He collapsed at school by his locker, just 11 years old. After 9-1-1 was called, the EMTs arrived and began CPR immediately. He was brought to our emergency department and we did everything we could — IVs, ventilation, sympathomimetic drips — but nothing worked. We couldn’t save him. The attending physician declared him dead — calling the code and noting time of death — as we, without a moment’s hesitation, stepped back into the noisy mix of an overcrowded emergency department.
Shaken — as I’ve been after every pediatric death I’ve ever witnessed as a nurse — I emerged into the hall to encounter another child’s livid mother, who’d stood outside the resuscitation room for 20 minutes waiting for a nurse to bring the medication her otherwise healthy child needed to be discharged from the hospital.
Under the hailstorm of her words — I was slow, I didn’t care, this hospital was crap — I felt not even an ounce of empathy. Wordless, angry, I retrieved the meds, administered them, and all but threw the discharge papers at the mother.
No excuses here: It was ugly, unkind, and unfair of me to treat this mother with such an edge. I still regret it.
That is often our world in emergency care. As nurses and physicians, we rush from room to room, family to family, crisis to crisis, expected to immediately let go of what just happened in one room and be present with the patient before us in the next.
And isn’t that what patients have a right to expect? Shouldn’t patients expect that their nurse or doctor is in a frame of mind that enables them to be authentically attentive? But how in the world can we provide the safest care if we ourselves are in tatters? There’s a sad truth here: We are not paid to be present. We are paid to get work done, no matter how impossibly sad, messy, or tragic that work is. And never does there seem to be enough time.
In the years since I moved from working in a trauma center in New York City to doing research at the University of Virginia, memories of that ER stay with me. Now, I’m studying an intervention that, while not a fix-all, may help prevent injury to patients and providers — it may even save lives. In hospitals on four continents, what we call “The Pause” has become a standard of care.
Here’s how it works: When a patient dies, any member of the care team tending him calls out for a pause. They might say something like, “Can we stop for a second to consider this person who’s died? They loved and were loved. They were someone’s friend and family member. Just for a minute, in our own way and in silence, let’s take a moment to honor this person and the efforts we each made on their behalf.”
The group is then silent for about 45 seconds. It’s personal, optional, and simple.
Preliminary results from our investigations have found “The Pause” is a boon to both healthcare teams and patients. Caregivers who practice it report a stronger sense of collaboration with the health-care team in moments of intense stress.
What’s more, providers consistently report that when they pause — no matter what they choose to do during those 45 seconds — they feel more grounded and ready to interact with their next patient or family. They feel more present.
Cited by the Schwartz Center for Compassionate Healthcare and the American Association of Critical-Care Nurses as a tool to elevate quality health care, this “Pause” keeps spreading. In short order (roughly the time it took you to get through the third paragraph of this commentary), health-care providers are finding they’re better grounded, and ready to face what’s next.
Pausing to breathe and reflect is nothing new, but encouraging caregivers to pause to honor a patient and a health-care team may be. “The Pause” may provide a compassionate edge toward better care for all of those involved. I wish to this day that we had paused at the end of the 11-year-old’s life, to honor him, ground our team, and prepare ourselves to face what would come next.
It would have helped me be much kinder to the next mother, her child, and the rest of the patients I treated that day.
Tim Cunningham, RN, DrPh, is director of the Compassionate Care Initiative at the University of Virginia School of Nursing. To read more about The Pause visit: thepause.me.
Hospitals cannot improve the patient experience without listening to — and acting on — patient feedback, Peter Pronovost, MD, PhD, senior vice president for clinical safety at Minnetonka, Minn.-based UnitedHealthcare, said in a 2015 blog post for Baltimore-based Johns Hopkins Medicine’s Armstrong Institute for Patient Safety and Quality.
Dr. Pronovost formerly served as director of the Armstrong Institute and senior vice president for patient safety and quality at Johns Hopkins Medicine. In this role, he worked with Jane Hill, Johns Hopkins’ patient relations director, to compile “patient wish lists” based on the most common pieces of feedback the hospital received from patient letters or surveys.
While the two leaders developed an overarching patient wish list for the health system, Johns Hopkins’ Patient and Family Advisory Councils also created individual patient wish lists to speak to their own patient populations’ specific needs, a spokesperson for Johns Hopkins Medicine told Becker’s Hospital Review.
Here are 10 things the parents of pediatric patients said they wanted from clinicians during a hospital stay, as compiled by the Pediatric Family Advisory Council for Johns Hopkins Children’s Center.
1. Meet our basic needs. Parents want to be oriented to the hospital once their child is admitted. Clinicians should inform parents where they can get food, how to pay for parking, when visiting hours are, etc.
2. Let us see you wash your hands. Parents worry about germs in the hospital. Clinicians can demonstrate they are dedicated to keeping a pediatric patient safe by washing their hands in front of the patient and his or her parents.
3. Introduce yourself before you start speaking. Parents want to know who clinicians are and how they will be involved with their child’s care as soon as they enter the room.
4. Communicate, communicate, communicate. Parents are always waiting for updates from clinicians and want to know as much information as possible. Parents plan their day around the times they get to speak to providers, so clinicians should let them know if they’re delayed.
5. Know my child’s entire medical history. Parents want clinicians to be as well-versed about their child’s medical history as possible.
6. Be present when you are with us. Parents want clinicians to take the time to answer their questions and outline a care plan for the day. They want to be involved in the planning and discussion of their child’s healthcare goals.
7. Tell us when there is downtime. A patient’s loved ones don’t want to leave and miss something important, so providers should inform them of opportune times to get food, take a nap, etc.
8. Answer the call bell. Parents want clinicians to promptly answer their calls and come to their child’s room as soon as possible.
9. Clean our room. Hospital rooms become a patient and family’s home away from home, so clinicians should help them keep the space clean.
10. Recognize sleep is precious. Clinicians should let pediatric patients and their families sleep whenever possible and group medical tasks together, especially overnight, to avoid regular disturbances.
– When a patient visits a hospital, she has the expectation that she will be treated with empathy, respect, and clinical excellence. At the core of each of these elements is the understanding that she will be safe. But all too often, the promise of patient safety isn’t upheld.
Adverse patient safety events and medical errors are the third leading cause of death in the United States, according to a 2016 report in the British Medical Journal. A separate 2017 survey from NORC at the University of Chicago and the IHI/NPSF Lucian Leape Institute found that 21 percent of patients experience a medical error.
To be fair, the US has seen a decline in adverse patient safety events in recent years. A 2016 report from HHS and the Agency for Healthcare Research and Quality (AHRQ) showed that between 2010 to 2015, approximately 125,000 fewer patients died due to avoidable hospital-acquired conditions than in years previous.
But just because fewer patients are experiencing preventable patient safety events does not mean that the job is done, according to Gary Yates, MD, a strategic consulting partner at Press Ganey and patient safety expert. Healthcare organizations must strive for zero preventable patient safety events because patient safety is a foundational element of a positive patient experience.
“Patient safety is fundamental to the promise we make to patients,” Yates told PatientEngagementHIT.com in an interview. “We like to think of the patient experience as being the convergence of quality, safety, and the experience of care.”
“When patients come for care, they expect that harm won’t come to themselves or their loved one,” Yates continued. “They expect us to deliver the highest technical quality care, and they also expect us to treat them with dignity and respect, and that care givers will approach them with empathy and understanding. Safety is a fundamental component of the overall patient experience.”
In fact, patient safety is so important that it tends to take up most of patient mindshare. Even when a health system delivers technically excellent and emotionally supportive care, one preventable harm can mar the entire patient experience. The patient will likely not remember any of the positive qualities of the healthcare encounter.
Healthcare organizations must set patient safety as a top priority. This will require an all-in commitment across hospital leadership and staff, Yates said.
“In order to prevent harm, in order to really make progress towards the goal of zero harm for patients, it requires an organizational commitment,” he explained. “That commitment includes a tightly aligned board, senior operational leaders, and senior physician leaders, all committing to what some would consider an audacious goal, but the right goal, which is a goal of zero harm to patients.”
That strong leadership, paired with a culture of safety, can help deliver on the goal to eradicate preventable patient harms, Yates said. Once organization leadership has bought into the goal of true patient safety, it is important that they include patients in obtaining that goal. After all, patients have a significant role to play in supporting patient safety efforts.
“The organization needs to invite patients and families into the conversation to help create an environment where they can truly be partners,” Yates stated. “Organizations can provide education on ways that patients can participate and encourage them to speak up, understanding that some patients and families may be reticent to speak up or ask questions to providers.”
Healthcare organizations are inviting patients and families to serve on patient advisory councils (PACs) more and more, Yates sad. Patient and family stakeholders are also being asked to sit on operational committees and some board committees. This is an essential part of integrating the patient voice into hospital improvement efforts.
Although patient and family advisory councils are becoming increasingly common in healthcare, there are some hospitals that have not jumped on board.
“Some hospitals and health systems are still reticent to robustly include the voice of the patient,” Yates pointed out. “There may be concerns that input from the patients might be a distraction for the organization. There may be concerns about confidentiality. There may be concerns just because it’s a change.”
However, those hospitals participating in PACs outweigh those who may be excluding patient sentiment. The insurgence of PACs in clinical and organization improvement are setting a good example for hospitals just beginning to consult the patient voice.
“The good news is that there are organizations that have successfully implemented initiatives such as patient advisory committees and are continuing to push the envelope,” Yates asserted. “There’s a wealth of experience in how to select patients and families for participation on operational and board committees, how to vet potential members, and how to onboard and educate them so that they are effective in their role and the organization’s comfortable with their role.”
Having a patient in the room is essential for changing the culture of safety. Healthcare organizations cannot properly serve the patient if leadership does not know how the patient wants to be served and which processes could best bring comfort to the patient. Understanding how patients and families need to see patient safety initiatives implemented is key to making programs successful.
“The conversation is just different when a patient is in the room,” Yates noted, quoting his peer Jim Conway, who previously served as the COO of Dana-Farber Cancer Institute.
Incorporating the patient into patient safety initiative goes beyond organizational improvements. Clinicians themselves need to be more inviting and allow the patient to participate in their own care. A patient who is engaged in care can serve as another check on patient safety protocol. This relationship works best when the patient is empowered to participate in care.
“One of the challenges to creating a true culture of safety in healthcare is dealing with the hierarchy gradient,” Yates said. “A hierarchy gradient exists when, in any relationship, one individual perceives themselves to be in a lower position of power than another individual. When the power gradient is large, then it’s unlikely that the person who perceives themselves as being on the lower end will be willing to speak up.”
Patients often perceive themselves on the lower end of that hierarchy gradient, and healthcare organizations are working to change that. The same strategies organizations employ to create clinical teamwork – communication, care coordination – can help integrate the patient as a part of that care team, Yates said.
The onus is on the clinicians to create a welcoming environment in which a patient feels she can participate in her own care and her own safety.
It could be difficult for a patient to ask a provider if he’s washed his hands before an exam. Clinical team members need to create a culture that gives the patient the confidence to do so.
How a care team interacts with the patient, greets her, demonstrates empathy, invites her to ask questions, or invites her to comment on aspects of clinical care are all important things to do, Yates said.
Healthcare organizations can also use various signage to reinforce that notion.
Ultimately, the provider needs to reach out to the patient and incorporate her into the care them. Clinicians who educate their patients, give them context to participate in clinical decisions, and treat their patients as members of the care team will help create a culture of health.
“One of the best ways to manage the authority gradient and minimize power distance is when the party that’s perceived as being in the higher power position invites others to participate and welcomes questions,” Yates explained. “It helps to set the tone and helps to create an environment where individuals are more likely to contribute.”
Although organizations should be working toward zero preventable patient harms, there will be missteps along the way, Yates acknowledged. Most healthcare organizations see some adverse patient safety events annually. The key is understanding how to interact with the patient following one of those adverse events.
“It’s important for hospitals and health systems to do a good job with disclosure and apologize as appropriate,” Yates advised. “Establishing an atmosphere where we’re transparent with patients when things go wrong is critical.”
Transparency is not only important for engaging patients and doing right by them when something does go wrong; it’s also important for the purposes of overhauling the culture of safety, Yates said. Being apologetic when appropriate is important for the patient-provider relationship and also important for clinical quality improvement.
“It allows for us to engage patients in helping us understand how we can improve going forward,” Yates concluded. “Being honest with the patient about what happened, apologizing as appropriate, and communicating with them about actions that are taken helps to assure patients that the underlying causes of what might have affected that patient or her loved ones is something that the organization is addressing to prevent it from happening to another patient.”
In 2002, my then 55-year-old father went to his doctor because of a severe headache. He was diagnosed with sinus infection and was given a nasal spray and sent home. His headache worsened into “the worst headache of my life,” and so the following day, he went back to his doctor. He was again diagnosed with sinus infection but this time he was prescribed with an antibiotic before being sent home.
After two days, my mother saw my father crawling on the floor. He could barely move or talk. He was rushed to a local emergency room where he was correctly diagnosed with a ruptured cerebral aneurysm, or a bleeding artery inside his brain. He was airlifted to Barrow Neurological Institute in Phoenix, Ariz., where a renowned neurosurgeon successfully performed an emergency brain surgery to stop the bleeding. After a few weeks in the ICU and rehab, he was discharged home. He survived and regained his health. Many patients, however, are not as lucky as him.
In fact, a quarter of a million people die each year as a result of medical error, which includes misdiagnosis or delayed diagnosis, improper or delayed treatment, inadequate monitoring of treatment, medication administration errors and improper surgical technique. It’s the third leading cause of death in the U.S. To put this into perspective: More people die as a result of medical error than the combined total 2015 deaths due to diabetes (79,535), influenza/pneumonia (57,062), suicide (44,193), and motor vehicle accidents (32,000).
The issue of deaths due to medical error has been an elephant in the room at least as early as 1999. That year, the National Academy of Medicine released the now famous To Err is Human report, which found that “health care in the United States is not as safe as it should be — and can be” because of preventable medical errors.
To Err is Human concluded that majority of medical errors “do not result from an individual recklessness” but are caused by “faulty systems, processes, and conditions that lead people to make mistakes.” The report’s recommendations thus focused on strategies for improving patient safety at national and hospital levels. These strategies included creating mandatory and voluntary reporting of medical errors and raising medical provider performance standards.
However, almost 20 years after To Err is Human was released, at a time when the U.S. has the most advanced technologies in medical care and arguably has the best quality of health care in the world, thousands of people are still dying not because of their medical condition but because of the medical care they received — or didn’t receive.
Patients can help prevent medical errors by being vigilant about their own medical care. If you have been diagnosed with a medical condition, ask your doctor about other medical conditions that could explain your signs and symptoms. Ask your doctor what’s the worst-case diagnosis and why it isn’t the diagnosis in your case. Ask questions about the medication you have been prescribed or are about to be given to make sure it’s the right one. Follow up on your lab or imaging results. Don’t assume that your test results are normal if your doctor didn’t call you. And know that doctors can make mistakes; they’re only human.
Dr. Michael Vinluan is the medical-legal consultant for The Law Office of Barry R. Glazer. You can reach him at email@example.com.
Listen to Peter Pronovost talk about medical errors, check lists, putting possibility above limits, having a humble and curious culture, solving problems regardless of the system, creating connected communities and more… Believing and Belonging | Peter Pronovost | TEDxBeaconStreetSalon
Published in the University of Delaware -The Review, March 8, 2016. http://udreview.com/human-error-plagues-hospitals-speaker-says/ – In January 2001, 18-month-old Josie King was admitted to the Johns Hopkins Hospital as a result of suffering third degree burns from a hot bath. Within weeks she healed and was scheduled to be released. Two days before Josie was scheduled to go home, the young toddler died as a result of careless human medical error…
Published in: Not Running A Hospital
Written by: Paul Levy
4/29/2015 – I recently attended an Oslo meeting of the Dr Foster Global Comparators, an international group of hospitals that have been working together to share data and insights related to quality and safety. What makes the group particularly interesting is their attempts to draw comparisons across national boundaries. This is no easy task, given the different manner (and for different purposes) in which countries collect administrative and clinical data; but the group has made good progress in several areas—notably GI, stroke, sepsis, and orthopaedics. At this session, I met committed and interesting folks from the UK, US, Denmark, Norway, China, Saudi Arabia, the Netherlands, and Australia.
While all the presentations were engaging, the one that most intrigued me was one offered by two surgical fellows from Imperial College, Christopher Nicolay and Stephen Williams. As I understand it, Christopher conducted much of the original research, and Stephen is now going to pick up on it and carry it forward. I’ll just present a quick outline here, as I’m confident they will formally present the results elsewhere, and I don’t want to steal their thunder.
The session was entitled, “The healthier your hospital the better your outcomes.” The hypothesis being tested was whether there might be a correlation between organizational health and clinical outcomes. The fellows first drew on the literature to help think about the elements of organizational health in hospitals. An initial definition by Chris Argyris (1958) set the stage: “A healthy organization is one that enables mature human functioning.” Then, a quote from Christin Shoaf et al (2004): “Organizational health blends the pursuit of individual wellness with organizational effectiveness to yield a strategy for economic resilience.”
Using interviews with many folks, a thoughtful model was derived for assessing organizational health for 22 acute care NHS trusts in the UK. Those assessments were then correlated with patient outcomes like mortality rates and critical incident reporting. Sure enough, there was a positive correlation.
While we’ll all look forward to the formal publication of these results, I can already predict two reactions to this kind of study. The naysayers will say that the concept of organizational health is just too fuzzy to quantify, much less correlate with measure of clinical outcomes (which, they will also say, are themselves too uncertain to use and rely upon.)
Others of us who have run hospitals, visited others, and studied others have seen that the quality of the work environment inevitably has an impact on patient outcomes. An organization in which staff wellbeing, effective communication, resilience, efficiency, and servant leadership are extant tends to be very good as a learning organization and tends to be more alert to the needs of its patients and more adept at clinical process improvement.
Stephen’s next step is to try to extend the research across national boundaries and investigate whether similar patterns might show up around the world. Congratulations to these two young men for taking on this topic and helping us gain deeper insights into the matter.