers followed Dave Mayer up to New York where he met with leadership from the Committee of Interns and Residents (CIR).  The next day they came to Brooklyn and followed me around the hospital where I work, Maimonides Medical Center.  In a paradoxical way it was fun (albeit a little nerve-wracking) to be involved in the filming.  The documentary is casting light on some very serious issues regarding transparency and safety in healthcare and it was a privilege to be able to discuss some of the hurdles residents face in being part of the next generation of physicians who will need to address these issues.  There were a few residents who had “cameos” in the filming, who I also wanted to recognize: Drs. Steven Shamah, Nidhi Shah, and Prasun Shah.  They are three of the incredible residents I get to work with everyday, and are proof that there is a changing cultural tide in our cohort of physicians.  As we were filmed on rounds, we discussed safety issues such as the importance of accurate medication reconciliation and fall prevention.

After participating in the Telluride Patient Safety Roundtable last summer, I have tried to integrate what I learned into my role as chief resident.  As a result, I changed much of how I approach patient safety and care quality concerns involving residents from looking to find individual fault to identifying system failures.  That hasn’t happened overnight and I certainly have not perfected this approach, but not surprisingly I’ve found that it more effectively engages residents in the process, as opposed to putting them on the defensive.  In academic medical centers, residents are the front line physician staff.  They typically evaluate patients before the attending physician, and are often the first to respond to acute changes in a patient’s status.  I’ve always enjoyed the opportunity to beat the attending to the diagnosis or stabilize a patient before they arrive because I think it has led to my own growth and independence as a physician.  With such high stakes, however, it is really important to have a clinical environment in which to identify and learn from errors without fear of reprimand or ridicule.  I’ve been fortunate to train in such an environment alongside colleagues like Steven, Nidhi, and Prasun.

Highlights From A Patient Safety and Quality Journey

Dave Mayer and Tim McDonald are two of the early adopters of the patient safety movement supported by luminaries and other early adopters like Lucian Leape, Don Berwick, Rick Boothman, and Cliff Hughes. Recently, I wrote on their acceptance of the American College of Medical Quality Founders Award, and promised to share some of the highlights of their collective body of work. Here are a few of those highlights:

  1. The creation of the University of Illinois at Chicago’s Institute for Patient Safety Excellence, one of the first of its kind in the US focused on the tripartite mission of clinical care, education and research. It is an interprofessional “confederacy” with membership from six health science colleges all working together with a medical center, leaving their personal agendas at the door, in efforts to make patient care safer and of higher quality. They recognized that the problem of patient safety and less than optimal quality is an interdisciplinary problem requiring an interdisciplinary solution. The Institute strives to discover and validate such solutions.
  2. The Telluride Patient Safety Roundtables and Summer Camps. The Telluride Roundtable is an annual retreat now going on nine years, where experts in safety, quality and health science education come together with patients, family members, residents and students to develop and refine health science education that supports a culture of quality, safety, and transparency in patient care. In 2013, over a span of three weeks, Dave and Tim will be bringing resident physicians leaders as well as medical, nursing, pharmacy and allied health student leaders – over 100 of them – to Colorado and Washington DC for educational immersion in quality, safety and the importance of open and honest communication in healthcare so they can go back to their schools and residency programs and “infect” others, sharing the importance of high quality, transparent patient care.
  3. UIC’s Masters in Patient Safety Leadership program – the first online, adult learning, interprofessional Master’s level degree program in the country where physicians, nurses, pharmacists, hospital administrators, lawyers and even patient advocates can come together and learn together. Dave shares that healthcare is a team sport today, and that all healthcare providers need to learn and practice together.
  4. A comprehensive response to patient harm that includes extreme honesty, full disclosure and early offer was created at Telluride in 2005 with input from Patients and Families. It has become known as The Seven Pillars Program and is the foundation of a multi-million dollar AHRQ grant that has allowed the pair to connect more than 1000 hospitals to these concepts. From a personal level, Tim shares that the program also includes their Best Practice – Physician Peer Support Program that is provided 24/7 for all physicians involved in emotionally challenging harm events.
  5. An award-winning educational film series entitled “The Faces of Medical Error…From Tears to Transparency”. The films are being used in medical schools, residency programs, hospital grand rounds and board rooms across the world to create conversations on how to make care safer and of higher quality. Many years ago Rosemary Gibson, a very wise woman, wonderful friend and mentor to both Tim and Dave, taught us the power of connecting the brain – the learning – with the heart – the emotion. Tim and Dave produced these movies with Rosemary’s words in mind and dedicated them to the families who have lost love ones due to unintentional harm. As Dave shares, they are the true heroes, the patent and family advocates who, despite their tremendous loss, give back every day in efforts to make care safer for others.

And what I’m personally thankful for is that they stuck with it — this is not a journey for weak of heart — and it’s not something for those driven by instant gratification. Changing an entire culture of an industry takes those like Dave and Tim, who can take their lumps along the way and keep moving forward because they care so deeply about the well-being of patients and the profession they have dedicated a lifetime to.