promoting transparency: the challenge of communicating patient safety information

1: Promoting Transparency:The Challenge of Communicating Patient Safety Information 3rd Annual Betsy Lehman Center Patient Safety Conference December 7, 2006 Boston, MA

2: Three Levels of Transparencyand Communication National level: transparency about the magnitude of preventable harm Patients and families: communicating adverse outcomes Health care organizations: transparency about performance on patient safety

3: Transparency &Communicationat the National Level Indispensable role of the media in communicating two key points: - the scope of harm and the urgency for patient safety - solutions, as noted in Newsweek article on Pursuing Perfection and the 100,000 Lives Campaign, Remaking American Medicine, WSJ, NYT, Boston Globe, Chicago Tribune, etc.

4: Transparency &Communicationat the National Level Double-edged sword of the media: - sensationalizing harm to patients, e.g. Oprah Winfrey show - media frenzy when errors occur in health care organizations

5: Transparency &Communicationat the National Level Other double-edge swords: - Limited reporting of local patient safety issues b/c of concern about offending local health care organizations - Kaiser Foundation study on reality television medical programs suggests that risks are not portrayed; this yields unrealistic expectations

6: Transparency & CommunicationWith Patients and Families Emerging social norm that errors should be communicated to patients and families I�m sorry� legislation Wall Street Journal articles on disclosure

8: Transparency & CommunicationWith Patients and Families Patient narrative�

9: Transparency & CommunicationWith Patients and Families The good news is that progressive health care organizations/systems � perhaps a dozen -- are on the journey to having conversations with patients and families Profiles in courage�

10: Transparency & CommunicationWith Patients and Families University of Illinois interviewed 16 law firms in Cook County and asked how they would handle a wrong site surgery 12 said they would get UIC �off the hook� and 4 said they would help UIC talk to the family; UIC has contracted with the four firms Health care organizations are using their purchasing power and buying different legal counsel

11: Transparency & CommunicationWith Patients and Families UIC has established a Patient Care Consultation Team that is trained and available 24/7 Similarities with Palliative Care Consultation teams?

12: Transparency & CommunicationOn Hospital/System Performance Public reporting of measures of system performance is essential to accelerate improvement in safety Hospital infections are one measure of system performance that is beginning to be publicly reported

14: �If I can�t picture it, I can�t understand it.� Albert Einstein

16: Transparency & CommunicationOn Hospital/System Performance Pennsylvania is the first state to publicly report hospital infections by hospital 16 states have enacted legislation requiring hospital reporting of infections The Consumers Union campaign StopHospitalInfections.org has been instrumental

17: Transparency & CommunicationOn Hospital/System Performance 30,000 + people have volunteered via the internet to help the CU campaign Questions: Are there lessons from other public safety campaigns, e.g. auto safety, environmental campaigns?

18: Transparency & CommunicationOn Hospital/System Performance �An object at rest tends to stay at rest and an object in motion tends to stay in motion with the same speed and in the same direction unless acted upon by an external and unbalanced source.� Isaac Newton

19: What should be done about hospitals/systems that don�t wish to be transparent and communicate?