Patty and David Skolnik were again faculty at the Telluride “East” Patient Safety Summer Camp this week. They came to lead the discussion after sharing the educational documentary film, The Story of Michael Skolnik, and their family’s story, with almost 75 medical and nursing students and resident physicians. As always, and as quite an understatement, the film is part of the patient safety intensive curriculum that illuminates the need for change in healthcare and healthcare education–not only to make it safer for all, but to also cultivate the skill sets that engender meaningful conversations built on honesty and trust between patients and providers. Following are reflections shared by Patty and David today, ten years after losing Michael to medical harm. Thank you, Patty and David, for your continued presence within healthcare, serving as a reminder that we still have much work to do.
David and I feel many emotions 10 years after our son’s death:
- Anger that we have lost our child unnecessarily
- Strange relief that Michael is no longer suffering
- Unexplainable sadness that Michael is gone and his dreams are unfulfilled
- Guilt for making decisions we regret because we trusted the doctor and didn’t look further
- Awe at the courage one young man could manage. Michael was a fighter; he had unbelievable strength to fight back
- Admiration, immense admiration for the love and unstoppable caring he showed through his horrible ordeal
- Appreciation for what we all learned from Michael, he had no room for weakness, failure or lies
- Regret that we lost our best friend and a large part of our souls
- Happiness that we had a child that never hesitated to participate in life or have any goal intimidate him
- A love of Michael’s was sailing. Through sailing he learned: ingenuity, resourcefulness, trust, caution, adventure, discipline, and perseverance
Michael has also taught us many other lessons that I want to leave with you, namely that we all have choices, choices about how we live and how we die. If Michael were here he would tell all of us:
- To smile always
- To laugh daily
- To sing every chance you get, whether others think you can or not
- To dance, even if you have to do it in a wheelchair or bed
- Not to feel guilty if you don’t know what you want to do with your life
- To meet new people and make new friends everyday
- To enjoy your body. Use it every way you can. It’s the greatest instrument you’ll ever own.
- Get to know your family and especially your parents. You will likely discover that they are the best friends you will ever have.
- Do one thing every day that thrills or excites you
- Respect those that earn it
- Be the Best medical professional you can
We are determined to make a difference for Michael’s life. This is what Michael would have wanted–to have his voice still heard and all the others that have no voice. Thank you for what you do and for helping us keep our promise to Michael–that we all leave the medical field better than he found it.
Hero – a remarkably brave person; somebody who commits an act of remarkable bravery or who has shown an admirable quality such as great courage or strength of character especially under difficult circumstances; somebody admired.
Carole Hemmelgarn is a hero.
In the video that follows, Carole poignantly shares her daughter Alyssa’s story, and why their family’s loss has been the driving force behind the change Carole is fighting for – the delivery of safer care for all patients and families. Every person lost to preventable medical harm is a tremendous loss. Carole, and other courageous heroes like her, including Patty & David Skolnik, Helen Haskell, Victoria & Armando Nahum and Sorrel King give their time, their heart and their stories so we never forget these unfortunate events are not just statistics.
They are my heroes.
I have been very fortunate through my career to have met, learned from, and become friends with many patient advocates from across the country. People like Helen Haskell, Patty Skolnik, Linda Kenney, Sorrel King, and Carole Hemmelgarn to name just a few. Their ability and willingness to turn personal loss into a life-long commitment to make care safer and of higher quality is quite inspiring…they are the true heroes of this mission.
The same holds true for Victoria and Armando Nahum who I was so fortunate to meet about two years ago. Over a period of 10 months in 2006, the Nahums had three family members stricken by hospital acquired infections, at three different hospitals in three different states, culminating in the death of their 27-year-old son, Josh. Like the families I mentioned above, they also turned their own personal loss into a crusade to reduce and hopefully eliminate hospital acquired infections by starting the Safe Care Campaign.
Last week at the Quality Colloquium, I moderated a morning long session on quality and safety at the bedside. Because patient partnership is a critical piece to any quality and safety mission, I asked Victoria and Rosemary Gibson, author and healthcare advocate, to be part of the panel and lead a patient partnership discussion with the audience. Both Victoria and Rosemary (as usual) were outstanding speakers, and had the audience fully engaged. However, during Victoria’s presentation, something truly special happened. Victoria shared the following video that she and her husband Armando created. Lke most in the auditorium, I had not seen the film before. The video delivered its message that morning in a unique and quite remarkable manner. Few times have I seen an audience as captivated at a medical meeting as they were last Thursday while we watched the Nahum’s two-minute film. The audience burst into spontaneous applause at the conclusion of the video, even though Victoria was still in the middle of her talk. It was an inspiring moment. The Nahum’s creativity and message captured us all that morning. Take a look for yourself:
The Nahum’s courage is powerful, and their message so very important if we are to escalate the fight to reduce risk and improve the quality of care providing to our patients. We need a greater sense of urgency around all of these efforts, especially at a time in the evolution of healthcare when competing agendas vie for attention and funding. Like Don Berwick, Carolyn Clancy and other healthcare quality and safety leaders who have inspired us to do better, patient advocates like Victoria, Rosemary, Helen, Patty, LInda and Sorrel are leaders who inspire us with their passion and commitment to help us get it right. It is encouraging to see them with a seat at the hospital conference or board room, as keynote speakers at national conferences, and included in hospital quality and safety improvement committees. How we thought we could do this important work without them still befuddles me.
Each new session of the Telluride Patient Safety Summer Camps, Dave Mayer and Tim McDonald share the Tears to Transparency educational documentary films — stories of harm that befell Michael Skolnik and Lewis Blackman–both promising young men–and the impact that harm had on their two families. As a result, Patty Skolnik and Helen Haskell (Lewis’ Mom) have dedicated their lives to changing healthcare for the better, and have become nationally recognized patient advocates. Through their new careers, both Moms have recognized the need to both “educate (and empower) the young”. The medical and nursing students and resident physicians who attend Telluride often have the opportunity to talk with both parents after each film in an open Q & A. Many students express this being a first exposure to the dysfunctional side of medicine. On the flip side, many also express having witnessed similar poor behavior by those entrusted with leadership positions in an academic medical environment.
Through the generosity of both Michael and Lewis’ families with the sharing of their stories, Telluride attendees are able to practice the difficult discussions focused on in the films in a place where open and honest communication is not only encouraged, but also modeled and set as the baseline. This also re-emphasizes the power of story to change behavior, and as a result, culture. Hopefully this sets a “new normal” for all Telluride alumni – a mindset they can take back to workplaces and educational systems where bullying or a lack of respect prevails and infuse new ideas. Or simply to carry these stories home in their heart, along with the power of the resulting discussions to further embolden environments where a just culture is the norm.
A trailer to the film, The Story of Michael Skolnik, played yesterday morning for our resident scholars is included above. We have been told more than once that the value of the conversations that follow these films each year are unmatched by anything yet to be experienced in the educational experience of health science students. The resident reflections on the Telluride blog today (found here) share some of the takeaways both The Lewis Blackman Story and Michael’s story have inspired this year. The theme from Michael’s story is “Can a conversation change an outcome? Can a conversation save a life?” Based on the enthusiasm for a new normal in Telluride this week, I am happy to report back that the answer to both questions is a resounding YES! When healthcare professionals and patients authentically share their stories and experiences it becomes contagious, inviting others to do the same. I’ve watched this yet again take hold in Telluride. Let’s take this idea viral along with the courage to do the right thing for patients, no matter how difficult, every time.
Patient and Family Advisory Councils – The Importance of the Patient Voice in Our Safety and Quality WorkPosted: November 26, 2012
Patient and Family Advisory Councils are forming in many hospitals across the country. Some institutions, like the Dana Farber Cancer Institute and Cincinnati Children’s Hospital have had “Patient Partnership” Council’s in place for over a decade, inviting the patient into healthcare decision-making and strategic planning, setting examples for those just starting the process. Aurora Health in WI, who received AHRQ funding to look at best practices around the formation of a Patient Safety Advisory Council for outpatient medication safety has provided guidelines for all to follow if they so desire to set up their own Patient Advisory Council.
But with many now rushing to engage patients, a few leading patient advocates have become a bit skeptical. Engaging patients is more than just addressing the call from the Institute of Medicine in their September report. It’s more than gathering people in a boardroom, serving lunch and feeling good about ourselves. It’s more than just checking the patient council box when the Joint Commission comes visiting. And it’s more than just asking patients about hospital room colors. It’s about true partnerships that define, and then measure, patient safety and quality improvement outcomes from projects that directly result from the time invested in these types of meetings. When done correctly, these partnerships become powerful and lead to positive changes in a number of areas. The culture of medicine is in transition, and like any industry, changing culture takes time, courage and the ability to take action outside our normal comfort zones.
This week, I had the great pleasure of spending time with a number of leading patient advocates – people who have devoted their careers to helping patients, caregivers and health systems better understand what is needed to lower risk and improve quality in patient care. Many are good friends and have been personal mentors to me through the years. People like Helen Haskell, Carole Hemmelgarn and Patty Skolnik, three remarkable women who continue to share their personal stories of loss so others can learn, and make care safer. People like Rosemary Gibson, Michael Millenson, Sorrel King and Victoria Nahum who have touched us all through their writings, educational materials and collective call for change. They have graciously agreed to help us at MedStar Health better understand and appreciate what terms like patient-partnership, shared decision-making, and transparency really mean to our patients. Their definitions and perspectives can be quite different at times from those I have thought were correct and published in the literature through the years. Many times I think I get it, only to realize that “I don’t know what I don’t know”. Tim McDonald, a good friend, mentor and patient safety leader, always likes to say we can be “unconsciously incompetent” when describing this phenomena.
We all met as a group last week, and the conversation took on a life of its own. With the advocates asking the tough questions, the conversation and discussions evolved organically and led to the open, honest discourse we all know is critical if real change has a chance to occur. Rosemary challenged the leadership in the room to measure our success by striving for the day when every healthcare provider working in our system was one that we as caregivers would refer a family member to – no hidden secrets on who we know is good, and who we would take our loved ones to for care. A second recommendation focused on outcomes data, and how to present it in a meaningful way–in a way that patients could truly understand, and then use it for decision-making. And more than one of our advocates implored us to create educational tools that patients could not only use to guide them through their hospital stay, but also make it clear they were a welcome and engaged part of the care team. Many health systems like MedStar already have different patient educational tools in place, but the group pushed us to think differently and be even more innovative in our approach to patient education.
The day ended with excitement around the different opportunities to create change right in front of us, and in fact, work has already begun on more than one consensus recommendation resulting from the meeting. We all look forward to the continued sharing of ideas with our council members, and graciously thank them for their insight and resolve to push us past our limits in the best interest of our patients.