Patient-centered Care Education (Shared Decision Making)

Our second day in Telluride finished with the residents watching the award-winning film The Faces of Medical Error…From Tears to Transparency: The Story of Michael Skolnik”. The educational film addresses the importance of informed consent versus shared decision-making conversations – an important aspect of open and honest communication in healthcare that is still lacking in many health systems. The film asks the question – Can a conversation change an outcome? Can a conversation save a life?”

After the film, the residents engaged in a two-hour conversation with faculty and safety leaders on issues related to informed consent and shared decision making. When Paul Levy asked the residents how much training they get on this topic, every resident in the room acknowledged this three-hour session on informed consent/shared decision making was more education than they have received during their entire medical school and residency training to date. A sad commentary on the current state of medical education in areas of patient centered care.

Telluride Day 1 Reflections

Dave Mayer and Tim McDonald opened the 8th Annual Telluride Patient Safety Educational Roundtable and Summer Camp. This being the eighth year the pair have taken time away from busy academic appointments, clinical responsibilities and family to continue to push forward in educating new physicians along with faculty on the just culture they know will make healthcare safe for all of us.

The residents and faculty were introduced to one another, and then we quickly moved into the week’s agenda starting with all viewing From Tears to Transparency: The Story of Lewis Blackman — a striking example of why we are all here and why there is still so much work to be done.

The residents kicked off the week sharing how some of their current environments were aware of the need for open and honest communication, yet failed to provide the support when an opportunity to have that conversation with a patient actually arose. Another mentioned the mainstay Morbidity & Mortality (M &M) conferences failing to address the real story, or even address the cases that could have been true teaching moments. In response, another resident shared that their institution had moved from the traditional M & M to a Quality Improvement conference. This is just touching the surface of the type of conversations Telluride engenders in a roomful of people intent on changing the medical culture for the good of the patient and those who work within in it.

The afternoon was filled with an excellent workshop on Negotiation, led by special guest faculty, Paul Levy, who broke new ground in transparency in healthcare while CEO at Beth Israel Deaconess Medical Center when he started a blog, Running A Hospital, and posted quality metrics online for the world to see. A wonderful summary of Day One in Telluride can be found on his blog as well.

Key take aways on negotiation from Paul’s workshop include:

  1. Understand your BATNA (Best Alternative To A Negotiated Agreement).
  2. Both parties can be made better through effective negotiation.
  3. Solving their problem is part of your problem.
  4. Create value in negotiation.
  5. Never threaten in negotiation but degrading the other side’s BATNA is fair game.
  6. Invent options–Learn about the other side’s interests.
  7. There are commodities, things, decisions with different value to parties in a negotiation–you can trade on those differences.

And finally, the day ended with a team building game that required new colleagues to work together through communication and system design in the best interest of our egg-headed patient.

McDonald, Mayer and UIC Awarded AHRQ Grant to Further Patient Safety Efforts

On June 11, the Department of Health and Human Services’ (HHS) Agency for Healthcare Research and Quality (AHRQ) awarded a number of grants to support State and health systems in their efforts to implement and evaluate patient safety approaches and medical liability reform. Transparent Health Co-Founders, Tim McDonald MD and Dave Mayer MD, along with the University of Illinois at Chicago, are the Principal, and Co-Investigator respectively, on one of the largest remunerated demonstration and planning grants recently awarded by AHRQ, a part of President Barack Obama’s patient safety and medical liability initiative announced last year. See press release for additional details.

“As Co-Executive Directors of the University of Illinois at Chicago Institute for Patient Safety Excellence [UIC IPSE], Dave Mayer and I feel highly honored that our grant proposal: The Seven Pillars: Bridging the Patient Safety – Medical Liability Chasm received notice of $3M in funding from AHRQ,” comments McDonald. “The grant provides UIC IPSE the resources to transport the “principled approach” to patient harm to at least nine other Chicago area medical centers.”

“The “Seven Pillars” approach, with its emphasis on transparency, 1.) Puts patients first 2.) Concentrates on effective communication 3.) Focuses on the prevention of medical errors and; 4.) Provides for a rapid, compassionate response when inappropriate care causes patient harm,” explains McDonald. “With a rigorous research model, we intend to demonstrate the effectiveness of this approach at improving patient safety while simultaneously reducing medical liability. Once demonstrated we hope the model will become a “best practice” throughout all of healthcare and replace the traditional “deny, defend, shame and blame” response to patient harm as it currently exists.”

This is continued affirmation that patient safety, as well as a patient-centered response to medical error, is becoming an even greater priority in the cultural shift medicine is beginning to embrace. We look forward to sharing more about the progress of the Seven Pillars project.

Welcome

Greetings! Welcome to our blog. So glad you found us.

Our hope is that this site generates important conversation among caregivers, administrators, patients, families, educators, policy makers and others on two very important issues in healthcare today: (1) the medical error crisis, and (2) while appreciating that medical errors will never be eliminated, how we respond to patients and family members when unintentional harm results from our care.

In an effort to stimulate this conversation and help lead change, our first educational film The Faces of Medical Error…From Tears to Transparency: The Story of Lewis Blackman addresses both of these important issues. The film premiered last September and in just five short months, The Story of Lewis Blackman has been used as a vehicle for change across the globe. In Chicago, Washington DC, Southern California, Australia, Japan and Europe, audiences have used the film to begin important discussions on medical error and open disclosure.

After helping lead the production of this movie for almost a year, I can say without a doubt creating this educational film has been one of the most rewarding experiences of my career. Helen Haskell empowered us all with her courage and commitment to improving the quality of healthcare. She has turned her son’s unfortunate story into an educational experience that we can all learn from and something that we will never forget. It is a true testament to the human spirit and the good that people can do despite the tragedy that befalls them. You can view a short trailer of the film on YouTube at http://www.youtube.com/transparenthealth to appreciate the power of many people like Helen who are committed to making a difference. Please let us know your thoughts on the trailer and the film.

As the world calls for greater accountability in healthcare, it is up to all of us to create change that results in safer, more transparent care. We are making progress towards this goal but there is still much work ahead. Open and honest communication around unintentional harm is an important component in solving the medical error crisis. Transparency allows for the education and empowerment of patients and family members to make informed decisions related to their care, ultimately resulting in better outcomes. Transparency also educates and empowers caregivers and administrators, helping us learn ways to improve our systems and avoid future medical error.

Please continue to visit our blog and share your thoughts. It is our hope this site will stimulate important discussions concerning open and honest communication after harm has occurred resulting in improved safety and reduced risk to patients. We will have thoughts and ideas from caregivers, administrators, policy makers, patient advocates and others from the front lines coming very soon…

Best regards,
Dave Mayer

The Story of Lewis Blackman Awarded Highest Honor by Filmmaking Peers

In addition to providing an unforgettable learning experience for health care providers, Lewis Blackman continues to touch the hearts of all who hear his story. Most recently, The Faces of Medical Error…From Tears to Transparency: The Story of Lewis Blackman, was awarded a 2009 Aegis Award—a worldwide film industry honor given to the very best film and video productions of the year. Of the 2,109 entries, The Lewis Blackman Story received top honors, achieving the highest score awarded by a panel of peer judges.

Greg Vass, Executive Producer at SolidLine Media and partner to Transparent Health in the creation of the film said, “It always feels great to be recognized as the best in our field, but I think it feels even better to be part of such a special production project—one that is truly changing healthcare.”

For all of us at Transparent Health, the journey of making this educational film has forever changed us for the better. By sharing Lewis’ story we hope to help providers understand better ways of both preventing and managing medical error while embracing transparency and full disclosure related to the care they provide. We also hope to empower patients and their families by providing relevant information they can carry with them to the hospital. Please view the trailer to the film and share your comments:

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