MASSACHUSETTS GOVERNOR SIGNS COST CONTAINMENT AND QUALITY IMPROVEMENT BILL

Governor Deval Patrick signed S. 2863 (the Cost Containment and Quality Improvement Bill) into law this past Sunday. The purpose of the bill is to help contain the skyrocketing costs of healthcare, while ensuring transparency and continued quality of care for residents of Massachusetts (press release).


Of particular interest to healthcare consumers is that 4 of the 6 quality improvement provisions that our friends on the Consumer Health Quality Council at Health Care for All advocated for were included in the bill and will now be enacted:


1. Public reporting of healthcare-associated infection rates;
2. Public reporting of Serious Reportable Events (or never events) and prohibiting hospitals from being reimbursed for care associated with the events;
3. Requiring hospitals to establish Rapid Response Methods; and,
4. Requiring hospitals to establish Patient and Family Councils.

We'll now have to wait and see what happens with the implementation phase of the bill, but we applaud Governor Patrick's, the Senate's, and the House's leadership on this important piece of legislation.

A GREAT READ AND WONDERFUL WAY TO SUPPORT MITSS!

We highly recommend a new book, The Best Practice, written by former Boston Globe journalist Charles Kenney. The book tells the story of some of the pioneers of the health care quality movement, from Don Berwick to Lucian Leape, who are finding ways to eliminate preventable medical errors and transforming American medicine in the process.


As an added bonus for MITSS, the Institute for Healthcare Improvement (IHI) has generously arranged for 10% of purchases made through a special Amazon.com link to be donated to MITSS. To purchase a copy of The Best Practice through this special arrangement, click here.

Where can you find MITSS this week? The Boston Herald!

This article in the Boston Herald from Sunday 8/3/08 features MITSS founder and Executive Director, Linda Kenney, and one of MITSS’ esteemed board members, Jim Conway. They were asked to comment on the progress and trajectory of apology and disclosure in medicine. Although we are always pleased when this topic is highlighted, it is likely that the column inches allotted were not enough to do it justice. So, we would like to put the question to you: How do you see the progress and direction of apology and disclosure in healthcare? How does it impact you personally?

CAN WE CONTROL OUR OWN OUTCOMES?

Have you all seen the latest article from CNN titled "Don't Become the Victim of a Surgical Error"? The article contains some good information, and, as patients and families, we should follow the steps listed.

But (and you knew there would be a but), the hair on the back of my neck always stands up when I read something like this. In the article, it does refer to the fact that these steps lessen the chance of a medical error happening. I feel, though, the story implies that if we follow a few simple steps, we can control our own medical outcomes. I did all those things prior to my surgery 9 years ago, and there was still an anesthesia complication that nearly took my life (see Linda's Story).


This past year, when I finally got my ankle replacement, I ended up with a post-op infection that I believe could have been avoided, but the systems in place made it impossible for that to happen. I ended up with two more hospitalizations, confined to bed with my foot elevated for three months, and on IV antibiotics for 7 weeks. I tried to advocate for myself, but the pharmacy and my insurance company made it impossible. With both experiences, I was left with the woulda, coulda, shoulda feelings that are quite normal after these types of events.



Is this a set up for people to think that if they do all the right things, they will be safe? So, I ask you, what do you think of the article?

Linda

THE POWER OF A PERSONAL STORY

Over the past six years on behalf of MITSS, I have had the great fortune of travelling the country and abroad. I have spoken at conferences and forums, large and small, speaking with patients, family members, and clinicians. It seems that everyone has a story. Each time I speak with someone who has been affected by a medically induced trauma, I not only relate on a truly personal level, but it has served to strengthen my commitment and resolve to change the systems which fail each of us every day.

There can be nothing more powerful than a personal story, and we have encouraged anyone affected by an adverse event to share their experience with us on our website. There have been some very moving entries recently added, and we invite you to take a look at our patient and family story page. Also, if you’d like to share your own story, please feel free. By sharing your personal experience, you may be helping someone out there to feel less isolated and alone.

Linda

WALKING THE WALK

There are a lot of people around the country "talking the talk" about disclosure and apology when bad things happen in health care. You may have read in the Globe last week about a wrong site surgery at the Beth Israel Deaconess Medical Center. Check out CEO Paul Levy's blog for a great example of an organization that is "Walking the Walk" and trying to do the right thing.

LIVE GHOSTS IN THE ROOM

MITSS Support Team Member and Doctoral Student in Psychology, Erin O'Donnell, shares some reflections regarding her godson's hospitalization. Erin chronicles a very common problem with seemingly routine healthcare communication -- one that needs to be addressed in our quest for true patient-centered care:

On Wednesday morning, my 4 month old godson received a heart transplant in another state. Naturally, this is a big moment and gift beyond words. There is so much that can be said about the magic and miracle of organ donation; the amazing donor families, the science and the great treatment teams. However, I would like to comment on the something else.

Today, my friend, my godson’s mom, called me and said, “People say stupid things sometimes.” She went on to tell me about how the person she thinks was the anesthesiologist (the doctor didn’t adequately identify her role) introduced her name to my friend when entering her son’s room in the Cardiac Intensive Care Unit. The doctor then began talking to the other surgeon in the room as if my friend, the mother, were not in the room. This conversation included saying, “Most transplant babies are off the ventilator after 2 days.” Everyone in the room knew that this was 4 days after the transplant. It was an insensitive comment to make in front of the mother in that manner. The part that my friend found most rude was that the comment could wait until they left the room, since it was information all parties present already knew. When I expressed my irritation with the fact that the treatment team was talking as if she weren’t in the room, instead of integrating her into the team, my friend said that such discussions happen ALL THE TIME! How many times in our lives do people talk about us or our loved ones in front of us and pretend as if we don’t exist in the room? Is this a strange phenomenon that has become commonplace in the healthcare setting? How should a patient or family member confront such behavior without being seen as a problem patient? How did this kind of behavior originate in the first place? I wonder if it started as some sort of communication shortcut.

I do not believe either of the providers in the room were intentionally insensitive nor do I believe that they are callous people. This is a more widespread problem. It seems there are great barriers to overcome when discussing the importance of integrating the patient and family in their own treatment decisions, particularly when there are still providers that “forget” that they even exist at all.

Erin O'Donnell
MITSS Support Team Member