Medical Malpractice 101: Patient Needs to Be First, Last, and Everything In Between

Larry Smith, Vice President of Risk Management at MedStar Health, is a true pioneer – one of a small number of leaders in healthcare who have developed early communication and resolution programs when harm from medical error occurs. Programs like University of Michigan led by Rick Boothman and Susan Anderson, University of Illinois led by Tim McDonald and Nikki Centomani, and MedStar Health led by Larry Smith and Steve Evans have long moved from a “deny and defend” approach to medical errors to one of open and honest communication. These programs have been able to bring closure and healing to all parties involved while using the court system and the long, difficult battles that result where no really wins except maybe the attorneys as a last resort.

This week, Larry recruited not only his own team of insightful and skilled Risk Managers, but also plaintiff attorney, Paul Bekman, Esq., defense attorney, Michael Flynn, Esq., and the Honorable Howard Chasanow, former Maryland Supreme Court Justice and now a full-time mediator, to participate in MedStar Health’s Quality, Safety & Risk Management retreat. It may sound like an unlikely gathering of peers to many, but for Larry, the only way to move towards the “just culture” required of high reliability organizations is to continue to unite those whom often seem disunited.

As the panel of experts shared what really occurs in court rooms in the aftermath of a medical error, all attendees gained a deeper understanding of the complexities inherent to managing a healthcare system. At a time when patients and caregivers are caught up in the pain, uncertainty and fear related to what is often a life-changing event, the medical-legal piece can either remove, or compound, the emotional, physical and financial costs involved. One thing many of the attendees learned was that when a patient forfeits control, and ultimately a say in the final decision of such an intimate and painful event, to a jury of peers with what can be at times an attorney not well-versed or well-intended when it comes to medical-legal matters, additional problems can be created for all involved. Claims filed often cost health systems millions of dollars, and patients many times do not receive what they truly deserve when cases are handed over to the courts. Judge Chasanow was truly inspirational and shared that true healing for all can be found through skillful mediation led by those knowledgeable in the intricacies of medical harm events–especially when led by those who have the patient and family’s best interest as the top priority. He also shared the amazing healing power that can result from two words –“I’m sorry”. When offered in a sincere and meaningful manner, anger and tension seem to dissipate and true progress towards closure and healing through mediation can begin for all.

Moving forward, we have two options:

Or a second option. A few years ago, Transparent Health put together a short trailer for a longer piece of work that sums up another approach to managing medical errors and the harm that can come from them. When harm is managed openly, honestly and with transparency, healing can begin. Here is that short clip:

Healthcare remains at a crossroad. If we are to truly achieve a Culture of Safety and drive towards Zero Harm, we must embrace open and honest communication, practice just culture principles that balance systems and process breakdowns with reckless personal accountability, and follow the wise words of Carole Hemmelgarn who so eloquently said it should always be “Patient first, last and everything in between”.

The Art of Negotiation in Medicine

A recent @NYTimesWell post, Teaching Doctors the Art of Negotiationby Dhruv Khullar (@DhruvKhullar), a dual degree candidate at Yale School of Medicine and Harvard Kennedy School, is a call to further arms on this specific communication skill so few receive formal training in–especially in medicine. Yet almost every day in a health providers’ life contains interactions with patients, colleagues and administrators that are opportunities to negotiate for better–adherence, outcomes, resources and systems’ improvements. He writes:

The medical profession is no longer one in which doctors dictate a given treatment course to patients, who are then expected to follow it. Rather, clinicians and patients deliberate about treatment options, weigh costs and benefits together, and determine the best course of action. This approach requires eliciting patient concerns and addressing underlying fears to arrive at the most effective strategy for maximizing health and well-being.

Screen Shot 2014-01-24 at 11.09.09 AMWhile medical schools have acknowledged the need to expand training around communication, training in negotiation specifically remains far from mainstream. One place the acquisition of this communication skill can be obtained, is the Telluride Patient Safety Summer Camps, where Paul Levy (@PaulfLevy) has joined the faculty the past two years, to teach a session on Negotiation to the health science student and resident physicians scholars. Levy, along with co-author, Farzana Mohamed, who recently published How to Negotiate Your First Job…, have led a favorite workshop by many attendees who have the opportunity to pick up what has traditionally been considered a business skill, though still not often taught to sales professionals in the real world.

As healthcare resources become ever more scarce, and the need to move from individual to systems’ thinking ever greater, so too does the need to influence the related necessary change. The ability to negotiate win-win outcomes are at the heart of Levy’s Telluride training session. Stereotypical sales scenarios where the polyester-suited fast talker takes advantage of the less armored victim is far from what it means to participate in a balanced negotiation, a discussion where one another’s BATNA (Best Alternative To A Negotiated Agreement) is the foundation for both parties being made more greatly whole by the final agreement. An almost zen-like approach to deal making, the single session sends Telluride alumni home with a tangible skill they can apply immediately–in “real” life and in healthcare.

As Khullar writes in the @NYTimes post mentioned:

Negotiation, in this context, is not about winning or losing, or haggling over price or scare resources. It’s about exploring underlying interests and positions to bring parties together in a constructive way. It’s about creative, innovative thinking to create lasting value and forge strong professional relationships. It’s about investigating what is behind positions that may seem irrational at first to understand the problem behind the problem.

Good Stories Rewire the Brain via @FastCompany

Screen Shot 2014-01-23 at 10.08.08 AMWe live in a time of information overload with amazing new tools to generate unlimited content, yet no reliable off-switch to know when to say when. A time when we seem to have little of it– bombarded with messages, information, advertising, emails, text messages, twitter feeds, facebook posts and more. Until someone creates an app with a more efficient way to sort the wheat from the proverbial chaff, grabbing the lastest best seller or classic novel can not only provide an escape from the onslaught of information, but also a rewiring of the brain, according to a recent @Fast Company article, Why You Should Read More Novels, by @shaunacysays. Experts share:

Screen Shot 2014-01-23 at 10.08.34 AM“The neural changes that we found associated with physical sensation and movement systems suggest that reading a novel can transport you into the body of the protagonist,” says neuroscientist Gregory Berns, the study’s lead author. “We already knew that good stories can put you in someone else’s shoes in a figurative sense. Now we’re seeing that something may also be happening biologically.”

Screen Shot 2014-01-23 at 10.07.30 AMOn more than one occasion, we have discussed how good stories inspire change by pulling us in on an emotional level (see How Do Great Storytellers Evoke Empathy) . Yes, cute kitties go viral before the latest data on chronic disease. But give that kitty to a 9-year-old girl whose best friend just moved away, stick the kitty up a tree and show Dad begging the fire chief to look at the “big picture” versus the risk of climbing an icy oak tree in sub-zero, January winds…well then, yes, you have a greater chance of fully engaging your audience. Stories like this, it appears, are engaging readers at the cellular level. But is this surprising? It has long been said words can hurt, but we’re only beginning to understand the true power words, and collectively, stories can hold to inspire change.

A few of my favorites are included as images on the page in support of a temporary rewiring, or simply to provide an escape from the pressures of the day. To see lists of additional “good reads” visit @goodreads on Twitter or online at!

Telluride Alumni Protecting Peds Patients via Good Imaging Decisions

Following is a Guest Post by Telluride Scholar and Alumni, Matthew Starr, MSIII, Saint Louis University School of Medicine.

Better imaging starts with better decisions.  The goal of the 100K Children campaign is 100,000 good decisions when imaging children by June 30, 2015–

The 100K Children Initiative began with a summit series convened by the American Board of Radiology Foundation. The goal of the meetings was to develop a national strategy for safe, appropriate and patient-centered imaging. The meetings brought together a broad group of stakeholders, including patient advocates, medical professionals, and oversight agencies.  I had the opportunity to attend two of the three summit meetings. Out of these meetings came several goals and objectives for optimizing medical imaging, a few of which are being addressed by this campaign.

My role in this campaign began with developing a series of process maps for the summit series. The maps highlighted the many pathways patients could take through routine healthcare scenarios. It became quickly apparent that a patient might receive unnecessary imaging studies because of the variations along the process pathways. As the campaign progressed, my role became focused on promoting our program to medical students, building a grass-roots effort to expand the reach of the campaign.

One of the things I found very interesting during my time in Telluride, were the discussion around how the IHI used medical students to promote the surgical checklist. The movement spread nationally mainly using the work of medical students. Then as a group in Telluride, we were able to develop a project of our own that focused on improving hand-washing practices at our various home hospitals.  I was able to use these discussions in Telluride as inspiration as I try to promote the optimization of medical imaging in children to healthcare workers across the country. My biggest message for students is that now is our time to take responsibility for the safety of patients. This movement is a way to get involved at your own hospital and community by informing both physicians and parents about the importance of appropriate medical imaging in children.

In summary, the 100K Children Initiative asks sites to report how often they make good imaging decisions for children.  In essence, we are celebrating the small wins that frontline teams achieve every day.  The structure comes from Chuck Denham/Steve Swensen’s 5 Rights of Imaging.  Focus will be the front end (Right study, Right order, Right way).5_Rights_Imaging

Measure Primary Target Secondary Targets Simple Tally*
1.  Right study:Observation instead of head CTs for children with minor head trauma ER Physicians Pediatricians, family practice physicians, and families ER nurses provide a count of the number of patients who don’t get a head CT but rather are given instructions for signs to watch for after head trauma
2.  Right order:Single phase CT studies (head and chest) Radiologists Referring physicians (ER, pediatricians, family practice) and families Techs count number of single phase head and chest CT exams that they perform
3.  Right way:How often was a child sized CT protocol used Technologists Radiologists, referring physicians, and families Techs count number of times they use a pediatric protocol
*Simple tally offers quick data turnaround and is based on the honor system.  Can use administrative data to verify each site’s progress with measures 1 and 2.  Can use dose reports to monitor each site’s progress with measure #3.

Enrolling sites

  1. An easy sell for the pediatric specialty centers since they are already following these recommendations.  They will become the key nodes in the local networks that prompt community hospitals to follow suit.  Children’s Hospital Association will likely be a key partner.
  2. Each site identifies staff in ER and radiology who will be responsible for collecting data on a weekly basis and submitting it.  How they collect the data is up to them.  We will learn as we go.
  3. Each week, sites submit their weekly count in each category.  Data is due each week by Monday afternoon.  Results are reviewed on a Tuesday morning conference call.

100K_Children_SLU_MapFor more information and how to get involved, check out the website — Follow us on Facebook (100K Children) and Twitter @100KChildren #ImproveImaging

The Continued Quest for a True Culture of Safety

The continued learnings that have come from the Asiana crash in San Francisco have reinforced one of the most important safety and quality issues affecting healthcare today–an existing culture that inhibits caregivers and support staff from holding each of us accountable and speaking up when we perceive a problem with patient care.

In a recent ETY post, Lessons Healthcare Can Learn From Asiana Flight 214, I shared the thoughts of Steve Harden as he applied the learnings from the Asiana crash to common weaknesses in patient safety. In a recent follow-up to his original piece, Harden reports on the interviews and investigations that have taken place since the crash last fall. He writes:

Though Captain Lee was an experienced pilot with the Korea-based airline, he was a trainee captain in the 777, with less than 45 hours in the jet. Captain Lee’s co-pilot on that fatal flight was an experienced instructor pilot who was responsible to mentor and monitor Captain Lee’s performance…(Lee) told investigators he had been “very concerned” about attempting a visual approach without the instrument landing aids, which were turned off. A visual approach involves lining the jet up for landing by looking through the windshield and using numerous other visual cues, rather than relying on a radio-based system called a glide-slope that guides aircraft to the runway.

…he did not speak up because other airplanes had been safely landing at San Francisco under the same conditions. As a result, he told investigators, “(he) could not say to his instructor pilot (that) he could not do the visual approach.”

What does this story have to do with healthcare? Harder emphatically shares that:

…after working with over 140 healthcare organizations, reviewing scores of root cause analyses, and conducting hundreds of real time observations in hospitals, clinics, ASCs, and labs – many of my experiences with healthcare staff sound just like Captain Lee’s interview. The culture in many of our healthcare organizations might as well have been created at Asiana.

Screen Shot 2014-01-16 at 12.23.16 PMThis past weekend, I was an invited participant on the Culture of Safety Panel at the Patient Safety Summit held in Laguna Niguel, CA. The Summit was founded by Joe Kiani, the CEO of Masimo, and was keynoted by President Bill Clinton. It also included a number of thought leaders from across the country who came together with one common goal…Zero Preventable Hospital Deaths by 2020. During our panel, I posed the question, “If we as caregivers struggle to take collective professional accountability for safety concerns happening around us, who will?  When we don’t stand up and share safety concerns about our patients with one another, we lose the most important element of any caregiver-patient relationship, which is trust.”

In his article, Harden asks the question, “How would (your healthcare teams) answer this question?

In 100 out of 100 cases where it is needed, am I absolutely sure that my most junior and inexperienced staff member, when they perceive a problem with patient care, can and will have a stop-the-line conversation with my most senior and experienced physician?

At the Patient Safety Summit this weekend, Dr. Mark Chassin the CEO of the Joint Commission, asked the audience almost the same question Harden posed:

How many in the audience can answer yes to the following question (paraphrasing): If one of your junior staff members saw a potentially unsafe condition, how many of you are confident the staff member would “stop the line” and report that potential unsafe condition?

About 2-3% of the audience raised their hands. Dr Chassin confirmed that when he has asked the same question at other meetings, the responses are consistently between 0-5%, with no raised hands being the most frequent observation.

Screen Shot 2013-09-01 at 8.33.40 AMHarden’s article and the panel discussions on accountability this past weekend at the Patient Safety Summit took me back to the words of Dr. Sidney Dekker, a Professor of Humanities at Griffith University in Brisbane, Australia. Dr. Dekker has a PhD in Cognitive Systems Engineering and is the author of Just Culture: Balancing Safety and Accountability:

Calls for accountability themselves are, in essence, about trust.  Accountability is fundamental to human relationships…Being able to offer an account for our actions (or lack of action) is the basis for a decent, open, functioning society.

The vast majority of caregivers want to do the right thing but the long-standing incentives and pressures to “look the other way” are powerful. To achieve a true safety culture, leaders need to be held accountable to removing these barriers and celebrating caregivers who raise their hand when safety concerns arise. Collective accountability can restore honesty and trust in our healthcare work place, and is essential to any healthy patient-caregiver relationship.

Keeping Patients Safe Can Be Fun Too

Virgin Atlantic shows that safety is anything but checking a box in this viral video that has now received over 8M hits on YouTube. As we move into 2014, what twists can we put on traditional training for patient safety that engages and moves people to change behavior? Share what you’re doing to turn the old into something new. Healthcare innovation comes in all different stories, shapes and sizes–it’s not just Watson and iPhone apps.

See the following video for a “behind-the-scenes” look at the thinking that went into this out-of-the-box safety video. What if we took this “yes, and…” spirit into every process and project in healthcare?

The Future of Storytelling: The Influence of Fiction on Science

What do Star Trek, Motorola, Stephen Spielberg, Minority Report, Raytheon, @ElonMusk, @JonFavreau, and Iron Man (the movie) have in common? All are examples of how science can influence fiction, and fiction can influence science.

@RobertWong, a graphic designer by training and a driving force behind Google Creative Labs, tells the story of how art, technology & design lovers come together with engineering experts to create the future.  Think Google Glass, cell phones, tricorders and more–What a way to kick off 2014!

For those interested, Wong also hosts a Future of Storytelling Virtual Roundtable Speaker Series weekly on Wednesdays, 12:30pm ET. Click here for more information.