Thursday, November 03, 2005

Notes from Dan Ford

From time to time my postings stimulate responses and observations from long-time friend, fellow alum, and health care executive head hunter Dan Ford. Some may remember the tragic story of the medical error that changed his life and that of his ex-wife.

Herewith his most recent message:

1) Go to www.themedform.org. A medication listing form for consumers (meaning every one of us, elderly parents, children, other family, friends), to keep organized, and for those periodic visits to the doctor and hospital. A good step to help prevent one aspect of medication errors. I was the last speaker at the press conference in Phoenix on Sept. 1 when this was announced, and the first consumer to complete The Med Form. A nice, symbolic gesture.

2) Our AzHHA Patient Safety Steering Committee visited the Palo Verde Nuclear Power Plant, west of Phoenix, on October 20, receiving a safety focused tour. Is the largest electricity producing plant in the country, servicing parts of CA, AZ, NM and TX. The plant re-opened the next day, after being shut-down for about two weeks. It had received a communication from another power plant about the potential for a serious safety issue. The problem never materialized at either plant, but Palo Verde was morally/legally obligated to shut itself down, while it examined the issue, which was potentially real because they could not find anything in their manuals that said it couldn't happen. They finally resolved it, got permission to re-open. Would hospitals do the same, e.g., an operating room, or are there too many political, fiscal, ego and role behavior issues that get in the way, even though there may be a serious potential safety issue?

Every leader at the plant carries a little "Leadership Observations" note pad. Each day he/she is expected to jot down two safety ideas, including input from other employees. They are assembled periodically, discussed, evaluated, used. They have a huge, conference-sized room devoted entirely to show and tell demonstration type safety training procedures, equipment, etc, in addition to classrooms for training. Their safety program oversight is divvied up between two executives. Roles are affectionately described as one being to protect the people from the facilities and the other to protect facilities from the people.

3) Your recent article on "Accountability in Health Care" was superb, Dick. I complimented you. We exchanged emails about the subject and you expressed an interest in finding the hospital trustee who asks how many of the 90,000-plus annual deaths identified by the IOM occurred in his hospital and insisted that steps be taken to prevent them in the future. I volunteered to help you find that one trustee. I am seeking that entire board and CEO who are so angry and livid about patient safety and the continued loss of lives and serious injuries, even with remarkable steps being taken with resources like IHI and others, that they are demanding and modeling the accountability. It is why I give patient safety presentations to provider audiences, to light such a fire.

4) For the last year, I have served on the Quality Committee of the Board of Directors of an Arizona health care system and recently joined its Patient Safety and Quality Council. The former is policy and the latter operations focused/action oriented. It is a great learning experience. I am able to contribute in a substantive way. I remind them that I am not a clinician. They remind me that they have plenty of clinical experts around the table and wanted someone what had experienced a medical error, who was passionate, objective, caring, candid, not shy, would ask the dumb and the dumb like a fox questions. I make the CEO's a little nervous when I suggest stretch versus conservative patient safety goals. The worst that can happen is that we do not meet the goals, while too many unexpected outcomes continue to happen. In spite of the fact that I am a "safe" consumer as an industry insider, this would seem to be one model for hospitals to involve consumers in their patient safety and quality endeavors.

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