I haven’t posted in quite awhile. Why? Because for the last 6 months I have devoted over 125 hours to creating a course that will provide you with the tools to fix our healthcare delivery system. Every system is designed to produce the results it achieves, and unfortunately at this time our healthcare systems are inadvertently designed to harm patients. You will learn how to apply the principles that high performing manufacturing systems to continually improve quality, you will learn how to apply the lessons you learned in team sports to becoming an integral member of your healthcare team. When patients become part of the healthcare team they are far more likely to receive higher quality, safer and more efficient care. You will learn how to recognize impending errors and dangerous conditions so that you can avoid harm. One of the most important lessons I will be teaching is how you can become an adaptive leader, a leader who can bring about change, and goodness knows our health systems need to undergo dramatic changes. And finally I will teach you how to organize others to achieve the goal of continually improving healthcare delivery. The course is free and it is offered through the University of Florida and Coursera. The Institute of Healthcare Improvement with the help of Michael Briddon has generously offered a number of teaching modules that have been incorporated into our course. Upon completing the course you can become part of the solutions. If everyone makes one or two small improvements every week or month our systems of healthcare delivery will steadily improve. WE ALL CAN MAKE A DIFFERENCE.
Meet Soojin Jun. She wants the world to learn from her Dad’s encounter with our health care system:
A morning walk in a fog reminded me how my Dad would have felt when he was ill. Cold, unclear, and alone…I was there but I couldn’t be there. When it came to death, only my Dad was called, not me.
I would have never known that the medical systems in US killed my Dad if I didn’t go to pharmacy school after my Dad lost his life; he died a week before his flight to S. Korea in an attempt to get better and more affordable care. Here’s the story of my Dad’s healthcare nightmare.
My Dad lost his appetite and couldn’t swallow well. He was diagnosed with esophageal cancer stage III. It was due to his 30+ years of smoking and drinking. The surgeon gave my Dad two choices: chemotherapy or surgery. Both options were presented as comparable options. My Dad chose chemotherapy. In hindsight it probably was a wrong choice, although no one could prove that; however, the option of surgery quickly disappeared when my Dad lost so much weight due to the chemotherapy and his inability to swallow food. By the time we decided he needed surgery, the surgeon told us it was too dangerous now and reprimanded my Dad for not trying to eat enough food and for making a wrong choice. During his 2 month hospitalization he had a G-tube placed and was diagnosed with diabetes. When his insurance refused to pay for additional hospital time, my Dad’s primary doctor suggested moving to the psychiatry ward to extend the hospital stay, and suggested this would be no different than being in a general hospital. My Dad was very unhappy during his 2-day stay and requested discharge. He was then placed in a nursing home.
After a month stay in a nursing home, his insurance again refused to pay for a longer stay because he was able to walk . My Dad didn’t want to burden me and he chose to stay at nursing home at a personal cost of $10,000/month. After a month, I brought my Dad to my home, his bank account depleted. A visiting nurse came once per week to our home. She gave me the list of 20 drugs and instructed me what to give and when. A friend suggested getting the second opinion and introduced us to a doctor at MD Andersen. The doctor told us further treatment would cost at least $40,000 and insurance wouldn’t cover out of state medical costs. My Dad chose not to get the second opinion. He wanted to live and turned to natural foods known to fight cancer, supplements, and acupuncture. He became anxious as he lost more weight and he decided to seek treatment in his home country of S. Korea. He booked a flight and we were all hopeful. We knew a second opinion and comprehensive diagnostics, treatments, and hospitalization would all be cheaper there.
While waiting for his flight, he suffered two episodes of hypoglycemia requiring ER visits, followed by severe abdominal pain that also required that we take him to the ER. As I watched my Dad suffering with severe pain, I realized he was going to die. Even in his pain, he didn’t forget to thank the nurse who injected the painkiller. The nurse placed her hand on my Dad’s forehead and told that he wasn’t in place that expected a thank you, but she seemed grateful that he did say thank you. She was the only healthcare professional who actually cared for my Dad, during this prolonged nightmare. We believe he died of a ruptured esophagus or bowel, but it was never suggested that we request an autopsy. I will never know the exact cause of my Dad’s death
A few months after his death, we received two bills: one from the psychiatry ward (the insurance denied coverage) and one from MD Andersen. We appealed these bills. The physician had insisted on the psychiatry ward charge despite my Dad’s reticence. He suffered those two days on a psychiatry ward for what reason? The hospitalization wasn’t even covered. Despite choosing not to travel to MD Andersen, we were charged a $500 registration fee. We spent months of writing letters, and these letters proved as painful to write as receiving the bills. We would have loved to have used their services, if only we had the money.
As a pharmacy student who now understands health care Soo has a number of concerns and suggestions that could have prevented her Dad’s experience.
Problem: The cultural/language barriers complicated the crucial time of decision-making and my Dad chose chemotherapy. We had no idea that the esophagus could lose reflexes following chemotherapy; and I now realize how wrong that surgeon was in telling my Dad to try to eat. In retrospect surgery probably would have been the best alternative.
Solution: My Dad would have benefited so much more if he had clear explanations of his options and consequences of the options.
Problem: With one exception none of those who treated my Dad seemed to care. And did I mention no follow up, no explanation, and no support was provided during the transitions of his care? If only one healthcare professional took enough time to talk to us and gave us clear idea, he could have lived little longer. All this combined with our mere trust in healthcare led to disaster.
Solution: If that nurse by his ER bedside could have appeared in the beginning or even the middle of his care, a healthcare professional that actually cared for patients with empathy, he might have been here today. Lack of continuity and coordination of care is a major issue for many patients. One caregiver needs to take responsibility for the coordination of each patient’s care. This takes teamwork and communication. If my Dad had been cared for by a true team, who knows, he might be with us today.
Final Comments: I will never forget my Dad’s experience. These memories will live on for the rest of my life, and that is why I will continue to fight for patients because we will all be patients someday, and we all have the right to get the right care. Aren’t you scared that you will be cared for like my Dad? It is the time to stand up together and fight against nonsense, ironic, and paradoxical healthcare in the US.
We have a supermarket chain in Florida called Publix. George Jenkins founded this remarkable company in 1930 at Winter Park, Florida. The success of his company has always been based on customer service. As he told his employees at the end of each orientation, “If there is ever a customer you can’t handle, give them my phone number, because I will.”
Publix has a guarantee posted in every store that reads:
“Publix guarantees that we will never knowingly disappoint you. If for any reason your purchase does not give you complete satisfaction, the full purchase price will be cheerfully refunded immediately upon request. We have always believed that no sale is complete until the meal is eaten and enjoyed.”
Publix has been rated by Fortune Magazine as one of the top ten best companies to work for (2005–2008) and is one of Forbes Magazine’s top ten largest private companies (2009). Publix consistently scores higher than any other supermarket for customer satisfaction based on the national American Customer Satisfaction Index survey (1995–2010). (See Critically Ill: A 5-point plan to cure health care delivery)
Publix attributes its success to a continual focus on its customers. The key question arises, if Publix supermarkets can guarantee their food after it leaves the store shouldn’t our health care systems be willing to guarantee the care they provide to their patients after they leave the hospital or clinic? Stories like those of Jess, Carla, Marty, Veronica, and Georjean, would never have to be told. Imagine if each time a medical error occurred, the caregiver and health system immediately informed the patient, deeply and sincerely apologized, explained how the health system was taking steps to prevent the same error from harming others, and then fairly compensated the patient. Patients injured by medical errors would no longer feel as though they were being ostracized. They would no longer lose their trust in our medical system. They would no longer be suffering the financial hardship brought on by their injuries. After all, these injuries were not the fault of the patient. Why have the very institutions whose charge is to help those in need turned their backs on the patients who morally and ethically most deserve their help? When our health systems and caregivers make mistakes, shouldn’t they do everything in their power to help those they have injured?
In December of 2008 Georjean had robotic assisted laparascopic surgery to remove her kidney that contained a large tumor. The good news was that the tumor proved be noninvasive papillary transitional carcinoma and had not spread to her lymph nodes or to any other adjacent tissues. She was cured. The bad news was that immediately following the surgery she began experiencing severe abdominal pain. The physicians and nurses minimized her complaints. However, on the second day after her surgery Georjean became hypotensive (her blood pressure dropped). She looked into her husbands eyes and told him she was going to die. He called for help and the surgeons rushed her to operating room where they discovered her bowel had been nicked during her prior surgery and over a billion bacteria had leaked out of her bowel into her peritoneum and into her blood stream. Her severe abdominal pain and septic shock had been caused by what is called secondary peritonitis, a very dangerous and potentially fatal infection. The large collections of pus and bacteria were washed out, and drainage tubes were placed throughout her abdomen,
Her infection was complicated by respiratory failure requiring that she be intubated (a tube placed in her airway), supported by a mechanical respirator, and moved to the intensive care unit where she remained for 20 days. Soon after being moved to a regular floor she was discharged to her home with multiple drains, only to return 6 days later because of additional undrained abdominal abscesses. A total of 8 abscesses required drainage, and one was infected with a fungus in addition to bacteria requiring strong anti-fungal therapy in addition to intravenous antibiotics. After multiple procedures and prolonged antibiotic treatment requiring over 2 months in the hospital, she was again discharged to her home in mid-March. Here she required a special vacuum dressing and continued dressing changes for open wounds that finally healed 6 ½ months after her original surgery. As she became more active she developed large hernias in both inguinal areas (lower abdominal areas) as well as a large midline hernia.
Her surgeon elected to delay repair because of all her recent suffering. Unfortunately because of her illness she had lost her job, and soon lost her health insurance coverage. Now she could not longer afford to visit her surgeon and could not personally pay to have her hernias repaired, and by the time she was able to get Medicare coverage her surgeon was fearful of operating. He warned that surgery on her extensively scarred bowel could cause further bowel damage. Because of her poor bowel function Georjean eats a very limited diet and has to wear a special binder to reduce her hernias. Many physicians have discharged her from their care because “You ask too many questions.” Now she asks no questions and agrees with whatever the doctor says, but she wishes they would help her to fully regain her health.
Problem – Georjean underwent resection of her kidney using a laparascope. Laparascopes minimize the size of the incision and usually allow the patient to recover more quickly. However laparoscopy is technically more challenging and makes visualization during surgery more difficult. As a consequence the surgeon accidentally cut into her bowel causing severe peritonitis and septic shock.
Possible solution – Physicians who have not undergone extensive simulation training in laparoscopic surgery should utilize open abominal exploration to reduce the risk of a complication.
Problem – The nurses and physicians minimized Georjean’s complaints about abdominal pain. They thought she was a troublemaker,
Solution – Doctors and nurses should carefully listen to their patients’ complaints and order the appropriate tests to exclude a serious cause. In Georjean’s case she should have undergone surgical exploration and drainage within the first 24 hours. This would have reduced the severity of her infection, and probably preventing her from developing respiratory failure, as well as reduced the number and severity of her abdominal abscesses.
Problem – Georjean lost her job and her health insurance as a consequence of a surgical error.
Solution – Shouldn’t the health system and physician who made this mistake have assisted Georjean both medically and financially, rather than dropping her from their care? Is this how you would want to be treated? Anyone in her shoes would agree that hospitals and caregivers need a new approach to caring for patients who are injured by a medical or surgical error. Potential solutions will be discussed in my next post.