More Great Advice from Nurses

Hello again-

The rejuvenating tips from nurses on how to cope with work-related stress keep rolling in. I just wanted to share the latest bits of advice with you.
Keep ’em coming! Keep spreading the word about this project!
-Sorrel
“I de-stress by dancing at least once or twice a week. I love dancing – it is something that helps keep me sane and gives me something to look forward to outside of work. One tip for work stress: Don’t take things personally. If a patient/colleague/family member/MD snaps at you, it’s not you – they are stressed out too. I find laughing defuses the situation – it helps them relax. It also prevents me from getting angry – which would just escalate the situation. Yeah, don’t take things personally is the best advice I’ve been given. I also vent to my nursing colleagues – it helps to know that other people are sharing your pain.” – C. Rae
“Take a moment everyday to reflect on what went well, what didn’t go so well, and what you can do better tomorrow.
Always take a moment to take a deep breath when the world is moving quickly by you and you can’t keep up. Who knows your speed might be what everyone should be moving at throughout the day.
Baking fresh treats for your co-workers is the best medicine and always makes a nurse’s day brighter.” – Sheryl C., RN, MSN, Washington, DC
“I find that in order to care well for others, I must first take care of myself. Without my health, I wouldn’t have the strength to perform the hard work nursing requires. Daily exercise and good nutrition are essential to helping me cope with stress. I love group fitness classes, weightlifting, and ‘clean’ eating!
I also set aside one night a week to relax and have a date night with my husband.” – Kathryn A., BSN, RN, South Lyon, MI
“As a NP I try to remember to always thank everyone for helping me to help my patients. It really is a group effort. And thanking people is a great way to defuse stress as it makes people feel appreciated. Surprising the staff every once in awhile with cookies or another treat goes a long way to making people feel appreciated. Praying with patients and staff is a great way to lessen stress.” – Kimberly B., MSN, CRNP, Pittsburgh, PA
“I know that it sounds sappy but…I try to appreciate all the good things, my family, my health, my job, etc. I don’t want to be in the position (like some of my patients and families) of having regrets (the could of, should have syndrome) in life. I am not waiting for retirement to care for myself, to tell my husband or children that I love them, or to just be in the moment. Life will probably always be too short but my glass is more than 1/2 full.” – Maureen
“I find good friends to be the best stress relief. I love my coworkers and we go out regularly to debrief about work and personal lives. I also value my non-nurse friends that I don’t talk about work with. They help me remember there is more to life.” – Anonymous
“We go through so much each day. I have been a nurse for many years, most in the Baltimore area. What really helps me is thinking about how the families and patients feel, particularly after losing a child. Sometimes we get so wrapped up in the technology and what we have to get done each shift. However, when I start feeling that way, I think, if this was my family, how would I feel and what can I do to make it better. That is how I cope.” – Joanne M., RN, MSN, NE-BC, FABC, Newark, DE
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Nursing Project Update

Thank you to all of the nurses who sent us their words of wisdom on how they deal with work-related stress. We are compiling these tips into a toolkit specifically for nurses. This project is under development.

Below this note are some of the great comments we have received. Please take a look. I hope you find them as helpful and inspirational as I do. Please, please keep the comments coming and spread the word to other nurses who many have a helpful tip they want to share. Remember, you can post your advice directly on the blog, or you can send an email to nursing@josieking.org.
Thanks, too, to everybody who has helped us spread the word about this project. Your efforts are really making a difference!
-Sorrel
“Having spent most of my nursing career working in Adult ICU, I find that staying ‘grounded’ literally helps keep me sane! I like to spend time outdoors – whether trout fishing on a beautiful stream or lake, working in my yard or garden, or just taking a walk really helps puts things in perspective. I especially find sharing time and talking with my family helps maintain balance.” – Tamma
“I think my staff is just the greatest. When our work life becomes very challenging I like to have lunch with the staff and catch up on what is happening in their home life. It does help maintain balance. We have mini “Lunch and Learns”; we lunch and learn that life does not have to be all serious.” – Mary Ann, Pittsburgh, PA
“One of the things that I feel has the most impact on helping nurses to cope with the everyday stress is the fact that we are a team of professionals and when push comes to shove, stand together and help each other – basically we are each other’s counselors. We openly discuss our feelings with our co-workers and cry together while giving each other hugs and letting each other know we are here and that we all understand what each other is going through. That kind of support is not felt in many other professions. We are a team of support and care for all!” – Tracy N., RN, BSN, MSN, Pittsburgh, PA
“Learning to de-stress, by spending time with my daughters or just me by reading a good book or going for a run with my dog. In my dream world every healthcare facility would have a gym and a massage parlor to help encourage all healthcare workers to take a moment to de-stress so we can think clearly.” – Kimberley S., RN, Ontario, Canada
“I try to look for the humor in an otherwise difficult situation, to make myself laugh and others laugh, and to remind us all to not take ourselves TOO seriously. Laughter IS the best medicine and a unifying force in the midst of stress.” – Sue
“I’m an optimist and try to maintain that optimism while working in a ‘negative’ or stressful environment. I like little quotes that I can hold onto. Sir Winston Leonard Spenser Churchill states, ‘A pessimist sees the difficulties in every opportunity, an optimist sees the opportunity in every difficulty.’ Thoughts like Churchill’s keep me going. Here is another one: ‘In order to succeed, your desire for success should be greater than your fear of failure,’ from Bill Cosby.” – Laura S., Lewes, DE
“I love to sew- especially baby quilts or crafts. While I’m sewing, I’m thinking about the new baby- and am always amazed by the miracle of new life and I know I have the opportunity to touch ‘life’ while I work. I am filled with wonder!” – Anonymous
“As a pediatric nurse, some days are definitely better than others. When the stress seems like it has taken over my life some strategies I use to cope include; having a good hearty belly laugh in the company of good friends, taking a trip to the playroom for some BINGO with the kids during a break, and remembering to step back for a minute to remember WHY I am a nurse and what my purpose is.” – Alicia
“I recently started beading and I love to see what my imagination can create. I also have done scrapbooking for many years. I love to recall the memories of the event. I have recently been asked to teach scrapbooking to middle school age children who attend after school activities programs.” – Lori
“I started exercising. Now to burn off stress, I run. In fact, I am running my first 5k this spring. I am also a bit (45 lbs) lighter, which is great, too. I feel so much better now that I have consciously taken my stressors off of me.” – Elizabeth, Michigan
“Exercise always makes me feel best – I love riding my bicycle and get together with a co-worker that lives close by. We’ll get together and chat and ride at the same time. I belong to a hiking/biking group. If I can get to a hike or ride once a week, I’m happy. The rest of the time is spent walking my dog when I have time to get out.” – Dorothee K., Pittsburgh, PA
“I think stress relief depends on the energy needed to be expelled or reversed.
When I need to de-stress and calm down, walks in the forest and on the beach of Lake Michigan can be the best (especially with the dog). Other calming activities have included yoga, reading a novel by the fireplace, and cooking with family/friends.
The other spectrum, of energy “release” needs, can be best met by a workout at the gym, working in the yard, cleaning the car or the garage, and my favorite of all, is going out after work with a fun group of friends for munchies and cocktails (try to do that every couple months!).” – Todd K., RN, Holland, MI
“As a pediatric nurse working in ICU and the Peds ER for over 25 years I have seen more than a lifetime’s share of tragedy and sadness when children are severely injured or killed. I have found peace in the ability to return to work to face another day only through the faith I have in God. I try to pray every day. I especially pray during a code – for the doctors and nurses administering care to the child, and for the parents. I found taking a walk or a drive and being quiet with God allows him to minister to my heart and heal me.” – Ann D., RN, Copiague, NY
“My faith has carried my through my nursing career for 30 years and it has never failed me. Surrounding myself with my family and a few close friends has also been very important in coping.” – Sandy
“I cope by listening to those who trust me enough to share their pain. Just by having someone open their heart to share the pure emotion, all of my stress seems to melt, and I find myself feeling very thankful and at peace with my life.” – Anonymous
“Personally, I make sure I stay in contact with those I love the most during the week. My children and grandchildren all live out of town. A phone call to any one of my grandchildren always lifts my spirits. Their energy is contagious, even over the phone.” – Kathy, Harper University Hospital
“I take my dog on a long walk and then once home drink a large glass of ice water to flush out any remaining stress hormones.” – Shelley, RN, Pittsburgh, PA
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Needed: Advice from Nurses

I need your help. We’ve been struggling with something here at the Josie King Foundation. Here’s the deal: we are creating a toolkit for nurses, something that will help nurses cope with the stresses of the job, something that will make their days a little better, something that will let them know how much we appreciate them. I know lots and lots of nurses. I’ve seen them at work in hospitals around the country. I’d like to think that I sort of have a notion as to what it must be like to be a nurse, but the truth of the matter is- I don’t REALLY know.

So, I am asking all of you wonderful nurses to help. Here’s what I’m looking for: quick tips on how to cope with the challenges of being a nurse. What do you do that helps you do your job well? What have you discovered that helps you deal with stress? It could be anything like:

  • “Once a week I buy fresh flowers to put in the nurses’ snack room.” – Sandy K., RN, Grand Rapids, MI
  • “When I come home after a long day on the job, I like to bake cookies with my eight-year-old.” – Sue S., RN, BSN, Tampa, FL
  • “I just started walking for forty minutes every day with my neighbor. It really helps clear my head, and my jeans fit a little better.” – Tamara M., RN, Houston, TX

Please post your tried and true tips below. You can also email your tips to nursing@josieking.org. We want to collect and share your great ideas with other nurses. If you would like to, please include your city and state, too.

I’ll be sure to share updates on this project as it progresses, but right now we need as many tips as possible from nurses. Spread the word to your nursing friends and colleagues, and have them post their tips, too.

Thanks so much for your help with this, and for all of your hard work with patients,

Sorrel

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Patient Safety Week

It’s Patient Safety Week- a time to reflect on all of the great patient safety projects and initiatives that have been under way. So many people have done so much to make our hospitals safer and for that I am forever grateful. But this is also a week to look ahead towards an even safer, better health care system. From what I can see, we have come a long way, but the journey is not over yet. There is work to be done.

I’ve heard from nurses and doctors all around the country who are planning on commemorating Patient Safety Week. There will be speeches announcing new safety programs, and ceremonies honoring caregivers who have done remarkable safety work. Patient safety is front and center, and I am excited about that.
Let’s stay invigorated. A few quick hopes of mine:
  • If you are a caregiver, keep focusing on improving how you communicate with your co-workers and patients. Even if your team communicates well, the nature of team work is one of continual change, and it helps to check in every now and then to make sure everything is still working well.
  • If you are a student, keep learning about patient safety and preventing medical errors. Ask your professor or mentor about the changes they have seen with regard to medical errors since they started practicing.
  • If you are a patient or family member, thank your health care team for incorporating patient safety techniques into their daily routine.
I’ll be commemorating Patient Safety Week with a few groups around the country this week. I hope that everybody is able to support Patient Safety Week in a way that is helpful and meaningful for them.
Keep up the good work!
-Sorrel
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IHI On Call: Talking with Nursing and Medical Students

The first time that I ever spoke to a room full of medical students was a few years ago at Johns Hopkins. I told them Josie’s story and at the end of the talk I asked them if they had ever head of the Institute of Medicine’s report “To Err is Human”. No one raised their hand. I remember feeling shocked that these students- who were taught how to cure diseases, deliver babies and mend broken bones- were not being told about one of the leading causes of death in our country- medical errors. The more medical and nursing students to whom I talked, the more I realized that it was indeed a rarely discussed topic. I found this frustrating and confusing. Since then I have tried to talk to as many medical and nursing students as I can. These young minds are the next generation, and if I could make a tiny difference in how they would care for their patients by sharing Josie’s story then I was going to do it.

I am grateful to the Institute for Healthcare Improvement (IHI) for creating the Open School (www.ihi.org/openschool). The Open School is a great resource for medical and nursing students to round out their patient safety education. They offer free courses in patient safety and quality improvement, sponsor essay contests, and host safety conferences for students of the health professions. Each month the Open School offers an On Call teleconference lecture, in which a guest speaking talks about a topic related to patient safety. Students from all over the country listen in and learn. I don’t believe anything can take the place of a classroom with a professor, however this may be the next best thing.
On Tuesday- with the help of modern technology- I sat at my desk in my home in Baltimore and had the honor of talking to a few hundred students from around the country. The session was called “Channeling Grief into Action”. Simon Mathews, a medical student at Johns Hopkins, moderated the hour-long session. I shared Josie’s story. I explained that Josie didn’t die because of one misplaced decimal point, because of one doctor or nurse. She died because of a lack of communication. After I spoke, Simon opened the lines to take questions from callers. I loved hearing from the students and I could tell that they had been moved.
For me it had been an hour well spent. It was my chance to make an impression on these brilliant minds that will take healthcare into the future. It was my chance to remind them of the importance of good communication and the need to create a culture in which reporting errors is considered heroic; a culture where doctors and nurses work as a team to prevent medical errors; a culture where the patient is heard and when a mother says, “Something is not right…” she is listened to. I hope I succeeded in delivering that message.
Thank you to IHI for realizing the importance of getting this information to students. Thank you Deepa Ranganathan for pulling the program together, and thank you Simon Mathews for being a great moderator.
For more information, check out the links below:
-An audio recording and a transcript of the session will be available at www.ihi.org/openschool at the end of the month. This link is also the gateway to all of the information about IHI’s Open School.
-IHI’s Open School blog (www.ihiopenschool.blogspot.com) has an open conversation about the session where you can post comments/questions. I’ll be checking in on the comments and responding to them.
-Want to take IHI’s educational programming wherever you go for free? You can subscribe to their informative podcasts at the Apple iTunes Store. Just go to the iTunes Store, search for “Institute for Healthcare Improvement” and click “Subscribe” to download IHI’s podcasts.
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Book News

When Josie was first in the hospital, I kept a journal. It helped me remember everything that was happening, everything we had to do. It helped me release some of the stress. When she died I continued to write. I wrote and I wrote and I wrote. I had to get my sadness, my anger out. It was one of the things that really helped me.

As I ventured into the health care industry, I continued to write off and on. One day I realized that I had what looked to be a book in the making and so I showed it to a few people. They told me to find a book agent, so I did. My agent told me I could get a book deal, and I did. Two years ago I signed with Grove/Atlantic, a publisher in New York. Since then I have been working on the book pretty much full time.

The book is called Josie’s Story. It is about how our family once was. It is about Josie’s death and how we struggled to survive. It is about making the decision to either let the grief and anger destroy me or do something positive, something for Josie. It is about the search for religion, the search for understanding what it means to forgive and the search for the reason why. The book is about my journey into a world I knew nothing about, the health care industry. It is about the wonderful doctors, nurses and other health care providers I have met along the way and the amazing hospitals that have invited me – in my small way – to help them become safer. But most importantly the book is about all of the wonderful things that have come from Josie’s death. Josie’s Story will be in bookstores in September 2009.

I continue to accept speaking invitations. Starting in early September, we will be able to have book signings after the speeches. If you are interested in learning more about speeches and book signings, click here. Of course, you can always email any questions about speaking requests to speaking@josieking.org. We will get right back to you.

As we get closer to our publishing date we will have more details to share.

One final note- a portion of the proceeds from the book will go to support the Josie King Foundation.

Thanks- as always- for your interest and support.

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“Questions Patients Need to Ask”

There is a great new book out there for patients and their families. It is called Questions Patients Need to Ask. Dr. David Shulkin, CEO of Beth Israel Medical Center in New York City, wrote it with the hopes that it would help patients and their families get safe care and be as informed as possible when in the hospital. Dr. Shulkin has been on the front lines of the patient safety movement for years now, and is truly passionate about patient safety.

It’s important to ask questions when in the hospital, or in any health care setting. We developed our Care Journal with that very thought in mind. Dr. Shulkin’s book is a great tool for empowering patients and their families. His book is informative and a must-read for anyone who is going into the hospital or who knows someone who is.
For more information, visit Dr. Shulkin’s website at www.questionspatientsask.com.
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Josie King Foundation and the Johns Hopkins Hospital Department of Nursing Patient Safety Heroes

On Wednesday the Josie King Foundation and the Johns Hopkins Hospital Department of Nursing recognized nine nurses, one clinical technician and one support associate for their work in patient safety at Hopkins Hospital. These professionals were nominated by peers in their unit for their outstanding work and are true patient safety heroes. I’d like to introduce them:

 

Maxine Bell-Trusty, Support Associate – Neurosciences

Maxine has taken a special interest in preventing hospital-acquired infections. She is what the literature calls a “positive deviant”- someone who does the right thing and is an agent for good. She single handedly advocated for two new practices in the Neuro Critical Care Unit: 1) using a fresh rag to clean each separate piece of equipment in isolation rooms and 2) requiring terminal cleaning of the patient’s room once they were taken out of isolation. We know from lab cultures that Bell-Trusty has reduced the prevalence of multi-drug resistant organisms on her unit. While we often worry that the “bugs” are winning, Maxine has won the battle in her unit.

 

Kelly Creighton, BS, RN – Medicine

After a serious event involving a monitor alarm in 2006, Kelly’s unit set out to improve the safety of patients on physiologic monitors. They determined that 27,000 alarms were set off on their 15-bed unit every 24 hours- that’s one alarm every three seconds. Creighton worked with her committee and the Clinical Engineering team to improve the situation, reducing “nuisance alarms” by 26%. Kelly literally took the noise out of the system, so that nurses could respond more quickly to patients in trouble.

 

Catriona Henderson, RN – Oncology
As part of her night shift routine as a charge nurse, Cat reviews all lab values for the patients on

her unit. She found inexplicable changes in a number of patients’ sodium values. So she followed her instincts (and her intellect) that something was wrong with the laboratory findings being reported in a large series of patients. Working with the lab, an investigation found that more than forty patients in the Cancer Center had incorrect sodium calculations made. But thanks to Henderson’s astute observation and quick action, only one patient was treated for the incorrect results (without any adverse effects).

 

Vicki Jackson, Clinical Technician – Emergency Department

Vicki championed doing “re-vitals”- that is reassessing patients in the emergency department. In the past two years, she identified significant changes in patients. One was having a heart attack, and the other a stroke. Because of Vicki, these two patients received the required treatment from the heart attack team and the brain attack team earlier than they would have. When minutes count, Jackson’s vigilance was life-saving.

 

Sara Nakamoto, RN – Gynecology and Obstetrics

Sara is a new graduate who joined Hopkins in March 2008 and she has already demonstrated an aptitude for promoting the safety and well-being of the very ill patients under her care. For example, Nakamoto discovered that a pre-mixed IV solution had one medication label applied over another label. The IV bag actually contained the solution noted on the hidden label, and this drug was contraindicated for the patient. Nakamoto’s patient had impaired renal funcation with only one kidney, and could have suffered significant complications had the drug been administered. For this patient, Sara was a hero.

 

Liza Raymundo, BSN, RN – Ophthalmology

Working the tail end of the night shift, Liza was preparing a surgical patient as the first case for the operating room one morning. The patient complained of not feeling well. Liza assessed the patient, whom she identified as having symptoms indicative of an impending stroke. She organized the ophthalmology team and facilitated the patient’s transfer to the Emergency Department where the required treatment was rendered in a timely fashion. Her quick assessment and critical thinking provided an immediate intervention so that the patient with an impending stroke was managed in a controlled environment.

 

Kathleen (Kathy) Robertson, MSN, RN – Surgery

The Hospital has been implementing an electronic provider order-entry system requiring all physicians to enter their orders online, and all nurses to document administration of medications in an electronic record. While the system was designed to be safer than paper-and-pencil versions, it was not fail safe. Robertson orchestrated the collaboration between physicians and nurses that was needed to develop the order sets, and implemented the change across the Department of Surgery. Many safety issues have arisen during this process. Robertson monitors these, and drives safety issues to the top of the priority list for system modifications. While many of our safety heroes have prevented individual patients from being harmed, Robertson is working to make the whole system safer.

 

Gloria Scott, BSN, RN – Pediatrics

On a unit where children and adolescents are treated for psychiatric illnesses that cannot be managed safely out of the hospital, security is a critical concern. Gloria Scott worked with the Pediatric Safety Team to add a security officer to the unit. The lay security officer could maintain a presence at the front door; identify visitors to determine if they are authorized; check visitors’ belongings; and lock away valuable or unacceptable items. However, the security officer was also needed to help with patients in a clinically appropriate manner. Scott explained the unit to the officer, taught the officer how to handle patients, and otherwise implement this new role.
Because of Scott, the environment is secure and the patients are safer.

 

Melinda Walker, RN – Psychiatry

The stories about Melinda are legion. In summary, she “sees” problems and fixes them. To give one example, Walker recognized a set of safety concerns in the electroconvulsive therapy (ECT) suite. She subsequently prepared a 30-minute educational program covering how to prepare patients for ECT; transport anesthetized patients safely; and maintain a smooth flow of patients through the recovery phase. Her educational program has been incorporated into the annual review that all RNs must complete. Walker is a safety hero for preventing harm from befalling
her patients.

 

As you can see, their work covers the gamut from actually saving a life to improving the systems so that errors can be caught before it is too late. Each had a different story to tell, but one thing that they all had in common was that in going the extra mile, in going beyond the call of duty they often faced push-back. They each persevered and fought for what they truly believed needed fixing. Some of these system changes have been adopted in other units, some will be published in medical journals, and I believe that all of them will make care safer for the patients of Johns Hopkins. It was an honor to acknowledge the work that they did- not to receive awards- but because they were simply compelled to do what they felt was right. I know that Karen Haller, Vice President of Nursing and Patient Care Services at Hopkins, joins me in sincerely thanking them for their commitment to patient safety.

(Thanks to Hopkins for providing the safety heroes’ stories!)

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Boston Part 2: Health Care’s Holy Grail

Energized from the previous night’s meeting with the HCA folks, I took a cab to the John F. Kennedy Library to a conference put on by Blue Cross Blue Shield of Massachusetts (BCBSMA). The conference was titled “In Pursuit of Health Care’s Holy Grail: The Quality Movement That is Transforming Health Care”.

The conference room was beautiful with a wall of windows as the backdrop of the stage, overlooking pretty Dorchester Bay. The audience consisted of doctors, nurses, health care leaders and public policy people all from the state of Massachusetts. These people had come together to celebrate the movement and to more importantly be inspired to continue on in the improvement of health care delivery at their hospitals. The centerpiece of the event was Charlie Kenney’s new book The Best Practice: How the New Quality Movement is Transforming Medicine.
The morning began with a welcome by Cleve Killingsworth, the Chairman and CEO of BCBSMA. It was apparent to me as I listened to him that he and his organization were committed to patient safety. It seemed that BCBSMA was going beyond the call of duty. BCBSMA isn’t sitting in the back of the room, merely observing the quality movement, but its leaders are committed to leading the way and I am grateful for that.
After Cleve’s opening remarks, I shared Josie’s story and my thoughts on Charlie’s great book. I recommend this book to anybody interested in learning more about the history of the patient safety movement that is truly changing health care for the better. I hope that the book can raise awareness on the reality of medical errors and inspire people to continue their work to improve patient safety or even to take up the cause.
I could go on and on about the interesting ideas of Charlie and other safety leaders like Don Berwick of IHI, Louise Liang of Kaiser Permanente, Uma Kotagal of Cincinnati Children’s Hospital, and Goran Henriks of the Qulturum in Jonkoping, Sweden, but instead I’d like to send you to Paul Levy’s blog “Running a Hospital”. In addition to being the President and CEO of Beth Israel Deaconess Medical Center in Boston, Paul is an amazing blogger. He was at the conference, and has done an excellent job on writing about the days events. Take a peek.
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Boston Part 1: The Grassroots of a First-of-Its-Kind Law

I flew to Boston on Monday, September 16, for a conference put on by Blue Cross Blue Shield of Massachusetts, which was to be held the next morning. Earlier in the week Jim Conway from the Institute for Healthcare Improvement contacted me and told me about a group in Boston that was doing some interesting things in the patient safety advocacy vein. He suggested that we meet.

And so Monday night I had dinner with five people from Health Care for All (HCA). HCA is a Massachusetts-based non-profit organization that is working to- among other things- create greater quality health care throughout the state. You can read all about them on their website. HCA sponsors the Consumer Health Quality Council- a very active and renowned coalition of health care consumers who have been personally affected by medical errors. The Council was created in 2006 and currently has about 40 members who are doing some impressive things: sharing their medical error stories with the public, advocating for improved health care, and meeting with legislators to introduce health care improvements into law.
A recent success included their year and a half-long work in the development and signing of a groundbreaking state law that includes:
  • mandatory reporting of all hospital-acquired infections
  • mandatory reporting of all “never events”
  • creation of rapid response methods at all hospitals
  • creation of patient/family councils at hospitals.
This was an interesting group. I urge those of you reading this who want to make changes within your state to check them out.
I’ll be back tomorrow with more from my trip to Boston, including the Blue Cross Blue Shield of Massachusetts’ patient safety event.
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