KHC 2014 Summit on Quality

I attended the sixth annual Summit on Quality, in Wichita, Kansas, sponsored by the Kansas Healthcare Collaborative on October 17.

The morning keynote was given by Eric Coleman of the University of Colorado Anschutz Medical Campus. He spoke about the complexities of coordinating care when a patient moves from a hospital to a skilled nursing facility or returns home, and the need for clinicians to carefully consider barriers that may prevent patients from receiving the care they need or being able to perform their own care tasks. The afternoon keynote was presented by Craig Deao. He is from the Studer Group, which helps healthcare organizations to develop the leadership and organizational culture necessary to deliver high quality care efficiently.

During the first breakout session I listened to a presentation describing how the University of Kansas Hospital (KU Med) has changed their organizational culture and improved both their patient satisfaction and quality scores. For the second breakout session I choose the session presented by a team from Atchison Hospital in which they described how barcode scanning of medications increases safety, and how they were able to implement barcode scanning in the challenging environment of the emergency department.

There were also many posters presented by healthcare organizations in Kansas describing their safety initiatives, and several awards were given for leadership in delivering quality care.

It was good to see many speakers talking about putting the patient first. I was glad to hear Dr. Coleman say that patient representatives need to be a part of committees that explore changes to how clinicians and staff interact with patients. And I think it was very appropriate that the session on barcoding opened with two brief stories of patients who died from medication errors. But I also wish that the presenters went a little deeper and talked about times when mistakes were made, when things went wrong, and when patients were harmed. I realize that these are uncomfortable topics, but cheering for successes is not enough. The failures and breakdowns have to be seriously discussed. Not only is there is a great deal to learn from these incidents, but there is value in simply seeing examples of healthcare professionals talking about patient harm.

Patient harm is as real as the successes that were celebrated. I encourage KHC to consider how both can be discussed.

I also would like KHC to think about how they can incorporate patient stories and the patient’s voice into their work. I suspect that I was the only patient advocate at the meeting, or at least the only one who is not employed by a healthcare system. There was much talk at the meeting about patient-centered initiatives. But at this meeting the patient’s voice was not only not at the center, it seemed to be completely absent.


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