Presented by Sherri Loeb, BSN, RN, on March 13, 2015 at the fifth Center for Health Literacy Conference: Plain Talk in Complex Times.

1. “The Impossible Dream”
Safe, High Quality, and Patient
Centered Care…
Our Perspective On A Broken
Healthcare System
1
Sherri T. Loeb, RN, BSN
sherriloeb@gmail.com
Copyright: 2013: Sherri T. Loeb RN, BSN !

2. Who am I…and Why am I
here??

3. Jerod’s Health Care Journey.....
• Routine physical in August 2011, was asymptomatic and felt in perfect
health; only complaint – minor low back pain
• PSA at the end of 2009 – 1.29 Normal value is 0-6.5 depending on age and
race
• PSA in 2011 – 535
• Biopsy: Gleason 8 (4+4) (positive 3 of 12 core samples)
• Stage IV prostate cancer at diagnosis with significant bone metastases
3Copyright: 2013: Sherri T. Loeb RN, BSN & Jerod M. Loeb, PhD.

4. A Tale of Two Cities
• August 2011 – December 2011
• Treated locally with std of care tx – failed initial therapy after a
little over 3 months of treatment
• Next option – std of care – “what insurance would cover” – No
talk about additional options, or clinical trials besides double
blind. Nothing geared specifically towards aggressive case.
• Fall 2011 - Diagnostic clinical trial NIH
• December 2011-January 2013 - Entered clinical trial after
failing1st line tx. Self referral to MD Anderson Cancer Center
in Houston Texas.
• January 2013 – Metastasis to liver and bone marrow, DIC,
Tx with two IV chemo agents and returned to almost full
functional status. IV combo not available locally.
4

5. A Tale of Two Cities
• June 2013- October 2013 “Magic” Chemo stops
working
• New chemo agent started – again not std of care locally
but showing promise at MD Anderson
• August 2013 – Liver mets and DIC return - one last
chemo suggestion –
• October 2013 Hospice care
• Passed away October 9, 2013
5

6. 6Copyright; The New Yorker Sept. 23, 2013!

7. 7
Local Hospitalization -
July 2013
• Missing vital signs
• No patient assessment
• Bypassing of CPOE alarm system
(audible and visible)
• No communication among
caregiver(s) and patient/family
members or physician to physician
• Lack of hand hygiene/Pt. ID
• Absence of Shared decision-making
Picc line experience
Copyright: 2013: Sherri T. Loeb RN, BSN & Jerod M. Loeb, PhD.
• 100% Hand Washing
• Phenomenal Communication – White
boards in ED and Inpatient Rooms
• Bedside Handoff Report between RN’s
• Patient Centered Compassionate Care
• Shared Decision Making
• Patient and Family Engagement
• Team Approach
• Excellent Transitions in Care
• Patient Safety Key in all areas of care
First Hospitalization in
Houston Cancer Center –
January 2013

8. Surviving A Health Care Crisis Requires Having
An
Relative/Friend With You At All Times
• Even health care professionals become
deaf, dumb and blind when in crisis mode
about their own health
• Navigation of the health care system
requires a map, a guide, and an
extraordinary amount of skill and stamina
– even for those who work in the system
• And that is before you have to deal with
insurers
88!
Copyright: 2013: Sherri T. Loeb RN, BSN & Jerod M. Loeb, PhD.

9. We Have Seen The Best Of Health Care And The
Worst Of Health Care….
• Drugs that work and then stop working
• Physicians who prescribe drugs that should not be
prescribed together
• Dispensing errors; failures to accurately reconcile
medications
• The interesting phenomenon of being hurt in order to be
helped
• Unanticipated drug-drug interactions
• Forgetting to be told the results of significantly abnormal
laboratory results
• Almost never being given good news without the
inevitable "but" that all cancer patients can associate
with
• An association with several oncologists who care and are
extraordinary role models - and some who are not
99!
Copyright: 2013: Sherri T. Loeb RN, BSN & Jerod M. Loeb, PhD.

10. Communication Failures Are The Rule
And Not The Exception
• Literacy levels are low…..and health
literacy levels are even lower
• Communication failures at transitions of
care are nearly ubiquitous…..and harm
patients every day
• These failures occur between physicians
and physicians, physicians and nurses,
nurses and nurses, and between all types
of caregivers and patients
1010!
Copyright: 2013: Sherri T. Loeb RN, BSN & Jerod M. Loeb, PhD.

11. 11
• With increased attention on transitions of care in light
of the recent scrutiny of duty hours, consultations and
other interphysician interactions, such as handoffs, are
becoming increasingly important. As modern medicine
increases in complexity, the skill of communicating
with medical colleagues throughout the continuum of
care becomes more challenging.
I’m Clear, You’re Clear, We’re All Clear: Improving
Consultation Communication Skills in
Undergraduate Medical Education
Academic Medicine, June 2013 - Volume 88 - Issue 6 p 753-758 Kessler,
Chad S. MD, MHPE; Chan, Teresa MD; Loeb, Jennifer M.; Malka, S. Terez MD

12. Betsy Gornet from Sutter Health.

13. 13New York Times October 13, 2014!

14. 14
The Reality......!
“I have the distinct feeling that the
patient in America is becoming invisible.
She is unseen and unheard....I gently
insist that we go to the bedside, but that
is often a place where the team is no
longer at ease. I realize what has
happened: the patient in the bed is
merely an icon for the real patient in the
computer.” A. M. Nussbaum, MD!
A Piece of My Mind!
JAMA!
July 17, 2013!

15. 15
Shared decision making is an approach where
clinicians and patients communicate together using
the best available evidence when faced with the task
of making decisions, where patients are supported
to deliberate about the possible attributes and
consequences of options, to arrive at informed ...
http://en.wikipedia.org/wiki/Shared_decision_making

16. …But Is It Truly Accepted And
Practiced??
The Value of Sharing Treatment Decision Making with Patients –
Expecting Too Much?
• Ethical responsibility of clinicians to facilitate patient involvement in
treatment decision
• More engaged patients are more informed
• Objectives of SDM are to fully inform patients and their families about
treatment options including risk and benefits and patient values and
preferences
• Does not support its potential to reduce overtreatment and costs.
• Clinicians are not adequately trained to facilitate SDM, especially eliciting
patient values and preferences for treatment.
16
JAMA October 16, 2013 Page 1559!
Corresponding Author: Stephen J. Katz MD, MPH!
!
JAMA VIEWPOINT

17. 17
The Hierarchy Gradient in Health
Care
Copyright © 2012 American Medical Association. All rights
reserved."

18. 18
Copyright © 2012 American Medical Association. All
rights reserved."
From: Communicating With Physicians About Medical Decisions: A Reluctance to Disagree!
Arch Intern Med. 2012;():1-2. doi:10.1001/archinternmed.2012.2360"
Percentage of participants who would ask questions of, discuss preferences with, or express disagreement to their
physician when relevant."
18!

19. 19
“I think there is a
revolution coming. In the
past, patients were
expected to be obedient
and compliant.”
Harlan M.
Krumholz, MD, SM
Yale School of
Public Health
July 2013

21. Patient and Family
Engagement
A set of beliefs and behaviors by patients, family
members, and health professionals and a set of
organizational policies, procedures and interventions
that ensure both the inclusion of patients and families
as central members of the healthcare team and active
partnerships with providers and provider organizations.
Benjamin K. Chu, M.D. Chair of the AHA’s Board of Trustees
21

22. “What I’ve learned from my odyssey thus
far…
We need to listen to the real voice of the
patient. What he/she is thinking/feeling/or
believing. I gave them lip service. I know
that now…I didn’t know that then.”
From John M. Eisenberg Honorary Lifetime Achievement
Award in Patient Safety and Quality - 2011
22Copyright Jerod M. Loeb, PhD April 2012

23.
• You treat a disease, you win, you lose. You treat a person, I
guarantee you, you’ll win, no matter what the outcome.
• Our job is improving the quality of life, not just delaying
death.
• We need to start treating the patient as well as the disease.
• You actually are a doctor and admitted it, you’d say, “I don’t
cure a huge percentage, I don’t have a 50 percent cure rate…
(but) I can have a 100 percent compassion rate.”
Hunter “Patch” Adams MD 1998
23

24. Patient Expectations 100%
of Time
• To be always told the truth.
• To have things explained to me fully and clearly.
• To receive an explanation and apology if things go wrong.
-Jim Conway, IHI presentation

25. Patient Expectations 100%
of Time
• To be listened to, taken seriously, and respected as a
care partner.
• To have my family/caregivers treated the same.
• To participate in decision-making at the level I choose.
-Jim Conway, IHI presentation

26. 26
Text
Chicago Magazine, January 2013

27. 27
Patient-centered care supports active
involvement of patients and their families in
the design of new care models and in
decision-making about individual options for
treatment. The IOM (Institute of Medicine)
defines patient-centered care as: "Providing
care that is respectful of and responsive to
individual patient preferences, needs, and
values, and ensuring that patient values guide
all clinical decisions."
Donald Berwick MD, MPA!

28. • Words can never express the gratitude of a terrified
parent when such kindness is shown … when we feel
seen, and that we matter. Think about it: as hospital
patients, a parade of people you do not know have
license to pierce and cut your skin, waken you out of
your sleep, expose your body, move your things out
of your reach, or refer to you as “the knee
replacement in 305.”
PAT MASTORS PATIENT | AUGUST 5, 2013
The gratitude of a terrified
patient when kindness is shown

29. 29
Reasonable
Expectations
That
Patients
Who
Are
Seriously
Ill
Deserve
To
Have
Ful>illed:
•
To
have
one’s
pain
and
other
physical
symptoms
regularly
assessed
and
competently
treated.
•
To
have
adequate
information
about
one’s
condition
and
treatments,
in
clear
and
simple
terms.
•
To
have
care
coordinated
between
visits
and
among
physicians
and
health
programs
involved
in
one’s
care.
•
To
have
crises
prevented
when
possible
and
have
clear
plans
for
managing
emergencies
in
place.
•
To
have
enough
nurses
and
aides
on
staff
in
hospitals
and
nursing
homes
to
provide
safe
and
high
quality
care
•
To
have
one’s
family
supported
in
giving
care,
in
their
own
strain
and,
eventually
,
in
their
grief.
Ira Byock MD!
The Best Care
Possible!

30. Making Individual Health Care Decisions
Can Be Hard – Even With Good Evidence
And Even For Someone In The Field For
Many Years
Technical Quality Is Important -
But So Too Is Patient Experience Of
Care
3030!
Copyright: 2013: Sherri T. Loeb RN, BSN & Jerod M. Loeb, PhD.

31. Every hospital should have a plaque
in the physicians’ and students’
entrances:
There are some patients whom we
cannot help; there are none whom
we cannot harm
31
Stanford University medical professor Arthur Bloomfield

32. 32
SAFETY
QUALITYSERVICE
ALWAYS

33. Sign By Employee Breakroom at Costco

34. 34
• Outpatient medication errors
• Lack of medication reconciliation leading
to missing of medications
• Medications that remain forever on
medication lists
• Wrong indication for medications
• Pharmacy/pharmacist attitudes
Med Rec and Med Errors!
Copyright: 2013: Sherri T. Loeb RN, BSN & Jerod M. Loeb, PhD.

35. 35
Ben Kolb
Died, Age 7
Medication Error
Errors Waiting To Happen
Jerod M. Loeb, PhD, January 2013!

36. 36
Our Most Recent Medication Error
Copyright: 2013: Sherri T. Loeb RN, BSN & Jerod M. Loeb, PhD.

37. 37
One Of My Medication Errors
Copyright: 2013: Sherri T. Loeb RN, BSN & Jerod M. Loeb, PhD.

38. 38
Text
Looks Pretty Normal, Right?
Copyright: 2013: Sherri T. Loeb RN, BSN & Jerod M. Loeb, PhD.

39. 39Jerod M. Loeb, PhD, January 2013!

40. 40

41. 41
My Most Recent Medication Error
Copyright: 2013: Sherri T. Loeb RN, BSN & Jerod M. Loeb, PhD.

42. 42

43. 43

44. 44
Surgical Errors!
Forgotten 13” Surgical Retractor!
New York Times, December 11, 2001!
Jerod M. Loeb, PhD, January 2013!

45. 45
FINDINGS: No intracranial hemorrhage. Mild patchy areas of
low-attenuation in the periventricular and subcortical white matter
bilaterally. Small area of encephalomalacia in the right high
convexity parietal lobe cortex A small area of right anterior
frontal lobe encephalomalacia. The rest of the brain
demonstrates preserved gray-white differentiation. No
hydrocephalus or midline shift."
"
Basal cisterns are patent. Visual is paranasal sinuses and
mastoid air cells are clear"
"
"
IMPRESSION: Intracranial bleed. Encephalomalacia in the
right cerebral hemisphere with patchy areas of low-attenuation in
the white matter, which are nonspecific. These may represent
ischemic degenerative changes of the brain, although would be
extremely early for patient's stated age of 35. Please correlate
with history of diabetes, hypertension, or sickle cell disease. If
there is suspicion for acute infarction, further evaluation by brain
MRI is recommended.."
How/Why Do Things
Like This Happen?!
November 2012

46. 46

47. Choose Your Disease Carefully, But Choose Your
Health Care Provider Even More Carefully
• Not all physicians or hospitals have the same
expertise
• Ratings (hospital and physician), while ubiquitous, are
often irrelevant, and many times, just wrong
• Access to innovative care depends on innovative
caregivers with innovative knowledge and awareness
• Patient’s values and desires matter, especially when
the evidence runs out as it often does in cancer
• Interdisciplinary vs. multidisciplinary
47
Copyright 2013: Sherri T. Loeb RN, BSN!

48. 48

49. 49

50. 50Harrisburg, PA – Dec 2011

51. Twenty Years Of Measurement In Health Care Has
Not Given Patients What They Want Or Need
— Measures of process, while improving quality, do not help patients
make better health care decisions
— Outcome measures matter, but are hard to measure
— Patient safety measures are (so far), not helpful to providers or to
patients (especially measures of improvement in patient safety)
— Where are the measures of patient choice?
— Incentive payment programs based on measures at the hospital
and physician level are a grand, uncontrolled experiment
— There are too many irrelevant and unreliable measures
51Copyright Jerod M. Loeb, PhD. January 2013

52. 52
Front-Line Lessons!
• The power of friendship triumphs
• Care is not the same from MD to MD or from HCO to HCO
★ Patients should not be compared
• Nursing and compassion are not the same
• Standard of care may be perfect for some - but not for all
• Importance of leadership, leadership, leadership
• Patient and family engagement means everything
• Hiring the right employees is key
Copyright: 2013: Sherri T. Loeb RN, BSN & Jerod M. Loeb, PhD.

53. Is this the answer… a magic
door?

54. — “...No, you can't always get what you
want
— No, you can't always get what you want
— No, you can't always get what you want
— But if you try sometime, you just might
find
— You get what you need....”
54

55. “Do something – if it works, do more of it; if
it doesn’t, do something else”
55Franklin D. Roosevelt

56. In Loving Memory of Jerod
56

57. Thank You
For Allowing
Me To Share
Our Story!
57