sherri loeb - "the impossible dream": safe, high-quality, high-reliability and...

“The Impossible Dream” Safe, High Quality, and Patient

Centered Care… Our Perspective On A Broken

Healthcare System

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Sherri T. Loeb, RN, BSN [email protected]

Copyright: 2013: Sherri T. Loeb RN, BSN !

Who am I…and Why am I here??

Jerod’s Health Care Journey.....

•  Routine physical in August 2011, was asymptomatic and felt in perfect health; only complaint – minor low back pain

•  PSA at the end of 2009 – 1.29 Normal value is 0-6.5 depending on age and

race •  PSA in 2011 – 535 •  Biopsy: Gleason 8 (4+4) (positive 3 of 12 core samples) •  Stage IV prostate cancer at diagnosis with significant bone metastases

3 Copyright: 2013: Sherri T. Loeb RN, BSN & Jerod M. Loeb, PhD.

A Tale of Two Cities •  August 2011 – December 2011

•  Treated locally with std of care tx – failed initial therapy after a little over 3 months of treatment

•  Next option – std of care – “what insurance would cover” – No talk about additional options, or clinical trials besides double blind. Nothing geared specifically towards aggressive case.

•  Fall 2011 - Diagnostic clinical trial NIH

•  December 2011-January 2013 - Entered clinical trial after failing1st line tx. Self referral to MD Anderson Cancer Center in Houston Texas.

•  January 2013 – Metastasis to liver and bone marrow, DIC, Tx with two IV chemo agents and returned to almost full functional status. IV combo not available locally.

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A Tale of Two Cities

•  June 2013- October 2013 “Magic” Chemo stops working •  New chemo agent started – again not std of care locally

but showing promise at MD Anderson •  August 2013 – Liver mets and DIC return - one last

chemo suggestion – •  October 2013 Hospice care •  Passed away October 9, 2013

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6 Copyright; The New Yorker Sept. 23, 2013!

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Local Hospitalization - July 2013

•  Missing vital signs

•  No patient assessment

•  Bypassing of CPOE alarm system (audible and visible)

•  No communication among caregiver(s) and patient/family members or physician to physician

•  Lack of hand hygiene/Pt. ID

•  Absence of Shared decision-making Picc line experience

Copyright: 2013: Sherri T. Loeb RN, BSN & Jerod M. Loeb, PhD.

• 100% Hand Washing • Phenomenal Communication – White boards in ED and Inpatient Rooms • Bedside Handoff Report between RN’s • Patient Centered Compassionate Care • Shared Decision Making • Patient and Family Engagement • Team Approach • Excellent Transitions in Care • Patient Safety Key in all areas of care

First Hospitalization in Houston Cancer Center – January 2013

Surviving A Health Care Crisis Requires Having An

Relative/Friend With You At All Times

•  Even health care professionals become deaf, dumb and blind when in crisis mode about their own health

•  Navigation of the health care system requires a map, a guide, and an extraordinary amount of skill and stamina – even for those who work in the system

•  And that is before you have to deal with insurers

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We Have Seen The Best Of Health Care And The Worst Of Health Care….

•  Drugs that work and then stop working •  Physicians who prescribe drugs that should not be

prescribed together •  Dispensing errors; failures to accurately reconcile

medications •  The interesting phenomenon of being hurt in order to be

helped •  Unanticipated drug-drug interactions •  Forgetting to be told the results of significantly abnormal

laboratory results •  Almost never being given good news without the

inevitable "but" that all cancer patients can associate with

•  An association with several oncologists who care and are extraordinary role models - and some who are not

9 9!Copyright: 2013: Sherri T. Loeb RN, BSN & Jerod M. Loeb, PhD.

Communication Failures Are The Rule And Not The Exception

•  Literacy levels are low…..and health literacy levels are even lower

•  Communication failures at transitions of care are nearly ubiquitous…..and harm patients every day

•  These failures occur between physicians and physicians, physicians and nurses, nurses and nurses, and between all types of caregivers and patients


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•  With increased attention on transitions of care in light of the recent scrutiny of duty hours, consultations and other interphysician interactions, such as handoffs, are becoming increasingly important. As modern medicine increases in complexity, the skill of communicating with medical colleagues throughout the continuum of care becomes more challenging.

I’m Clear, You’re Clear, We’re All Clear: Improving Consultation Communication Skills in

Undergraduate Medical Education

Academic Medicine, June 2013 - Volume 88 - Issue 6 p 753-758 Kessler, Chad S. MD, MHPE; Chan, Teresa MD; Loeb, Jennifer M.; Malka, S. Terez MD

Betsy Gornet from Sutter Health.

13 New York Times October 13, 2014!

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The Reality......!“I have the distinct feeling that the

patient in America is becoming invisible. She is unseen and unheard....I gently

insist that we go to the bedside, but that is often a place where the team is no

longer at ease. I realize what has happened: the patient in the bed is

merely an icon for the real patient in the computer.” A. M. Nussbaum, MD!

A Piece of My Mind!JAMA!July 17, 2013!

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Shared decision making is an approach where clinicians and patients communicate together using the best available evidence when faced with the task of making decisions, where patients are supported to deliberate about the possible attributes and consequences of options, to arrive at informed ... http://en.wikipedia.org/wiki/Shared_decision_making

…But Is It Truly Accepted And Practiced??

The Value of Sharing Treatment Decision Making with Patients – Expecting Too Much?

•  Ethical responsibility of clinicians to facilitate patient involvement in treatment decision

•  More engaged patients are more informed

•  Objectives of SDM are to fully inform patients and their families about treatment options including risk and benefits and patient values and preferences

•  Does not support its potential to reduce overtreatment and costs.

•  Clinicians are not adequately trained to facilitate SDM, especially eliciting patient values and preferences for treatment.

16 JAMA October 16, 2013 Page 1559!Corresponding Author: Stephen J. Katz MD, MPH!!

JAMA VIEWPOINT

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The Hierarchy Gradient in Health Care

Copyright © 2012 American Medical Association. All rights reserved."

18 Copyright © 2012 American Medical Association. All

rights reserved."

From: Communicating With Physicians About Medical Decisions: A Reluctance to Disagree!

Arch Intern Med. 2012;():1-2. doi:10.1001/archinternmed.2012.2360"

Percentage of participants who would ask questions of, discuss preferences with, or express disagreement to their physician when relevant."

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“I think there is a revolution coming. In the

past, patients were expected to be obedient

and compliant.” Harlan M.

Krumholz, MD, SM Yale School of Public Health

July 2013

Patient and Family Engagement

A set of beliefs and behaviors by patients, family members, and health professionals and a set of organizational policies, procedures and interventions that ensure both the inclusion of patients and families as central members of the healthcare team and active partnerships with providers and provider organizations.

Benjamin K. Chu, M.D. Chair of the AHA’s Board of Trustees

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“What I’ve learned from my odyssey thus far…

We need to listen to the real voice of the patient. What he/she is thinking/feeling/or believing. I gave them lip service. I know that now…I didn’t know that then.”

From John M. Eisenberg Honorary Lifetime Achievement Award in Patient Safety and Quality - 2011

22 Copyright Jerod M. Loeb, PhD April 2012

•  You treat a disease, you win, you lose. You treat a person, I guarantee you, you’ll win, no matter what the outcome.

•  Our job is improving the quality of life, not just delaying death.

•  We need to start treating the patient as well as the disease.

•  You actually are a doctor and admitted it, you’d say, “I don’t cure a huge percentage, I don’t have a 50 percent cure rate…(but) I can have a 100 percent compassion rate.”

Hunter “Patch” Adams MD 1998

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Patient Expectations 100% of Time

•  To be always told the truth.

•  To have things explained to me fully and clearly.

•  To receive an explanation and apology if things go wrong.

-Jim Conway, IHI presentation

Patient Expectations 100% of Time

•  To be listened to, taken seriously, and respected as a care partner.

•  To have my family/caregivers treated the same.

•  To participate in decision-making at the level I choose.

-Jim Conway, IHI presentation

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Text

Chicago Magazine, January 2013

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Patient-centered care supports active involvement of patients and their families in the design of new care models and in decision-making about individual options for treatment. The IOM (Institute of Medicine) defines patient-centered care as: "Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions."

Donald Berwick MD, MPA!

•  Words can never express the gratitude of a terrified parent when such kindness is shown … when we feel seen, and that we matter. Think about it: as hospital patients, a parade of people you do not know have license to pierce and cut your skin, waken you out of your sleep, expose your body, move your things out of your reach, or refer to you as “the knee replacement in 305.”

PAT MASTORS PATIENT | AUGUST 5, 2013

The gratitude of a terrified patient when kindness is shown

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Reasonable Expectations That Patients Who Are Seriously Ill Deserve To Have Ful>illed:

•  To have one’s pain and other physical symptoms regularly assessed and competently treated. •  To have adequate information about one’s condition and treatments, in clear and simple terms.

•  To have care coordinated between visits and among physicians and health programs involved in one’s care. •  To have crises prevented when possible and have clear plans for managing emergencies in place. •  To have enough nurses and aides on staff in hospitals and nursing homes to provide safe and high quality care •  To have one’s family supported in giving care, in their own strain and, eventually , in their grief.

Ira Byock MD!The Best Care Possible!

Making Individual Health Care Decisions Can Be Hard – Even With Good Evidence And Even For Someone In The Field For

Many Years

Technical Quality Is Important - But So Too Is Patient Experience Of

Care


Every hospital should have a plaque in the physicians’ and students’ entrances:

There are some patients whom we cannot help; there are none whom we cannot harm

31 Stanford University medical professor Arthur Bloomfield

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SAFETY

QUALITY SERVICE

ALWAYS

Sign By Employee Breakroom at Costco

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• Outpatient medication errors

• Lack of medication reconciliation leading to missing of medications

• Medications that remain forever on medication lists

• Wrong indication for medications

• Pharmacy/pharmacist attitudes

Med Rec and Med Errors!


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Ben Kolb Died, Age 7 Medication Error

Errors Waiting To Happen

Jerod M. Loeb, PhD, January 2013!

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Our Most Recent Medication Error


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One Of My Medication Errors


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Text

Looks Pretty Normal, Right?


39 Jerod M. Loeb, PhD, January 2013!

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My Most Recent Medication Error


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Surgical Errors!

Forgotten 13” Surgical Retractor!New York Times, December 11, 2001!

Jerod M. Loeb, PhD, January 2013!

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FINDINGS: No intracranial hemorrhage. Mild patchy areas of low-attenuation in the periventricular and subcortical white matter bilaterally. Small area of encephalomalacia in the right high convexity parietal lobe cortex A small area of right anterior frontal lobe encephalomalacia. The rest of the brain demonstrates preserved gray-white differentiation. No hydrocephalus or midline shift.""Basal cisterns are patent. Visual is paranasal sinuses and mastoid air cells are clear"""IMPRESSION: Intracranial bleed. Encephalomalacia in the right cerebral hemisphere with patchy areas of low-attenuation in the white matter, which are nonspecific. These may represent ischemic degenerative changes of the brain, although would be extremely early for patient's stated age of 35. Please correlate with history of diabetes, hypertension, or sickle cell disease. If there is suspicion for acute infarction, further evaluation by brain MRI is recommended.."

How/Why Do Things Like This Happen?!

November 2012

Choose Your Disease Carefully, But Choose Your Health Care Provider Even More Carefully

•  Not all physicians or hospitals have the same expertise

•  Ratings (hospital and physician), while ubiquitous, are often irrelevant, and many times, just wrong

•  Access to innovative care depends on innovative caregivers with innovative knowledge and awareness

•  Patient’s values and desires matter, especially when the evidence runs out as it often does in cancer

•  Interdisciplinary vs. multidisciplinary

47 Copyright 2013: Sherri T. Loeb RN, BSN!

50 Harrisburg, PA – Dec 2011

Twenty Years Of Measurement In Health Care Has Not Given Patients What They Want Or Need

�  Measures of process, while improving quality, do not help patients make better health care decisions

�  Outcome measures matter, but are hard to measure

�  Patient safety measures are (so far), not helpful to providers or to patients (especially measures of improvement in patient safety)

�  Where are the measures of patient choice?

�  Incentive payment programs based on measures at the hospital and physician level are a grand, uncontrolled experiment

�  There are too many irrelevant and unreliable measures

51 Copyright Jerod M. Loeb, PhD. January 2013

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Front-Line Lessons!

•  The power of friendship triumphs

•  Care is not the same from MD to MD or from HCO to HCO

★  Patients should not be compared

•  Nursing and compassion are not the same

•  Standard of care may be perfect for some - but not for all

•  Importance of leadership, leadership, leadership

•  Patient and family engagement means everything

•  Hiring the right employees is key


Is this the answer… a magic door?

�  “...No, you can't always get what you want

�  No, you can't always get what you want

�  No, you can't always get what you want

�  But if you try sometime, you just might find

�  You get what you need....”

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“Do something – if it works, do more of it; if it doesn’t, do something else”

55 Franklin D. Roosevelt

In Loving Memory of Jerod

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Thank You For Allowing Me To Share Our Story!

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