It has been five years since my father died. It took 3.5 years for us to learn what happened. In March my mother and I spoke publicly about this for the first time.
My family has started working with the Collaborative for Accountability and Improvement. They work to help hospitals to establish Communication and Resolution Programs (CRPs) for responding to patient harm in ways that promote healing, learning, and accountability.
This video was filmed at a training session at Lakin, Kansas. My mother and I gave the first presentation at this event.
If you are interested in an effort to use the stories of patients and their families to improve healthcare, take a look at the website for the Patient Voice Institute. This is a great way to bring attention to what works well in healthcare and what needs to change. I encourage you to spend some time reading about these experiences. Our story is included.
I was at the Kansas Healthcare Collaborative (KHC) 2015 Summit on Quality two weeks ago. During the presentation on the Kansas Hospital Engagement Network I learned something disturbing: many hospitals throughout the country agreed to a goal of reducing preventable patient harm by 40% by the end of 2014, as compared with 2010 levels. This goal was set by a program called Partnership for Patients from the Center for Medicare and Medicaid Services (CMS).
Let me state that again: the GOAL — the target that hospitals are striving for as they serve the community — is to reduce preventable patient harm by 40%. I was not aware that harm comes as a mix of acceptable harm and unacceptable harm and the concern is getting rid of the unacceptable portion.
But if hospitals are striving for such a goal, I simply ask that they fully explain this to patients and families. And to help, I would like to provide some ideas for facilitating this communication. Continue reading
I strongly believe the term “second victim” needs to be abandoned. I suspect this term serves a purpose in making the topic of medical errors more palatable to healthcare workers. But I don’t think the choice of words is appropriate. I hope I can explain why. Continue reading
A newspaper in my mother’s town ran an article announcing that the emergency room received a Women’s Choice Award and was “among America’s best hospitals for emergency room care”. I was curious about the award, so I looked into this. I am sharing what I learned because it is an example of how publicly available hospital performance datasets can be used to mislead and misinform healthcare consumers. Continue reading
We had a good amount of interest from the Kansas legislators about our bill to require disclosure of unanticipated medical outcomes and harmful medical errors. But it didn’t receive a committee hearing this 2015 session, so the bill is on hold until January 2016.
(And I just realized I haven’t posted anything for three months. I attribute that to the current phase of my life: just-finished-PhD-and-now-looking-for-job.)
My mother had several productive meetings at the Kansas Statehouse this week. Our (slightly revised*) bill should be introduced into both the House and Senate in the next few weeks.
Here is the one-page handout I created that summarizes why the bill is needed. It also answers several commonly asked questions.
* In an effort to focus our bill on the topic we care about most (requiring disclosure of unanticipated medical outcomes and harmful medical errors), we decided to drop the section that provided “apology protections”. If another group wants to argue for that, we will leave that task to them.