The Doctors Company (TDC) and their Foundation (TDCF) have been committed to medical education for many years. They have been the major supporter of our annual Telluride Patient Safety Summer Camps for medical and nursing students the past four years, providing full scholarships to sixty medical and nursing students last year so they could attend this week-long immersion in safety, quality and transparency.
I have been honored the past two years to be invited to attend TDC Annual Advisory Board Retreat. The retreats have become a favorite meeting of mine, as well as one of the best educational meetings I have attended. One of the presentations I enjoy hearing most is given by Dr. Richard Anderson, the CEO of TDC, who opens the meeting with an update and discussion on the current medical malpractice environment. Dr. Anderson shares claims data along with insightful narrative so that a “novice” to the medical malpractice industry like I am can understand and appreciate the challenges healthcare really faces today.
A couple of numbers he shared this year really hit me:
- The average cost of a claim at TDC is $97,000
- 82% of all claims filed do not result in any payment to the patient and/or family
A couple of things came to mind as I reflected on those two facts. First, where is all that money going? If the $97,000 isn’t going to patients or families, who was it going to? Who was getting all that money? The second thing was the pioneering work done by Rick Boothman, Susan Anderson, Skip Campbell and others at the University of Michigan highlighted in the article entitled Liability Claims and Costs Before and After Implementation of a Medical Error Disclosure Program. After full implementation of a disclosure-with-offer program at the University of Michigan, Boothman and colleagues observed:
- Decreases in the monthly rate of new claims from 7.03 per 100 000 patient encounters to 4.52
- Declines from 232 lawsuits (38.7 per year) to 106 (17.0 per year)
- Declines in median time to claim resolution from 1.36 years to 0.95 year
They also appreciated decreases in monthly costs associated with total liability, patient compensation, and non–compensation-related legal costs. Through an open, honest, timely and effective communication approach to unanticipated outcomes, they were able to successfully start addressing the excessive costs Dr. Anderson referred to associated with liability claims.
Maybe there is a better approach to the “deny and defend” model we have seen used through the years.
One additional figure Dr. Anderson shared also hit me hard this year. The number of claims filed asking for compensation above $10,000,000 has tripled over the last year, with the total claim pool going from $400,000,000 to $1,200,000,000 in total costs in just twelve months. Even gas prices haven’t risen that fast. Has the severity of patient harm suddenly tripled over the past year or are there other factors contributing to this sudden escalation?
If interested, The Doctor’s Company website contains numerous healthcare, patient safety and risk reduction resources. Click here for more information.
So many of the healthcare stories shared in the mainstream are those that focus on patient harm, or egregious behavior by providers. It can make us forget that while these occurrences are still far too frequent, they are not the norm. For every patient harmed, there are roughly three success stories rarely shared. Stories of care teams, often operating in systems yet to be designed for optimal success, who manage to use the wonderful technology, knowledge and compassion at their disposal to send a patient home safely. While every patient story is of great value, so are the stories of those care providers whose voices are less frequently heard. When patients and providers work together throughout the course of a healthcare encounter real magic occurs. Human connection has power to heal, and will always complement any prescription or treatment. And it costs absolutely nothing…
Here is one of those success stories, recently shared by a colleague. Melissa, a patient in the Vidant Health system, was found to have an aortic dissection immediately after giving birth to her son. She shares with viewers a triumphant and tear-jerking healthcare experience, as well as what made her time with Vidant so positive and successful despite the odds. Following are a few of those highlights for those who don’t have time to view the entire video:
- Melissa felt she was listened to by the care team
- She needed someone to be human and care, and that is exactly what her healthcare team did
- Someone cared enough to push harder within the system when her survival depended on it
Here is Melissa’s story, in her own words. There is a wonderful tribute to the healthcare team that was part of her “family” during this challenging time in her life. If you have time, Melissa’s story is well worth a few moments of yours. It is also a story worth sharing–one that healthcare colleagues and consumers will equally appreciate.
I continue to enjoy following all the quality and patient safety work being led across the country by resident physicians. Many have come into healthcare with a much different perspective regarding quality, safety and outcomes than my generation did years ago. Be it the daily focus by the media on preventable medical errors, required transparency of outcomes, or the newer reimbursement models based on quality and safety, this new generation of physicians is asking the right questions and looking for the right solutions. It is why the premise “Educate the Young” is such a critical component to any enduring culture change.
In this spirit, we want to share another wonderful example of how resident physicians are changing the landscape of quality and safety in healthcare for the better. The AAMC webinar highlighted below, The House Staff Patient Safety Council: Creating a Culture of Safety and Openness, is being led by Nate Margolis and Say Salomon, both Telluride Patient Safety Summer Camp Scholar Alums, who are helping inspire resident physicians on how to lead change in their own academic institutions. What a great example of “pushing it forward”.
Date and Time: Wednesday, October 30, 2013 3:00 pm ET
Duration: 1 Hour
Description: In support of the Best Practices for Better Care Initiative commitment area to teach quality and patient safety to the next generation of doctors, this webinar will spotlight two institutional approaches to creating a culture of safety and openness by leveraging House Staff Patient Safety Councils to improve care processes and outcomes.
House staff patient safety councils create a culture of safety, engage residents in process improvement, and help satisfy ACGME requirements. A successful resident driven project will be described in which the distribution of badge buddies, incident report guidelines, and an incident reporting presentation increased house staff adverse event reporting in a 3-hospital academic program. In addition, the Safety Council activities and outcomes from Woodhull Medical Center will be shared. Some examples of their core projects include: the triaging of critical care value from an ambulatory care clinic, standardization of hand off processes and just culture conferences to improve quality of care delivered to its patients.
–Nate Margolis, M.D., is a chief resident in Radiology and the co-chair of the House Staff Patient Safety Council at NYU, Bellevue & Manhattan VA hospitals
–Say Salomon Jr., M.D., is an Associate Chief Resident in Internal Medicine at Woodhull Medical and Mental Health Center
To register, click here. It should be a great discussion!
Paul Levy extended an open invitation to healthcare colleagues on the New York Times Opinion page in a letter to the editor entitled, Invitation to a Dialogue: When Doctors Slip Up. Here is an excerpt from that letter:
The tendency to assign blame when mistakes occur is inimical to an environment in which we hope learning and improvement will take place. But there is some need to hold people accountable for egregious errors. Where’s the balance?…People in the medical field are well-intentioned and feel great distress when they harm patients. Let’s reserve punishment for clear cases of negligence. Other errors should be used to reinforce a learning environment in which we are hard on the problems rather than hard on the people.
This has been a continued struggle, both spoken and unspoken, for years. As Paul points out, well-intentioned and hard-working physicians, nurses, pharmacists and other care team members come to work each and every day trying to help heal those in need. However, our current health care system fails them (and our patients) when they come to work. The system also fails to create a learning environment where well-intended caregivers can share potential areas of weakness or events because of fear for their own careers. Because the existing culture of medicine has been very slow to change, I have always believed that educating the young was a silver lining of sorts–or a way to rebuild our culture from the ground up. Educational content on open/honest communication with patients and colleagues has been the core curriculum at the Telluride Patient Safety Student & Resident Summer Camps for the last four years, and that has been shared with over 300 resident physicians, and medical, nursing, pharmacy and law student alumni. It was with great pleasure that I read Telluride alum, Stephanie Wappel’s following response to Paul’s NYTimes piece this weekend – one of the few selected from many responses (see additional comments, including MedStar’s Human Factors Engineering Director, Dr. Terry Fairbanks, & myself here):
I was fortunate to attend a conference on patient safety for which Mr. Levy was a faculty leader. I agree that we need to change the culture regarding the disclosure of medical errors. We cannot learn from what we do not know, and what we do not know can seriously harm our patients.
One strategy that has been implemented at my home institution is the celebration of “good catches.” Every Monday, all hospital employees receive an e-mail that features the “good catch” of the week, in which an error was detected and reported before it had the potential to cause harm. Any hospital employee can report these good catches.
They range from a nurse’s realizing she received the wrong dose of medication from the pharmacy to a medical student’s stopping her patient from getting a procedure that the physician thought he had canceled in the new electronic ordering system. Obviously, the institution is also working on discovering how that error occurred to prevent similar ones.
It is no easy task to change a culture, but this seems to be a good start.
Washington, Oct. 16, 2013
The writer is a resident physician at Georgetown University Hospital
The Good Catch Program Stephanie mentions has been a concerted effort of our Patient Safety team at MedStar Health to share some of the learning opportunities that arise on a day-to-day basis in healthcare, celebrate those for their courage to report them, and face them head on versus hiding from them.
If health care is to achieve safety successes seen in other high-risk industries such as aviation, we must learn to balance safety and accountability. For caregivers who knowingly and recklessly violate safe practice, discipline is the right course and much needed. But most errors that lead to patient harm occur because of bad systems or processes, not bad people. Until we can be open and honest about our mistakes, learn from them and support our well-intentioned colleagues, we will continue to struggle.
On July 6th, Asiana flight 214, a B-777, hit the sea wall on approach to San Francisco airport (SFO). Three passengers died.
I recently received a well-written and insightful article describing what we in healthcare can learn from the cause-analysis findings coming forward from this unfortunate event. Richard Lockwood, AVP for Quality and Outcomes at MedStar Washington Hospital Center (MWHC) passed on the article, written by Steve Harden, as he found it useful given MWHC has been on a high reliability (HRO) seeking Journey the past two years. Richard’s experiences are guideposts as we embark upon the same journey for our entire health system. Having started his career in the commercial nuclear power industry, and having been a key contributor to the design and execution of the that industry’s HRO journey, Richard has proven an excellent resource to me and others when it comes to understanding some of the barriers healthcare organizations may face as they continue on their resilience journey.
Excerpts from the article follow, and more information on the author, Steve Harden, can be found here:
The effort to stop patient harm due to preventable medical error in healthcare can be assisted by examining some of the factors in the loss of life in aviation…Critical lessons for healthcare can be gleaned from…what is known about the training and culture that pervades the airlines in South Korea…Here are four lessons that healthcare can learn from the tragic accident.
1. Beware of over-reliance on technology: The pilot in command of the flight that day had over 10,000 hours of flight experience…However few of those hours were logged while in actual physical control of the airplane – what pilots call “hand-flying.”…Almost all of their flight time is accrued while the airplane is actually being “flown” by the computer.
Over-reliance on technology causes several issues including degradation in basic flying skills, and a tendency for a “lack of engagement and mindfulness” in monitoring the computer and the computer generated flight path.
The lesson for healthcare is clear…Electronic medical records, computerized physician order entry, and decision support tools will never replace “basic flying skills” in medicine.
How many times have we heard our informatics teams share that same advice when we ask them why our EMR’s are not solving many of our safety problems?
2. Culture eats initiatives for lunch: …Culturally, it is bad form to mention something that might reflect badly on the senior person of the group…During the last two minutes of the accident flight, the descent path to the runway was..clearly wrong, yet none of the other three crew members in the cockpit said anything to the Captain.
The lesson for healthcare? You may have a TeamSTEPPS program. You may have a great Lean process improvement program. Neither will yield the sustainable results you want if you don’t work on your organizational culture.
3. Protecting the powerful is counter-productive: …You can overcome 3000 years of culture, but it takes a concentrated effort by leadership to over-communicate the expectations, to reward the new behaviors, to celebrate the results, to personally model the new behaviors, and to eliminate those unwilling or incapable of change.
The lesson for healthcare? As Harden points out, allowing the mindset that “I know s/he is disruptive and hard to work with, but s/he is a big producer”, cannot be tolerated if an organization wants to achieve success in their HRO seeking journey. Disruptive and abusive behaviors are in direct conflict with high reliability seeking cultures which embrace respect and caring for fellow associates and team members.
For me, the following point referenced from Harden’s article is the most important take-away from this learning. We see many wonderful examples every day of caregivers speaking up and taking action when needed – similar to what Harden describes:
4. Even one person who can speak up and be assertive can save a life: Despite all the cultural barriers that might have prevented it, one of the Asiana flight attendants used a TeamSTEPPS behavior when it mattered most. After the crash and when the airplane had come to a stop, the Captain announced that the passengers should not evacuate. One of the flight attendants saw flames outside the window and called the Captain on the intercom to let him know they needed to evacuate. This willingness to speak up undoubtedly saved a lot of lives.
We know many of the answers, and what needs to be done to make healthcare safer–culture change, stop protecting the powerful especially when safety is at stake, and celebrate those remarkable caregivers who speak up even when they fear possible retaliation for voicing their safety concern. We hear these recommendations over and over. It’s not rocket science, but they are still challenging to put in place while many of the historical incentives remain misaligned.
Following are thoughts by guest author, Lynne V. Karanfil, RN, MA, CIC, Corporate Director, Infection Prevention, MedStar Health-Corporate Quality & Safety, Faculty Associate|National Center for Human Factors Engineering in Healthcare
Aye maties! Give me your life!
As folks celebrated Talk Like a Pirate Day on 9/19/13, days earlier the CDC posted their own skull and cross-bones. The pirates here are resistant bacteria causing people to lose their lives at a rate of 23,000 a year in the US. How did we become captured by these pirate bacteria? A picture is truly worth a thousand words. We are getting to a point in time that has been predicted. And its scarier than any pirate!
As Wayne Campbell, MD chief of Infectious Diseases at MedStar Union Memorial so eloquently stated at a recent Board meeting:
The emergence of antibiotic resistant bacteria marches on. The most recent iteration is a bacteria common to all humans, Klebsiella pneumoniae. This bacteria may now carry genetic information that allows it to be resistant to the vast majority of antibiotics, and the few antibiotics that remain active are seriously toxic to human kidneys. We are in a bind to safely treat this common bacteria that has emerged after years of antibiotic bombardment made it an impending threat. No antibiotics are currently in the pipeline to help us, and we will have cases in the future of this bacteria being completely untreatable.
If you ever took only a few days worth of an antibiotic or begged your doctor to give you an antibiotic for a disease that isn’t treated with antibiotics, like the flu, then you need to walk the plank! I admit I am guilty. I wanted to get back to work earlier and asked for antibiotics when probably not needed. I was fortunate not to develop C difficile. C difficile causes unrelenting diarrhea and this bacteria is causing havoc in the US, especially in our hospitals. The other is carbapenem-resistant Enterobacteriaceae (CRE), commonly known as resistant Klebsiella or E coli, as Dr. Campbell discussed.
Taking antibiotics and using proton pump inhibitors (drugs that reduce acid reflux) are some of the contributing factors that are making C difficile more common than Methicillin-resistant Staphylococcus aureus (MRSA), and now considered an urgent threat to public health in the US.
We all need to do our part! Taking antibiotics only when appropriate, completing the prescribed dose and, if experiencing diarrhea after taking an antibiotic, alerting the prescribing doctor are three weapons we can use to beat back these potentially deadly bacteria. For more information on antibiotic resistant threats, click HERE and head to the CDC website.
We have written extensively on ETY about the value of embedding the principles of high reliability seeking organizations into health systems. We have been on our own high reliability seeking journey at MedStar Health, partnering with Healthcare Performance Improvement (HPI), a leading high reliability consulting group. I have come to know the tenets of high reliability are excellent ways to keep our patients and care providers safe.
This past July we invited Denise Murphy, RN and VP Quality & Safety from MainLine Health, to speak at our Quarterly Quality, Safety & Risk Management retreat. Denise shared firsthand what a health system can accomplish once they embrace a high reliability culture. She noted that 100% of MainLine caregivers and employees went through high reliability training – no exceptions – which speaks to the important roles everyone in an organization plays in striving for zero patient harm. And MainLine Health has started seeing tangible success from all their hard work.
To move towards high reliability, patient safety must trump everything else. High reliability organizations always put safety at the center of everything they do. As James M. Anderson, Past President & CEO of Cincinnati Children’s Hospital and Medical Center said in their hospital’s quest for high reliability:
“There is no priority higher than patient safety. If there is a conflict between safe practice and speed, efficiency or volume, then safety wins – hands down.”
High Reliability leaders are not only vocal but they are also very visible. They “walk the talk” by role-modeling high reliability characteristics, start all their meetings with safety stories, and engage their associates in weekly Leadership Safety Rounds.
Like Mainline Health, MedStar Health has already interviewed over 500 leaders and associates from across our system to identify which high reliability tools and techniques should be implemented. Steve Evans, Executive Vice President for Medical Affairs for the MedStar Health system, started off our last High Reliability meeting by saying “We want to be able to tell our patients, friends and families this is the place to be. It’s the safest organization to receive care.” Steve cited “unconscious competence” as the greatest risk to any organization. We need to change our thinking from “I’ve done this procedure or task many times – everything will go well”, to being mindful and always asking others “what could possibly go wrong today”. Healthcare providers in high reliability organizations acknowledge their own vulnerabilities, take nothing for granted, and are quick to adopt new tools or techniques shown to reduce patient risk.
Airplane pilots understand human vulnerability – the best pilots can make a mistake. It is why pilots would never disregard the numerous risk reduction tools implemented in aviation that help trap human errors before they lead to harm…things like pre-flight briefings, maneuver read backs, and checklists. The best caregivers also can make a mistake. Physicians, nurses, pharmacists and others who understand that anyone can make an error when the “holes in the Swiss cheese” align are the caregivers I want taking care of me or my loved ones.