Telluride Lessons on Quality vs Safety…and more!

Quality Improvement vs Patient Safety

Quality care is defined by core values (6 per IOM – STEEPE):

1) Safety: minimize harm
2) Timeliness: minimize wait times
3) Effectiveness: minimize ineffective treatment/tests
4) Efficiency: minimize waste
5) Patient centered: minimize paternalism
6) Equity: minimize disparities

Quality improvement is the journey to achieve those values. Patient safety is one of the core values.

Thoughts from Monday 6/5/2017:

Today we watched a video of a young boy who died from a medical error.  He had pectus excavatum and underwent a Nuss procedure.  Unfortunately he got such a high dose of the IV NSAID – ketoralac – that in addition to acute kidney injury, he developed a duodenal ulcer that perforated and led to septic shock and death.  

Of the many tragedies including the death, the family was left helpless, “as if on an island,” said the mother while in the hospital.  They had no idea who their providers were and how to get in touch with their surgeon.  The hierarchy of residents was never explained.  Their concerns were dismissed by multiple providers and erroneously attributed to the wrong diagnosis of gas pain.  

Although I have not lost a family member to a medical error, I do recall the frustrating time I was on the side of the patient, my father, as his family advocate, at a hospital in which providers entered and left without clear introductions, assessments, and plans.  It was nervewracking to not be able to see the data – vitals, labs, and their progress notes.  I hated having to wait on the surgeon to come, even though I know as a surgeon the legitimate reasons for such waits.  My dad is 80 and not medically literate.  He looks at his providers in the eye, nods, and says yes when asked if he understands why he is taking certain medications or going for certain procedures.  However, I know he does not truly understand, and I verify this when I ask him myself what the plan is.  I wish the providers would instill a “teach-back” confirmation of understanding.  Getting a confirmatory nod with eye contact does not equate with understanding.  All providers need to know this.  We can do a better job educating all providers – physicians, nurses, therapists, nutritionists, etc.

This holds true even with my wife and me.  I have angered my wife many times for “not listening.”  She tells me that I forget things she has told me, even when I make eye contact and say “uh-huh” when she is speaking to me.  Yes, I admit I need to take personal responsibility for being a better active listener to my partner, and show respect for what she says.  However, I am more aware than ever after this conference that I am fallible.  If my mind is on something else, I am not listening.  Therefore my wife and I will be instituting a “teach-back” policy where if we are making an important point, we ask the other person to repeat the point made.  Let’s see where this goes.

Thoughts from Tuesday 6/6/2017

Today we talked about giving informed consent.  We learned the story of a young man who was not informed of the alternatives and risks for a certain neurosurgical procedure and was left paralyzed, blind, and mentally disabled before dying from repeated infections 3 years later.  

I think I know what it takes to give a really good informed consent.  I would want a quiet private space, perhaps with a vase of water and cups.  I would want the patient’s strongest advocates – parents, partners, siblings – at the bedside.  I would make sure they have a notepad and pen, and voice recorder.   

I would start by introducing myself, and my position within the hierarchy of providers.  I would diagram my rank as a resident in relation to my attending, and the difference in years of training and number of operations performed between my attending and myself.  I would describe each person’s role in the surgery includine the various nurses and anesthesia team members.  I would ask them what they know of the current problem, and the potential complications.  I would spend time to figure out their goals of care and their values.  Then I would discuss the proposed procedure in adequate lay term details, risks, and benefits.  I would draw pictures.  Then, I would discuss the alternatives and those associated risks and benefits.  Then I would discuss the risks and benefits of doing nothing.  I would have all the numbers for success and failures, complication rates, and mortality rates.  I would have copies of the data from papers to support what I have said.  I would have pamphlets of each procedure ready for them, in their language whatever it might be, and have a translator present if needed.  I would give them time for questions and ask them specifically “What questions and concerns do you have?  Take your time.  I have all day.  Call me any time.  Here’s my cell phone.  Feel free to think about this and get back to me.  We can meet again next week.”  I would discuss all of their out-of-pocket costs of each procedure based on their insurance.  I would discuss the pre-op labs and tests needed, and describe the instructions and what to expect the night before the surgery, the day of the surgery, and the course to expect after the surgery.  I would inform them of when they can get back to work, and what changes to expect to occur with their bodies and relationships with others during recovery.  

However, the reality of the situation is far from what I know is ideal.   

There are innumerable barriers to what is ideal including time, knowledge, and resources. 

It will likely be the intern who gets the consent, a mere signature, who has less than 5 minutes to spare and who does not know all the information off the top of his head.  Really, who knows all the frequencies of every complication?  Could he or she name 5 complications for 5 valid ways to do a hernia repair, and give the national, hospital-specific, and attending-speicifc percentages for those complications?  Could he draw out a chart of the pros and cons of each procedure and align them with the patient’s values and goals?  Is there time to search for this data with the patient using pubmed to look through papers and other tools that measure complications rates?  Is there already a standardized consent for every procedure and alternative with every pertinent complication?  Is there an arabic language written consent for my patient to read and go over with his familiy?  Is there an in-house translator for every language?  Is the consenter culturally competent to read body language?  Is there a phone translator for every language?  How much is lost in translation?  What deems sufficient cultural competence?  What is sufficient training in cultural competence?  How and when do I assess for health literacy?  

I wish I had the answers. 

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