Patient Advocacy for Healthcare Quality Earp, French, Gilkey

1. Patient Advocacy for Healthcare QualityEarp, French, Gilkey Chapter 10 The Contributions of Patient Advocacy in Patient Safety

2. Emergence of the Patient Safety Movement The first “error reporting” may be traced to Emory Codman, a surgeon, who in 1913 made a practice of publishing an annual report of his hospital’s medical errors so that patients could judge for themselves the quality of care.

3. Modern Patient Safety began in two areas • Medication. In 1975, Michael Cohen began a lifelong journey to improve medication safety, establishing the Institute for Safe Medication Practice in Ontario, Canada. • Anesthesia. In the 1980s anesthesia professionals were prompted to address the issue of preventable medical error after a sensational television exposé raised public concern. Leaders in anesthesia established the Anesthesia Patient Safety Foundation in 1985.

4. High Profile Events Brought More Widespread Attention to Patient Safety in the mid-1990s Affected institutions included: • University Community Hospital in Tampa, where a surgeon amputated the wrong leg of Willie King • Sloan-Kettering Cancer Center in New York where a neurosurgeon operated on the wrong side of a patient’s brain • Butterworth Hospital in Grand Rapids, Michigan, where a surgeon, during a mastectomy, removed the wrong breast of a cancer patient • Quincy Hospital in Boston where a surgeon removed the wrong kidney from a patient after failing to check x- rays • Martin Memorial Hospital in Florida where an anesthesiologist injected Ben Kolb with a high dose of a concentrated form of epinephrine, killing him • Herman Hospital in Houston where Jose Martinez died from a 10-fold overdose of digoxin • Dana-Farber Cancer Institute in Boston where a 4-fold overdose of chemotherapy led to the death of Boston Globe reporter, wife and mother, Betsy Lehman, and harm to another patient, Maureen Bateman.

5. Seminal Reports on Patient Safety by the Institute of Medicine • To Err is Human: Building a Safer Health System (2000) • Crossing the Quality Chasm: A New Health System for the 21st Century (2001)

6. Formation of Patient Safety Organizations Consumer Advocacy Organizations • PULSE • Consumers Advancing Patient Safety (CAPS) State and Federal Organizations • The Massachusetts Coalition for the Prevention of Medical Errors Private, Nonprofit Organizations • National Patient Safety Foundation • Institute for Healthcare Improvement • Leapfrog Group

7. Case Study: IHI’s 100,000 Lives Campaign Since December 2004, the Campaign has enrolled more than 3,000 hospitals to implement up to six evidence-based, life-saving interventions: • Deployment of rapid response teams • Reliable, evidence-based care for acute myocardial infarction • Prevention of adverse drug events (ADEs) through medication reconciliation • Prevention of central line infections using a series of scientifically grounded steps called the “central line bundle” • Prevention of surgical site infections through delivery of the correct peri-operative antibiotics • Prevention of ventilator-associated pneumonia using the “ventilator bundle”

8. Case Study: IHI’s 100,000 Lives Campaign Campaign highlights include: • More than 50 health care organizations are serving as local field offices (or “nodes”) for the Campaign • Over 90 national partners – among them the American Medical Association, American Nurses Association, Centers for Disease Control and Prevention, Centers for Medicare and Medicaid Services and the Joint Commission on Accreditation of Healthcare Organizations – are actively involved • Nearly 100 hospitals that have demonstrated success with specific interventions are acting as “mentor hospitals,” sharing their knowledge and experience with other hospitals aiming to achieve excellence in those areas • By 2006, an estimated 122,300 deaths were prevented over the course of the 16 month-long campaign

9. Future Goals: Patient Advocate Engagement Across Levels of Patient Safety • Policy/environment • Healthcare organizations • Hospital micro-systems • Patients’ experience of care

10. Patient Advocate Engagement for Patient Safety: Policy/Environment • Efforts by WHO, JCAHO, IHI, NPSF, CMS to fully integrate patient advocates in strategic and operational planning, task forces, and educational sessions • Inclusion of patient advocates on boards of trustees (e.g., NPSF and the JCAHO) • Regional support groups for patients, family, clinicians needing help after incidents • Inclusion of advocates in adverse event and near miss reporting systems

11. Patient Advocate Engagement for Patient Safety: Organizations • Statement of commitment to partnerships • Membership on patient and family advisory committees • Inclusion of patient advocates on patient safety and quality committees as well as in root cause analyses • Explicit expectations and policies supporting on-going communication, full disclosure and apology • Participation in walk rounds, patient care unit rounds • Inclusion of advocates as faculty in new employee orientation, customer service training, clinical programs • Advocates as search committee members when hiring new staff

12. Patient Advocate Engagement for Patient Safety: Hospital Micro-Systems • Family visiting in ICUs around the clock • Hospital environment supports patient and family presence and participation as part of interdisciplinary collaboration • Family, patient participation on hospital operating committees

13. Patient Advocate Engagement for Patient Safety: Individual Experience of Care • Verifying medications prior to administration • Participating in joint care planning, goal setting • Evaluating the outcomes of care, quality of life • Activating rapid response teams

14. Patient-Centered Guidelines for Safety: Honoring Patient Expectations 100% of the Time Patients can expect to: • receive high quality, safe care. • be listened to, taken seriously, and respected as care partners • have their family/care-givers treated the same • participate in decision-making at the level they choose • always be told the truth • have things explained to them fully and clearly • receive an explanation and apology if things go wrong • have information communicated to all members of the care team • have their care documented in a timely manner • have these records made available to the patient if requested • count on coordination among all health care team members between and across all settings • be supported emotionally as well as physically (Institute of Medicine, 2006, p. 137)