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Sorry Works! Blog

Making Disclosure A Reality For Healthcare Organizations 

Part III - Sorry 12 Years After Fatal Medical Errors...

Website: http://www.sorryworks.net March 29, 2012 Doug Wojcieszak, Founder & Spokesperson Contact phone/e-mail address: 618-559-8168; doug@sorryworks.net

PART III -- SORRY 12 YEARS AFTER FATAL MEDICAL ERRORS - A PERSONAL JOURNEY Last summer I was waiting at the bank getting frustrated. I had made an extra principal payment the month before, but the payment had not been properly applied to my account. The local branch of this BIG, national bank was having trouble getting their own people seven states away to fix the snafu. I was cooling my heels, feeling trapped and generally unhappy when my cell phone sprang to life. It was a pleasant sounding gentleman from Cincinnati by the name of Jim May, who is the CEO of Mercy Health Partners.

Mercy Health is a division of Catholic Health Partners (CHP), and readers of this space will remember that CHP recently bought the hospital where my brother died from medical errors in 1998. As a short summary, CHP flew me home to offer an apology and explain safety changes that have been implemented since my brother's death. We have had several additional meetings, including one meeting where I gave a brief talk to the CHP leadership team on my brother's story and my work in Sorry Works! teaching disclosure to healthcare organizations and caregivers. The original newsletters are below.

During that phone call in the bank lobby, Jim May told me he was one of the people who heard my presentation to the CHP leadership team and he had a question for me: "Had I ever considered joining a hospital safety & quality committee?"  I was surprised and flattered, and stuttered that I had maybe given the idea a passing glance over the past few years, but now he had my full attention! Jim went onto explain there was some openings on their quality committee due to term limits, and he encouraged me to apply.

The next step was for me to meet Jim and two other board members in Cincinnati for a lunch. In short, the lunch was a chance for both sides to figure out if this was a good fit. A few months later Jim formally extended an invitation to join the quality committee, and I accepted. This was a great honor for me and my family. My parents are very happy.

I attended my first committee meeting in January, and my second committee meeting was earlier this month. Great experiences. To be able to contribute some ideas and thoughts, and also ask questions is very rewarding. It's a good feeling. I've also attended a board dinner, and have had lunch with my committee chairman. Not only do I feel like I'm contributing to Mercy, but I'm also learning a ton. It's a positive experience all the way around.

I encourage you, our readers, to think of this story from your perspective. This may be a way for you to get some patients-families involved. To be fair, it won't be right for every case...sometimes the family member whom you think would be "perfect" for such a committee simply can't participate because the pain is too great. You just have to see. I respect CHP/Mercy for taking time to make sure this was a good fit for everyone.

Moreover, many healthcare professionals have cases/stories in their files similar to my family. Cases that have been "legally closed" for years, but patients, families, and caregivers never received emotional closure and healing. It's never too late to reach out and try to heal people.

I truly encourage healthcare professionals to look for these opportunities. See directly below for another story of a family being involved in a hospital safety committee -- another terrific story.

Sincerely,

- Doug

Doug Wojcieszak, Founder Sorry Works! PO Box 531 Glen Carbon, IL 62034 618-559-8168

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When Things Go Wrong, Admit Mistakes Joe Cantlupe, for HealthLeaders Media October 13, 2011

Something went wrong a few years ago when Michelle Malizzo Ballog underwent surgery to replace a temporary stent in her liver at the University of Illinois Medical Center, Chicago, IL. Tim McDonald, MD, chief safety officer, tells me he remembers vividly the text he received from a nurse as Ballog stopped breathing: Come quick. Things going badly. Cardiac arrest.

The 39-year-old woman suffered cardiac arrest, lapsed into a coma and died several days later. Within hours, McDonald and other hospital officials, including the risk management officer, went over details of Ballog's hospital stay with her family.

McDonald had the sense that the father felt that "here we go, here's the whitewash." No, hospital officials told him, "We'll look into this." They did, McDonald says, and they found that hospital errors were to blame.

In the crucial minutes after Ballog's death, the hospital responded to stunned and questioning family members, and talked about things that went wrong. And the Malizzo family not only didn't sue the doctors, but her father, mother, and sister responded to McDonald's offer to join them on a safety review committee to prevent future medical errors.

What occurred did not turn tragedy into triumph, but served as a lesson - one step at a time - in which communication and cooperation helped detour the spiral of medical malpractice litigation.

UIMC's relationship with the Malizzos reflected "effective communication and appropriate resolution," McDonald says. "And appropriate resolution isn't always about money. That's the crux of our program."

Indeed, UIMC's communication style that was on display with the Malizzos was formed in its patient safety program that allows nurses, physicians, and administrative staff to move quickly to report, review, and effect change following patient safety errors, McDonald says.

Since 2006, the hospital has established a protocol known as the Seven Pillars: Crossing the Patient Safety Medical Liability Chasm.

Last year, UIMC received a $3 million federal grant for the program as a demonstration project. The program objectives, as outlined by McDonald, are to "improve patient safety and mitigate medical liability risk through improved communication with patients and family, disclosure and early (monetary) offer when patients suffer preventable harm, and learning from mistakes to prevent future harms."

When UIMC began reporting on unsafe conditions, and harmful events, staff reported about 1,500 occurrences the first year – a number that seemed "highly" inaccurate, McDonald says. However, staff "spread the word that leadership was behind this" reporting initiative. Now, there are about 8,000 such events reported annually, McDonald says.

"To some extent, we know everybody's worried about getting sued," he said. "But if you take a principled approach to harm, you can avoid a whole lot of lawsuits, and come to appropriate non-adversarial resolutions. In a whole lot of our cases, we've avoided protracted litigation that brings docs in and everything else."

McDonald says UIMC "embraces the concept of collective accountability" when appropriate and "reaches out to the family for quicker resolution before they decide to go to trial."

At least 40% of physician leaders surveyed in the HealthLeaders Media 2011 Intelligence Survey say fear of lawsuits is a major influence regarding their decisions to order tests or procedures. More than 60% of physicians age 55 and older have been sued at least once, according to the American Medical Association.

The AMA and dozens of other medical groups are pressing the Joint Congressional Committee on Deficit Reduction for a legislative package that includes a medical liability reform element. The physician groups want the committee to consider a "reasonable limit on non-economic damages" that would reduce the federal budget by $62.4 billion over the next 10 years, as the Congressional Budget Office calculates it.

While the political debate continues over medical liability, McDonald and the University of Illinois Medical Center show some improvements can be done, one step at a time, within hospital systems themselves.

After Ballog died, McDonald and his staff told the family uncomfortable details of what had happened. The Chicago Tribune reported that monitoring errors were made when she was placed under anesthesia and surgery, and that her parents were stunned that her death was caused by preventable errors that they didn't know about at first.

The hospital eased the family's concerns by being upfront. When the nurse wrote the text message, it was part of the hospital's "hotline" action plan for adverse events for which the hospital could be at fault.

"We maintained trust with (the family) and communicated throughout," McDonald says. Referring to the medical errors, "I would tell you, nobody behaved recklessly, and it was all mistakes and lapses that the entire team made which, truth be told, the institution could have been a little more on top of," he said.

As hospital officials evaluated the mistakes, the focus became being "part of the solution, instead of part of the problem," McDonald explained.

In the hours immediately following Ballog's death, UIMC made clinical changes to require an anesthesia specialist be present for procedures such as hers. McDonald says that it is difficult in a litigious climate for doctors and hospitals to embrace new systems and acknowledge that things went wrong.

"We know that liability and tort issues are up front, and you need to embrace those and understand those and move forward, where you are telling the legal system, 'we don't need no stinkin' legal system to tell us when we've not done something right,'" McDonald says. "When we know we haven't done the right thing it is incumbent upon us to fix it and be honest about it and let's cut the baloney. At the end of the day those who should worry about assets are those who behaved recklessly."

As members of the UIMC's patient safety review committee, Michelle Malizzo Ballog's father, mother, and sister drive for an hour and a half to attend meetings. They have been contributing members of the panel, McDonald says. Michelle's dad Bob Malizzo "will say things in a very respectful way like, 'wait a minute, weren't we talking about this problem a year ago, and didn't you say you would fix it?' McDonald says. "It's awesome."

About one year after his daughter's death, McDonald walked in the hospital and was surprised to see Bob Mallog hooked up to a machine for a cardiac procedure.

"He told me, 'this is the place where my heart was broken,'" McDonald recalls, "'and I'm trusting you to fix my heart.'"

Healthcare leaders, please take our 2012 Industry Survey. Contribute to the top source of healthcare industry insight, see the results from your peers (published online in February), and be entered into a drawing for an iPad.

Joe Cantlupe is a senior editor with HealthLeaders Media Online. He can be reached at jcantlupe@healthleadersmedia.com.

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February 28, 2011 Doug Wojcieszak, Founder & Spokesperson Contact phone/e-mail address: 618-559-8168; doug@sorryworks.net

PART II -- SORRY 12 YEARS YEARS AFTER FATAL MEDICAL ERRORS - A PERSONAL JOURNEY Last fall I shared with you the story about being contacted by the hospital system that now owns the hospital where my brother died from medical errors. The original e-newsletter from last fall is directly below. In that newsletter, I promised to keep you posted on developments.

Last Monday I went home to Cincinnati to meet again with Jana Deen of Catholic Health Partners (CHP) and visit Jewish Hospital, where my brother Jim died and which CHP purchased last year.

I had never stepped foot in Jewish Hospital before...I was living in St. Louis at the time when my brother died, and simply had received updates and the final news over the phone. However, I am somewhat familiar with the hospital....it's right down the street from our family's church, and across the street from the mall where we regularly shop. As I child, I remember the hospital being somewhat small, but as I grew up the hospital also grew in size to the large, urban facility it is today. My brother died in that large, urban hospital. After my brother's death, it was too painful for my parents to drive by the hospital on their way to church or the mall. They would take the long way around to get to church or the mall, even if traffic was backed up.

So, I was curious to step into the hospital, and curious how the meeting would go. Jana had scheduled a meeting with the new president of the hospital, the chief operating officer of the region, and the residency director. We met in a private conference room on the second floor. Everyone apologized for my brother's death, and told me the meeting was long overdue. That was good to hear. It was also good to hear specifics of how medicine at Jewish Hospital has improved since my brother died....how lives are being saved today. But, then Steve Holman, the new Jewish Hospital President, shared a story of his own. I learned that like me, Steve had lost a brother in a hospital.

Steve's brother - Dennis - had been involved in a horrific car accident at age 14. Dennis' injuries were so traumatic that the doctors thought he would not survive, however, Dennis defied the odds. But, Dennis had to learn how to live again, including re-learning how to walk, eat, and other basic functions. Unfortunately, Dennis had suffered brain trauma, and like many brain trauma victims, he displayed compulsive behaviors.

One day at age 19, Dennis came home and announced to his mother that he wanted to kill himself. Mrs. Holman quickly called the hospital to have Dennis admitted. She told Dennis to pack a bag and drove him to the hospital. Beside the door where Dennis entered the hospital was a big sign that read all bags will be searched. However, nobody searched Dennis' bag. A nurse escorted Dennis to his room, told him to put on a hospital gown, and she would be back to check on him in a few minutes. Dennis asked the nurse if she was going to check his bag, and the nurse declined to do so. The nurse exited the room, took a few steps down the hall, and heard a gun shot. Dennis had killed himself with a gun he had packed in the bag -- a bag that was never searched despite hospital policy and Dennis' own request.

As Steve put it, the nurse not checking his bag was a signal to Dennis that it really was his time to die. Very tragic. Steve's family did not receive an apology or admission of wrong doing and only heard from the hospital's lawyers.

To say the least, Steve Holman and I connected last Monday. He was not just another hospital CEO (I've met lots of them!)...he was a person who had walked a mile in my shoes. He understands me, and I understand him. Moreover, I firmly believe that as the new CEO of Jewish Hospital he is going to do everything possible to make sure there are no more stories like Dennis Holman or Jim Wojcieszak, but if those mistakes occur (and they always will in healthcare so long as humans are involved), Steve will be there for the patient, family, and his clinicians.

The power of this story and encounter is there are lots of people like Steve Holman working in hospitals, practices, and healthcare organizations all around the country and the world. Healthcare professionals who have lost their own loved ones to errors and/or were involved in events that led to the death of a patient. I've talked to and hugged many of these people. These folks have mourned their stories, but, now, thanks to disclosure, these folks have a real avenue to share these stories and improve healthcare. To make sure their loved ones and/or their patients didn't die in vain. Perhaps this is your story. Prior to our meeting, Steve said he never really shared the story of Dennis...but now he has. It's your turn now. You have the encouragement and avenue through disclosure to positively channel your grief. Step up, share your stories, and demand that today's patients and families are treated better with disclosure when things go wrong.

Steve, Jana and myself talked about ways we can memorialize my brother going forward with work on disclosure at Jewish Hospital and the entire CHP system of hospitals - and also use the story of his brother, Dennis. I will keep you, our readers, posted on the efforts as we continue forward. This is going to be very meaningful.

It was very fulfilling to have this meeting, and it has given me great peace. I'm very happy.

After the meeting, I decided to stop by my brother's grave. I had not been there for years, because, as I wrote in last fall's newsletter (see below), I don't believe Jim is there. He's with God and still watching over us. But, this time, I felt pulled to visit. To me, the meeting at Jewish Hospital felt like this story is coming full circle, and going to the grave and saying a pray was a way to further complete that circle. There is much more work to do on disclosure, but, on a personal level, healing and peace are more present for my family and me. My mother can now drive by Jewish Hospital on the way to the church or the mall.

In closing, I especially want to encourage every healthcare, insurance, and legal professional to really think about this newsletter from your perspective. Every reader of this e-newsletter surely knows of one or more stories/cases similar to mine and Steve's....where the case is "legally" closed but the emotional wounds for patient, family, clinicians, and the institution are still wide open and begging for attention. Use our stories as an example and as encouragement to reach out to these people, and to also learn from these events. And, no, I can't guarantee every patient/family will welcome the phone call or e-mail, but many will. And the wonderful healing and learning are worth the risk of an e-mail not being returned or phone being slammed down. Try it today. Peace and healing can be yours too.

Again, I want to publicly thank Jana Deen of Catholic Healthcare Partners and the entire CHP team for their compassion and friendship. I also want to thank again Jim Conway of IHI for introducing us.

God Bless,

- Doug

Doug Wojcieszak, Founder Sorry Works! PO Box 531 Glen Carbon, IL 62034 618-559-8168 (direct dial)

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October 7, 2010 Doug Wojcieszak, Founder & Spokesperson Contact phone/e-mail address: 618-559-8168; doug@sorryworks.net

SORRY 12 YEARS YEARS AFTER FATAL MEDICAL ERRORS - A PERSONAL JOURNEY I've told the story of my brother Jim's death to medical errors in a Cincinnati, OH hospital countless times in live presentations as well as the Sorry Works! Book, media interviews, and other venues and forums. I've used this story to teach healthcare, insurance, and legal professionals about the power and importance of disclosure...and it's a very effective teaching tool. It focuses people like nothing else. But I've always hoped - secretly - that by continually telling the story I would be contacted by the hospital or providers who were involved in Jim's care. I always hoped this would happen, but never truly expected it.

After the lawsuit was settled, we heard nothing...nothing from the hospital, nothing from the doctors or other staff for 12+ years. But I can't say that anymore.

By happen chance, I was visiting my parents in Cincinnati in mid- August when I received the e-mail. The e-mail came from Jana Deen, Chief Patient Safety Officer for Catholic Healthcare Partners (CHP) in Cincinnati. CHP had bought out Jewish Hospital, where my brother had died, earlier this year. Jana was alerted about my story by Jim Conway from IHI.

I was sitting at my parent's kitchen table, late at night, catching up on work and e-mails after the kids and my wife had gone to bed. My Dad was also in bed, but mom was still up reading magazines and casually watching television. I got up from the kitchen table and said, "Mom, you're never going to believe the e-mail I just received..." For over an hour, mom and me just sat there and talked....and cried. I learned things about Jim's death I had never known.

I sent an e-mail back to Jana and we scheduled a time to talk the following week.

The day of our scheduled phone call I was anxious, to say least. Would Jana really call me? was the question that kept racing through my mind. But she did...and we had a very good conversation. She said she was notified by Jim Conway and then investigated my brother's case, and even though the case is 12+ years old, people still remembered. She sincerely apologized and asked how my parents and the rest of the family were doing. Then she asked me to think about what CHP could do for us now, and invited me home to Cincinnati at CHP's expense to meet with their CEO, Mike Connelly. Furthermore, Jana asked to come hear me give a Sorry Works! presentation, again at CHP's expense. To say the least, I was impressed and moved by the compassion showed by this former ER nurse.

I immediately called my folks after the conversation with Jana, and they were impressed too. I told them Jana asked us to think about what CHP could do for our family. Mom and Dad gave a quick and firm response: Show us Jim didn't die in vain. Show us how medicine learned from the mistakes that killed Jim as well as the mistakes in handling the relationship with our family post-event.

A few weeks later I met Jana in person the first time, in New Jersey. I was giving a presentation to a residency program retreat along with my co-presenter and friend, Dr. Peter Schwartz. Jana and I met for dinner and we must have talked for well over an hour. We talked about Sorry Works! and disclosure, and the challenges facing healthcare systems struggling to adopt disclosure and increase safety. We also talked about other stuff and just got to know each other. Jana is a nice person. And the next day she was impressed with the Sorry Works! presentation and said it gave her lots of ideas.

A week later I flew to Cincinnati for my meeting with Jana and her boss, Mike Connelly. Again, I was a little anxious and not sure what to expect - but it was another good meeting. Jana and I sat in Mike Connelly's office, a beautiful view of the Cincinnati skyline in the background, and the three of us talked about my brother who used to work in downtown Cincinnati...and take me to Reds' games. My big brother. And what his death meant to our family, and what the disclosure movement means to us now. Mike had read my book prior to the meeting, and acknowledged the late 90's (when Jim died) were a very secretive time in medicine. Discussions surrounding errors were minimized, and always focused on justifying mistakes as opposed to learning from them. Fortunately, times are changing. For example, Mike told me how if my brother's case had happened today in one of their hospitals, the president of that particular hospital would be required to meet with my family within 24 to 48 hours. Mike and Jana said by making this meeting a requirement, it forces leadership to get involved, which increases accountability and learning. Mike and Jana described how they are working across their system to learn from mistakes and truly improve their processes - as opposed to justifying things. It was a long conversation and I won't go into all the details, but it gave me a good feeling. Moreover, we discussed things we can do with Jim's story and case....those who have heard or read the story know it is full of rich learning opportunities for clinicians and leadership. We have some wonderful ideas in process I will share down the road.

And by happen chance, CHP was holding a system-wide safety seminar for their hospitals the day I visited with Mike and Jana...and they invited me to sit in. Again, it was comforting to see a large room of medical professionals seriously talking about how to better serve patients like me. Medicine is trying to get it right. There is a lot of work to do and it won't happen overnight, but I believe the effort is there.

After the meeting, I went home to have dinner with parents. I thought about stopping by Jim's grave on the way home, but decided against it. My surviving brother Robert has often said to me, "Jim' s not there." Bob's right....Jim is with God and still with us too. He's watching over my parents and the rest of the family, and continually dropping pennies in the airports I travel through. So, I sped home and had a wonderful dinner and evening with my parents. I told them everything, and they were pleased. Healing.

So that's the story...so far. There will be more to come and I will keep you posted. Obviously, this development is very meaningful for my family....and I want to publicly thank Jim Conway of IHI for his help. There is a lesson, however, beyond my family that is hopefully resonating with readers of this newsletter: It's never too late to say "sorry." If you've worked in a hospital, medical practice, insurance company, or law office for any period of time you probably know of several closed cases that didn't receive complete and proper closure. You know of patients, families, and clinicians who are still suffering....still haunted by the fact they couldn't talk. I sincerely urge every reader of this newsletter to search their hearts and think about such cases, and make that brave step. Reach out --- and not that every patient or family will welcome the gesture, but many will. Many patients and families need this, and so do the clinicians and other staff. Good can come out bad, even after many years. A lot more good is going to come out of Jim Wojcieszak's death and I can't wait to share it with you. Stay tuned.

God Bless,

- Doug

Doug Wojcieszak, Founder Sorry Works! PO Box 531 Glen Carbon, IL 62034 618-559-8168 (direct dial)

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