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Idea Three: Put a Face on the Problem,
Starting at the Board
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Patient stories, especially stories about harm, are a powerful
way to engage the hearts of Trustees in quality and safety
issues. An emerging “best practice” for Boards
is to hear the stories of patients and families on a regular
basis, perhaps at every meeting. This primer is intended
as a practical guide to Boards on how to bring patient stories
into their regular agendas. Four methods of bringing patient
stories forward are summarized, beginning with the easiest
and least controversial, and progressing to more difficult,
but perhaps more powerful methods.
If none of these has been a regular practice of your Board,
it is strongly recommended that you take action to implement
at least one of these methods within the next few months.
1. Brief story told by staff
This method can be used at
any meeting, and its principal purpose is to
illustrate a data element that the board
will be reviewing as a part of the meeting.
The point is to make
sure that the board viscerally understands
the personal impact of a safety defect such as a central
line-associated
bloodstream
infection or a decubitus ulcer, rather than
just seeing a run chart of rather abstract data.
The story should be told briefly, without too much
technical detail, in plain language. It can
be told by any of the
staff who usually attend the Board or Board
Committee meeting. Following is an actual example of such
a story as told
to
a Board Quality Committee
As you know, we spend the first 5 minutes of
every meeting with a brief story about
a patient’s care. The purpose
of these stories is to illustrate the
sorts of things that can go wrong in care, so that
you can have a better understanding
of the data that we show you about quality
and safety mishaps at these meetings. It is not our
purpose in telling the story
that the Quality Committee should work
on coming up with solutions to these kinds of problems,
or get into lots of
detail about any one patient’s
experience.
Just to remind you, we don’t
use the names of patients, family, physicians
or staff
in these
stories.
Today’s patient story is
about a 79 year-old woman who came in
to our hospital with congestive
heart failure,
or CHF. Shortly after admission, she
was placed on several medications and treatments
for her CHF. One of the medications
(a beta blocker) was prescribed in a
fairly strong dose—perhaps
more appropriate for a younger person.
Our systems—pharmacy,
nursing, computer order entry—didn’t
detect that the dose was too strong for
an elderly woman. Over the first
12 hours in the hospital, as the medications
took
effect, her blood pressure dropped lower
and lower (a side effect of the medication).
During
that
12 hour period,
there were several “handoffs” of
responsibility for this woman—from
one nursing shift to another, and from
one physician “shift” to
another. The team caring for her was
busy caring
for lots of
other sick patients.
In the midst of all this, concerns about
her falling blood pressure were not transmitted
from one shift
to the next.
Her BP eventually reached such a low
point that the patient was in shock,
and she
went
into cardiac
arrest.
A code blue
was called but was unsuccessful, and
the patient died 15 hours after admission.
The slide on the screen is the current “run chart” for
mortality rate at ____ Hospital. This woman would have been
one of the deaths—perhaps a preventable one—that
occurred during this month here—November—and
is an example of the sort of issue that we’re working
on when we say we’re trying to reduce “preventable
deaths” at ____ hospital. Not all
deaths are preventable, obviously, but
this one probably
was.
Any questions before
we go on with the quality report, in
which we will discuss our overall strategy
for reducing
the likelihood
of these
sorts of preventable deaths?
Important elements of such stories are:
•
It’s a story about harm that occurred in this
hospital, not some other hospital somewhere in
the country.
•
The story is recent, not from years ago (so no one can claim “We
used to have that problem but now it’s fixed.”)
• The story illustrates systemic issues, rather than individual
negligence.
• The story is scripted, as above (actually written out)
• The story is directly relevant to data being reviewed
by the Board or Committee at that meeting.
2. Short video tape of a patient or family
member telling about an experience.
Another way to bring patient stories
to the Board is to do a videotaped
interview of
a patient or
family
member, after
a harm event. The focus of the interview
is to understand the effect of the
harm event in personal,
and to transmit
the visceral impact of the event
to the Board. The videotape can also illustrate
an element
of the safety
data that
the Board is overseeing. There are
two basic questions in the
interview
• Tell
the story of what happened, as you experienced
it.
• Tell us how what the
impact of this event has been
on your life.
This
method requires more advance work from hospital staff.
Interviewees must
be selected,
the interview
scheduled, the videotape must
be edited, and so forth. But
these
tapes
can
be very powerful mechanisms
to “activate” a
Board on issues of quality and
safety.
Example: Before the annual Board
retreat, hospital staff interviewed
the husband
of a 71 year-old
woman who had
experienced a surgical site
infection after a knee replacement. The
husband described how they
learned of the
infection, the prolonged pain
and poor physical
function
that
resulted, the
uncertainty and fear, and the
draining, constant demands
on the caregiver
(the husband). He ended the
interview with “…and
the worst part was that I was unable to plant our garden
this year, because I was so busy taking care of all these
other things for her. It’s the first year in our 49
years of married life that I haven’t planted the garden.
It’s been my pride and
joy, but not this year.”
And then the Board went on
to discuss the data for the
hospital
on surgical
site
infection rates, and
engaged
in a vigorous
conversation with medical staff
leaders and administration
about what was
being done
to
reduce such infections,
with a far greater sense of
urgency than prior to the video.
3.
Commissioned “deep dive” interview
of a patient or family member
after a serious harm event
In this method, the Board asks
the CEO, along with one or
two key Board
members,
to do
a personal
interview with the
patient and family members
involved in a recent serious
harm event,
and also
to conduct
similar
interviews
with
the nurse(s),
pharmacist(s), physician(s)
or others who were directly
involved
in the
event. This
process
might take a few
weeks to complete,
after which the Board will
ask those who did the interviews
to present
a report to the Board,
followed
by a deep
discussion of the implications
for the Board.
This process has two purposes.
One purpose is to catalyze
the personal
transformation
of CEOs and
Board leaders.
Simply stated, most human
beings cannot participate
in this
difficult, painful interview
process and
emerge unchanged. The second
purpose is
to
provide an opportunity
for the
Board to
develop a much deeper understanding
of the cultural and systemic
forces that lead to tragedies.
How? The process is simple
to describe, difficult to
execute. The steps include:
•
The Board must “commission” the deep
dive. This can be initiated by the CEO,
or by the Board, but it is a
formal request of the Board.
• The
Board must designate its representatives in the process (usually,
the Board Chair
and the Chair of the Quality Committee, if there is one)
• An
event must be selected (it is best if this is an preventable,
serious, recent harm event)
• Patient
and family permission must be obtained
•
Staff members and physicians at the “sharp end” of
the event must be contacted
and scheduled for interviews
• Interviews
must be conducted (these are often emotionally laden, and
must be focused
on listening to those being interviewed for two principalelements: content
(what happened) and emotion (how do you feel about what
happened.)
• A
meeting of the Board should be devoted to hearing and discussing
the report of those who did
the interviews, and translating any lessons learned into improvements
of the system.
4. Full Board conversation with a patient or family
member
In some circumstances,
the Board might wish
to invite
a patient
or family
member to meet
with
the Board
itself, so that the
Board can hear directly
about the patients’ view of
what happened, and how it has affected them. This is obviously
a very difficult moment for the Board, especially if the
event involves preventable death or permanent injury, and
if liability risk is involved, as is often the case. But
such meetings can be extremely important to the evolution
of the Board’s understanding of the issues faced by
the organization, and can also be a vital first step toward
healing of the breach of trust and confidence that these
sorts of event represent to patients and families. One key
outcome of such conversations is that patients or family
members would say: “The Board listened to me, and is
committed to take steps to ensure that this won’t
happen again.”
There are no good scripts
for how to have such
meetings, but there
are some
excellent
guides
to medical apologies
that should imprint
the conversation, such
as
the Harvard Risk
Management
Foundation’s
approach.
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