sherri loeb - "the impossible dream": safe, high-quality, high-reliability and patient-centered care

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  • The Impossible Dream Safe, High Quality, and Patient

    Centered Care Our Perspective On A Broken

    Healthcare System


    Sherri T. Loeb, RN, BSN

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

  • Who am Iand Why am I here??

  • Jerods 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.


  • 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


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

  • 7

    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 RNs 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

    8 8!Copyright: 2013: Sherri T. Loeb RN, BSN & Jerod M. Loeb, PhD.

  • 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

    10 10!Copyright: 2013: Sherri T. Loeb RN, BSN & Jerod M. Loeb, PhD.

  • 11

    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.

    Im Clear, Youre Clear, Were 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!

  • 14

    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!

  • 15

    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 ...

  • 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!!


  • 17

    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."


  • 19

    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 AHAs Board of Trustees


  • What Ive 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 nowI didnt 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, youll 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, youd say, I dont cure a huge percentage, I dont have a 50 percent cure rate(but) I can have a 100 percent compassion rate.

    Hunter Patch Adams MD 1998


  • 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

  • 26


    Chicago Magazine, January 2013

  • 27

    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: "Pr