Restoring Health Care

Go To James's Project

2010-07-31T13:03:00.001-04:00

Please visit James's Project.
All the most up to date posts on my work is being placed there.
Thank you!

Rubber duckies, Free ranging, and Stupidity

2010-06-17T22:13:00.010-04:00

June is National Safety Month. There is alot of work to be done to keep children safe.

On the ride home from a hospital presentation on Patient Engagement last Friday, I was caught off guard listening to the author of "Free Range Kids". I had heard of this woman who encouraged her nine year old son to ride the train in New York by himself. It seemed a bit insane to me but I had not heard or bothered to learn more about the details, so I had no place to judge.
Her word choice for how she advocates raising children is scary - Free Range Kids - puts children and cattle on the same level. But again, that was me being judgemental. Listening to her speak on my local NPR station, the annoyance wore off and deep concern set in.

She commented on the absurdity of products that are being marketed to parents as the must-haves to keep children safe making one wonder how did anyone survive childhood without these inventions? Kneepads for crawling babies? Helmets for toddlers (that do not have a medical need)?

But then she included in that group of the absurd - bath duckies with temperature gages on the bottom to protect the child from water that may be too hot.

Immediately I thought of Josie King.
Eighteen month old Josie was brought to the hospital after she was scalded by bath water at home. Though the vast majority of children are well enough to return home within twenty four hours for a bathtub injury, Josie never went home. The home accident became an iatrogenic injury when Josie was exposed to the additional threat of lack of patient safety in a hospital.

Whatever can reasonable be done to keep children safe in their surroundings should be employed. Rubber ducky temperature gages are an easy, inexpensive, reasonable tool for parents and caregivers to reduce their child's unnecessary exposure to significant risk. Knee pads for six month olds are just stupid.

It is also stupid to equate these two when it comes to promoting successful, healthy child rearing activities.

Allow your children a reasonable amount of increasingly appropriate responsibility and freedom. Each child is different in maturity and independence preparedness. There is no prescribed date and time for riding trains. It is a matter of common sense. Common sense says spending two dollars on a bathtub rubber ducky is a wise investment saving money, lives, and heartbreak.

Seeing it differently calls into question whether Free Range mom is more interested in controversy than kids healthy development.

An All American Boy & His Flag

2010-05-29T12:55:00.003-04:00

Memorial Day 2002 was the first year that the holiday brought on new meaning; though at the time and in the years since I wondered what was making me feel so melancholy. Nine Memorial Days later, I finally get it.

The flag.

Read more at http://www.jamessproject.blogspot.com/ where I am transferring my blogging to to allow it to be more personal. More real. More about how preventable medical errors and patient-physician communication affect patients and clinicians on a day to day basis.

St. Christopher's eliminates preventable infection in NICU

2010-05-07T19:43:00.003-04:00

Deep within the 117 page 2009 annual report of the Pennsylvania Patient Safety Authority is a sliver of light into what neonatal hospitalized patients face. A study from 2006 at St Christopher's Hospital in Philadelphia on ventilator-associated pneumonias (VAP) is shared. VAPs are a preventable medical error.

At St. Christopher's in 2006 after noticing an increased rate of VAPs that were significantly above the national average, the hospital proactively initiated a literature review and collaborated with other pediatric hospitals. Per the report, this "multidisciplinary team implemented a series of revisions to an existing pediatric ventilator bundle to better serve the neonate population."
The changes that were implemented addressed standards for oral hygiene of neonates depending on their gestational age at birth, "securing endotracheal tubes using standard procedures, discarding all tubing and circuits from standby ventilators, altering the frequency of ventilator circuit, tubing, and disposable oxygen equipment changes, adopting a standard for depth of suctioning and suction pressures, implementing a patient flow sheet to document completion of bundle elements."

As a result of this proactive and standardized steps, the hospital continually attained a drop in the incidence of VAPs in the NICU each year, until 2008 when the NICU incurred zero VAPs for an eighteen-month period (between June 2007 & December 2008).
Read more here.

How will the mechanic complete another cunning battery?
To help build a pedicatric safety community join James' (STB) Project. The 100% volunteer driven project works to inform, protect, unite, and persist to save babies and children in healthcare.
To stay updated on public health and pediatric safety news, subscribe or follow me on Twitter and Facebook.

Why, What, When of James' STB Project

2010-05-04T10:04:00.008-04:00

It is hard to maintain a restorative mindset when preventable death and pain keeps rearing its ugly head in pediatrics.

This morning I learned of the death of a 40 day old baby who had been diagnosed with a treatable CHD (congenital heart defect) - but the parents had never been told of the diagnosis. So the patent ductus arteriosus killed the child.

I shed a tear and screamed in my heart.

The parent should have been told. Of course, there is no guarantee as to the outcome - but what would have been guaranteed is that the family would have been a part of the treatment team. If tragedy still struck, there would have been a community of support built already the parent and the medical team.

This brings me back to why I am here to begin with.

Why James died.

Why I ended up enduring the additional trauma of civil litigation.

Why the book is titled, "Split the Baby".

Such a phrase can evoke disturbing imagery. Trust me. What James looked like after the medical interventions was worse than anything you can imagine. Which is probably why the judge did not allow but one photo of James (taken before medical intervention) to be shown to the jury.

The title is pulled straight from my lawyer's arguements during the motion for a mistrial. With a verdict of negligence but no responsibility, the court had in fact split the baby between medicine and law.

Between what juries are allowed to hear/see of the medical record and the rest that is in there.

Between what people want to believe about the healthcare industry and what really happens.

Negligent but not responsible.

Of course, to fully understand you must read the book. I wrote the book so medical and law students can learn from the case without me having to rehash every painful detail. But it is there for everyone to read and learn from.

Negligent but not responsible.

How could that possibly be considered a positive for the defense?

I imagine the clinicians involved never wanted things to happen as they did.

I did not want them to suffer either.

Resolution. Restoration of a harm. Peace. That's what I was (even if naively) hoping for.

I did achieve some. Still working on more.

I am glad that I went through with the whole case so it could be public. I am grateful for an attorney who did not force me to take money when it was never about the money.

But I am sad again. And reining in the anger.

So back to James's (STB) Project. It is here to help bring awareness and support of parents and clinicians in pediatric patient safety. We all need this to save lives and livelihoods.

New links will be up soon. James's socks will be available for purchase at cost to bring awareness and build the pediatric patient safety community.

The tags attached to the newborn socks have 3 must-dos for parents navigating a pediatric healthcare journey.

On the back, the tag can be customized by condition/disease - CHDs, Downs, Trisomy, Diabetes, etc.

Mother's Day - A little history

2010-04-28T07:15:00.005-04:00

The following article, written by a grieving member of The Compassionate Friends, sheds light on how Mother's Day came about and who it was designed to honor. This article does not mention, however, that the mother of Anna Jarvis (mentioned below) was actually trying to start a Mother's Day with the help of a friend in the 1870's - in the wake of the Civil War with thousands of freshly grieving mothers needing comfort. This is still quite timely as the United States has the worst infant mortality rate among industrialzied countries. At the same time, our sons and daughters have been fighting at least two wars on foreign soil for the past eight and a half years.

"Mother's Day Revisited"

Many of us in TCF do not look forward to Mother's Day. On this holiday, when the whole nation is celebrating the joys of parenthood, grieving parents often feel a special anguish. Mother's Day this year looms as particularly difficult milestone for me. Sunday, May 10, 1998 is not only Mother's Day but also the second anniversary of the death of my ten-year-old son, Jacob.

Because this day of private sadness also happens to be a day of public cel-bration, I decided that I should start thinking early about the occasion. I engaged in a little research about the holiday and learned a story that I think is worth sharing.

Mother's Day was the creation of a woman named Anna Jarvis in the early years of this century. Anna, who never married and never hadchildren of her own, devoted herself to establishing a national Mother's Day as a way of honoring her beloved mother, who died on May 9, 1905. In Anna's view, her mother deserved a memorial because she had lived selflessly and endured considerable suffering -seven of her eleven children had died in early childhood. According to historians, Anna's mother mourned the deaths of her children throughout her life. Anna insisted that the holiday always fall on a Sunday so that it would retain its spiritual moorings. Because of her efforts, President Woodrow Wilson finally proclaimed the second Sunday in May as Mother's Day.

Although Anna couldn't prevent the new holiday from quickly becoming a marketing phenomenon, she did try. Speaking out against "the mire of commercialization" that threatened to engulf Mother's Day, Anna attempted to preserve her creation as a true "holy day," a time for solemn reflection and prayer. Mother's day, then, was borne of a daughter's grief and love. More importantly, it was intended as a tribute to a bereaved mother-a bravewoman who lost multiple children but who managed to live with an abiding kindness and generosity toward others.

I like knowing this background, and my attitude towards Mother's Day has been colored by the knowledge. The holiday now makes me think of the common sorrow that links all bereaved parents. I feel a bond with Anna's mother that stretches over time and space. In a broader sense, the woman for whom the holiday was founded reminds me of people I've met at TCF who have continued to live productive, meaningful lives in the face of unthinkable loss. Finally, Mother's Day in its origins symbolizes both the joy and the vulnerability inherent in parenthood. Anna's mother knew all too well that from the moment a child is born, hope and the possibility of tragedy go hand in hand. She understood the fragility of life.

Enriched by its own history, Mother's Day is easier for me to tolerate. The coincidence of dates this year-Mother's Day and the anniversary of my son's death-is not as jarring as it once seemed. Although the commercial images of the modern Mother's Day still make me wince, I can turn off the television and envision the kind of day that Anna Jarvis had in mind: a time for quiet reflection and the sharing of cherished memories.

By Barbara Atwood, Tucson Arizona TCF

30 grams

2010-04-16T08:10:00.006-04:00

Still quietly (er, how quiet is blogging?) restoring my own health care. In the past two weeks I have done without all refined sugar while in the past week, I have added the challenge of getting 30 grams of fiber a day.

I never knew just how hard that is!

Artichoke's are my new best friend!

But I hit a road bump yesterday as some emotions began to unexpectedly seep up to the surface and it was time to let them out after a long period of suppression.

From the time my dad died and my very well-meaning doll of an aunt put a yellow bowl of Hershey Kisses in front of me, sweets were my friend in grief, anger and challenges. But I am not 12 anymore.

I also realized yesterday, not too unlike the volcanic eruption in Iceland, being honest with those around you, sharing the anger or conflict in a constructive and meaningful way can actually be quite beautiful.

It certainly remains scary and threatening, but working with others around us, we can set up boundaries and pathways to navigate through natural events in life.

Oh, and this morning I had to dress for another visit to a hospital patient safety committee and two pairs of pants I couldn't fit into this winter, FIT! Yohoo!

I have a long way to go, but the 30 grams of fiber, no sugar, and honesty are getting me there.

Anyone else working on any of this?

The Real story on "Frivilous Lawsuits"

2010-04-11T07:54:00.001-04:00

You need look no further than the corruption on Wall Street that has spun the world into today’s financial meltdown rivaling 1929 to see the importance of our right to justice in a courtroom. Now more than ever, consumers need open doors to the court house to enable us to seek justice. Marketing civil justice as “frivolous” is itself frivolous.

For years, those on Wall Street have used bogus stories about “frivolous lawsuits” as a marketing tool to create a negative impression of the civil justice system and help improve their bottom dollar. By using the myth of “frivolous lawsuits” to push for legal reform, corporate interests hope to prevent our access to a court room when they operate irresponsibly. They also have been successful in “polluting” the minds of citizens who serve on juries to create a prejudice against viable lawsuits. The truth is that there is nothing faulty or frivolous about our civil justice system. The civil justice system is the last resort for people who have been seriously wronged by the gross misconduct of the most powerful forces in America: large corporations, big pharma, polluters, medical special interests and insurance companies. It’s time you hear the real facts about our civil justice system: 1. Lawsuits are down Even our highest conservative leaders can’t deny the facts. According to Bush Administration statistics, personal injury trials in federal court are down 80% and those in state courts are down 31.8% since 1985.

In 1985, 3,600 tort trials were decided by a judge or jury in U.S. District Courts. By 2003, that number had dropped to less than 800.2

2. Verdicts are down Lawsuits aren’t the only things that are down. So are verdicts. In Pennsylvania alone, over the years 2000-2003, there were twenty five cases with verdicts over a million dollars. In 2006 there were just ten.3 Nationally, large awards in medical malpractice cases are down 56% since 1991, and punitive damages – extra awards for pain and suffering – were granted in less than1% of all civil actions began during 1991-1992, 1996 and 2001.4

3. The civil justice system is a vital tool in keeping consumers safe Taking away the ability for an individual to bring action against a negligent company allows the negligent company to continue promoting the injurious product or practice. Without a healthy civil justice system, companies would not be held accountable for their misconduct and we have already seen what happens when businesses have no one to answer to.

4. It’s not lawsuits that harm America but greedy corporate practices A study by the American Association for Justice shows that medical malpractice insurance carriers increased their net premiums by 120.2% during the period 2000-2004, although their net claims payments rose by only 5.7%. Thus, they increased their premiums by 21 times the increase in their claims payments.5 This means that while malpractice claims against doctors have remained stagnant, the companies providing malpractice insurance to them have consistently and dramatically increased the rates they’re charging these doctors. Our doctors are being cheated by the big insurance companies. It’s putting profits over people.

5. Those who know firsthand know best According to a 2006 survey by the Federal Judicial Center – the research and education agency of the federal court system – most federal judges do not see “frivolous lawsuits” as a problem.6 This comes when, over the last eight years, there is a much more conservative, pro-business federal judiciary. The New York Times studied this with a front-page story entitled “Supreme Court, Inc.”

6. Businesses themselves admit “frivolous lawsuits” aren’t a concern A 2006 study by the National Association of Manufacturers finds business leaders put “fear of litigation” at the bottom of their list of concerns.7

7. Auto-related personal injury claims are decreasing Automobile personal injury claims, which make up the majority of all injury claims, have fallen 5% since 1993 and 14% since their high in 1996.

8. There are already checks on “frivolous lawsuits” Judges are granted the authority to throw out suits they deem frivolous before the case even gets started, and they often do. They can also sanction the attorney bringing such case.

9. A Certificate of Merit is required In Pennsylvania, the state Supreme Court imposed a rule requiring attorneys to file a certificate of merit saying an expert is convinced the claim is meritorious before it can proceed.

10. Almost every lawsuit is legitimate According to a recent study in the New England Journal of Medicine – a doctor-oriented publication – almost every medical malpractice lawsuit filed in the United States has a meritorious basis.

1 "Federal Tort Trials and Verdicts, 2002-03”, Bureau of Justice Statistics, 8/17/05 2 "Civil Trial Cases and Verdicts in Large Counties, 2001”, Bureau of Justice Statistics, 4/04 3 http://www.courts.state.pa.us/Index/MedicalMalpractice/intro.asp 4 http://www.centerjd.org/error.php?page=MB_2007punitive.htm 5 http://www.justice.org/CJD_-_Med_Mal_Report_-_July_2005.pdf 6 Federal Judicial Center study, 2005, published in Business Insurance, April 11, 2005 7 Study by National Association of Manufacturers, 2006

If Maddy can Do it.

2010-04-11T07:53:00.001-04:00

"These are very complex issues, but it is really all about relationships." ~Madeline Albright, first female United States Secretary of State Whether international relations, law building or health care delivery it is all about the relationships. Not only the relationships between insurance companies and the insured, but also between insurance companies and the uninsured, between physicians, between physicians and nurses, between risk managers and the patients who walk through the door. Some of these entities never cross paths in person but they have a direct impact on each other's choices an decisions in medical care. My youngest son spent a full week in the NICU before coming home. The twenty four hour access to their new babies that parents are offered on 8 Ravdin at The University of Pennsylvania NICU allows relationships to be built. Relationships are built between parents and the clinicians, parents and other parents, and especially between parents and their new babies. This is the base of which we all start, needing human contact to build strength and an ability to heal. Whether a preemie or full term - life that starts out attached to 21st century technology, requires the free and ageless tools of human touch and connection for a chacne to thrive and survive. And, the need for connection to others never ends.

Locking Away Humanity

2010-04-11T07:51:00.000-04:00

There are alot of broken hearts and relationships in my life and I always wonder when I see humanity's resilience take a positive hold somewhere how I can get a little "peace" of that. How is a movie about violent prisoners relevant to the health care discussion?

Watch this brief trailer of "The Dhamma Brothers".
Many of the questions raised by the stakeholders in this movie can be considered for the benefit of all stakeholders in health care.

Is humanity being locked away in the delivery of medical care? What are we breeding in our hospitals? Bu ignoring the humanity of every provider and every patient a passive and, sometimes, active violence comes creeping in through sarcasm, carelessness;, aggressive responses in daily discussions; defensive stances in communications; laziness, risky behavior; dismissal of best practice policies as invasive, overbearing, and not beneficial; immodesty, cruelty, poor word choices; intolerance for imperfection; bullying; unwillingness to listen; inability to offer compassion. How can we release humanity within the boundaries of the gargantuan system? Individuals can begin.

A collective of individuals willing to initiate the subtle changes that affect change - learning how to listen; accepting responsibility for behaviors; being accountable to it; daily implementation of best practices when peers are arguing against it; self reflection; allowing time for relationship building with peers and patients; building a community of support for the individual and the work; daily meditation or reflection on what, when, how, who and where our behaviors had effect; strength to offer meaningful repairs.

"What is not to understand about compassion, love and understanding?"

Week 1: Forgiveness & Cardio

2010-04-04T23:56:00.005-04:00

Week 1 down - many more to go

The first week of the hundredth time I gave up refined sugar is Easter week. Planning continues to be a challenge in my fourth decade.

Exercise was consistent all week. It consistently woke up the muscles I didn't know I still had in areas I can't see under the flab.
This time is not the same. Reforming my health is about more than the extra poundage I have accumulated. It's about how it got there, why I hold onto it, and the biggest challenge in getting rid of it.

Forgiveness.

My Facebook status on Easter Sunday mentioned my prayers "that I can forgive".

Forgive myself that is.

I forgave the doctors, nurses, hospital, and health system that were party in James's wrongful death. I cannot forget and I may not agree with most of them on most everything. I do forgive them though; which is what has made it possible for me to seek post-verdict conversations with a couple of them.

Forgiving myself is much harder.

How do you forgive a mother who had to bury her child? As a mom, it was job to make sure my James lived longer than I. I failed him.

Forgiving myself is going to be another mountain to climb. As a brave weightloss guru said recently, "This is my mountain to climb." (Kirstie Alley)

Grief is a mountain I have been finding excuses not to master. There has been a lot of loss and as much advocating and talking and writing I do, I can't change the one thing I still want - my son back. Grief is not pretty and it is not comfortable. In eight years, I have been trying to find a fast track way through it. Perhaps all I found in those years was busy work that kept me from the real work. As a favorite preschool tune goes, "can't go under it, can't go over it, must go through it!"

I will be back on the hills of Valley Forge this week. Walking, climbing, shedding, and searching for forgiveness.

What's the healthiest way to get through grief and personal forgiveness?

Budding

2010-03-31T15:15:00.003-04:00

Spring is sprouting.

People and plants are busy dusting off and opening up. Hopefully, there is always time to take care of yourself. I keep telling that to myself so maybe I will actually do it.

Chanticleer here I come!

Reforming My Health - Day1: Sugar v Artificial sweeteners

2010-03-30T09:29:00.004-04:00

I have just struggled through breakfast. First one I have had in months. Generally I eat one meal a day, snack throughout, and enjoy sugar way too much. All that has added up to one overweight - yup, fat - mama.

So,in the hopes for new health for all Americans, I will follow the advice of a trusted physician friend and start reforming my own health care. And in the spirit of transparency and community, I am sharing the journey with anyone who cares to join me. From what I hear, finding a community of support helps success.

I started a few days ago with keeping track of what I was eating. I was not eating much but the simple math was clear:
NO breakfast + sweet tooth + little exercise = Fat

Fortunately, I have low blood pressure, low cholesterol levels, and normal glucose levels. So, healthy for now except too big for my britches (so to speak).

So, today I suffered through a measured 1/2 cup of Quaker oats and raisins. I tried sweetening it with cinnamon and a tablespoon of applesauce because I am conflicted about the wisdom of using natural sugar vs. a chemical sweetener.

Anyone have any input on what is better, or what the recommendation is?

I need to figure out what to put in my decaf coffee.

Letter to Attorney General - A Constituent's response

2010-03-29T13:04:00.004-04:00

It is always a challenge to be restorative - especially when things hit close to our hearts and our passions. The current debates surounding health care are hitting many hearts and passions. Despite what I may personally feel about the insurance mandate within the new health care law, an expensive lawsuit taxpayer funded by one group of elected officials against another group is counter-productive to the end goal for all parties. Again, the acute and longterm needs of consumers (patients, families, and physicians) will be lost in the arguement.

Please consider drafting a letter or make a phone call to your attorney general. Ask that they please stop this lawsuit and sit down and discuss the issues with the other elected officials. Your constituency has put faith in you and this group of legislators to put the little guy first.

Here is my letter to my attorney Tom Corbett who is also running for governor this year.

Dear Attorney General Corbett:

Thank you for your service to our state. It was my honor to participate in electing you into office. I have been proud to work to maintain a balance in our government in terms of political parties.

I also am working to establish a pediatric patient safety collaborative. I have spoken on health care safety issues and alternative dispute resolution in health care for a number of years at a variety of venues including the Quality Colloquium at Harvard. I have also continued to offer free local, community based education on such topics as hand hygiene awareness, how to advocate for a loved one in a hospital, and post adverse event communication between patients/families and clinicians.

I am reaching out to you today to ask for the privilege of a brief conversation with you (or a member of your staff) regarding your recent decision to engage in litigation over the constitutionality over the insurance mandate in the recent health care legislation.

I learned personally how expensive and painful litigation is. After the wrongful death of my son in a hospital within the Jefferson Health system, the only way for to find answers at the time was to engage an attorney. I have learned through my own insistence there can be other options. While I greatly appreciate that I was able to utilize that right and I believe everyone should have access to courts when needed, I am deeply distraught by the decision of your office to resolve this health care issue in this manner.

I implore you to not look at this issue as part of an election year campaign strategy. Please consider how this will harm the overall health of our state by increasing conflict, reducing the opportunity for dialog & understanding, and neglecting the alternative methods for addressing the insurance question.

Please forgive my idealism, but out of painful experience I have learned survival needs positive options. With more community-based education of the Pennsylvania populous as a whole to what this mandate will mean and look like, there could be a successful voter referendum during primaries to help address this concern. It may help garner more support for your candidacy as well. It may also help Pennsylvania step into the national spotlight as a leader in conflict dispute resolution and meaningful tripartisan (two parties and the voters) leadership.

I look forward to hearing from you on some possible times for a discussion.

Thank you for your time.

Most sincerely,
Mary Ellen Mannix, MRPEFounder, The STB Project
Restorative Practices Facilitator & Consultant
maryemannix@ymail.com

Is a birth defect a "preexisting condition"?

2010-03-27T23:38:00.005-04:00

A recent news story highlighted the plight of a newborn boy, Houston, born with a congenital heart defect. The child's defect is known as transposition of the great arteries. For a full term infant with no other anomalies, the typical treatment is a surgical repair in the child's first month of life. It is often rarely diagnosed prenatally.

Houston's parent's insurance company designated his birth defect as a preexisting condition. On those terms, it denied the child health insurance coverage the day after the president signed the new health care bill into law.
Read the full story here.

There are a number of issues and concerns that this story brings up for me.
To be able to fully understand my own discomfort for this reality is to figure out what questions I have. I will focus on one now and perhaps share more later.

The First Query:
Without promoting one side or the other - I am surprised that the pro choice movement would let this slip or that the pro life movement hasn't jumped on it.

By identifying this child as having a "preexisting condition" prenatally, the insurance company has in fact recognized the child legally as "a person".

If this action were to stand, IMHO, there is a logical argument that federal court would have jurisdiction (especially if the insurance company has its corporate ofc in a state different than the home of the denied newborn patient) and could possibly rule as to whether these actions are legal - if legal then abortion would have to be ceased at the time at which the condition is considered preexisting.

In office now, a truly frivolous lawsuit

2010-03-24T14:16:00.006-04:00

Among Tom Corbett's top priorities if he were to be elected Governor of Pennsylvania:

"Excessive and frivolous lawsuits hinder job growth and hurt Pennsylvania taxpayers by increasing costs for businesses, healthcare, and consumer goods and services. As part of Tom Corbett’s plan to revitalize Pennsylvania’s economy, he will work to pass meaningful legal reform."

In the past decade, republican legislators have taken the lead to limit court access to individuals harmed in the health care industry.
In 2002 in Pennsylvania, limited tort reforms were passed. Pennsylvania has seen a significant decrease in the number of medical malpractice cases on our court dockets, while in the same time frame there has been a significant increase in the number of sentinel events endured by Pennsylvania's patients (PA Patient Safety Advisory 2008 Annual Report).

For a foundation, Dictionary.com offers this definition of frivolous:
~characterized by lack of seriousness or sense
~self-indulgently carefree; unconcerned about or lacking any serious purpose.
~(of a person) given to trifling or undue levity.
~of little or no weight, worth, or importance; not worthy of serious notice.

According to a legal dictionary frivolous can be defined as:
: lacking in any arguable basis or merit in either law or fact .

The most common plea for lowering costs to improve health care overall from republican legislators has been to limit lawsuits.

As a parent who saw her child suffer unnecessary trauma (wrong surgery, lack of informed consent, known broken ventilator, failure to rescue, hospital acquired infection, ventilator induced pneumothorax) in a local health care system for his entire life and knows firsthand the challenges to have a fair case heard, it has been painful to continue seeing the word frivolous put in front of lawsuit time and time again - especially where it pertains to health care. I, and most of my peers, that move forward in litigation hold steadfast with the similar goal - without transparency and disclosure from the medical providers, it has been a way to bring awareness and possibly limit the chance of future tragedies.

Access to courts by patients and family members is extremely difficult. The plaintiff has to pay for the medical records and the two expert corroborating opinions necessary to even file a case. This significant upfront cost is only the first challenge to get an attorney to take the case. Since only one half of one percent of Pennsylvania's medical malpractice cases filed (Reiders, 2009) ever receive compensation attorneys more often than not turn away credible cases.

This current motion by attorneys general of 13 states (including Pennsylvania's Attorney General, who is also running for Governor) is, however, appropriate to label "frivolous".
The Attorneys general's goal is stated by the PA AG "to protect the citizens of Pennsylvania whose rights will be violated when the health care reform legislation, passed last night by the U.S. House of Representatives, is signed into law by President Obama."
My son and my surviving children need protection within the health care system. This lawsuit that seeks to block funds and access to quality care will not increase the chances of survival for any patient in any hospital, today, tomorrow or in 2014. The only thing it can possibly accomplish is to give these AGs a national spotlight and free media campaign dollars. It is seriously self-indulgent, and by definition - frivolous.

Pennsylvania's patients and families (and those from the other states whose Attorneys General)face an increase in taxes and a loss of vital services if this frivolous political lawsuit were successful.

Seeking the blockage of this lawsuit is not to condemn nor endorse the health care bill as is. Instead, it is recognition of the lack of patients and physicians being protected by this irresponsible use of taxpayer dollars and legislators time. Please let's keep the courtrooms free to address the needs of patients and clinicians. According to Tom Corbett, they are clogged enough with frivolous lawsuits - like this one.

What risk managers are really afraid of (or, Why Delaware County, PA-Republican-bred "little ole me" is now for a public option)

2010-03-03T15:32:00.006-05:00

Anyone who has read even the most minimal about me knows I sued a doctor. To be precise, at initial filing I brought civil suit against four -five docs, a large health care system, a hospital and its supporting foundation.

There is a mountain of research based evidence to explain why I, or any medical malpractice plaintiff, litigates. (For those new to the conversation, the short answer is - communication & prevention. Read more here.)

What remained a mystery to me (and it appears most of the world) is in light of all this practical and real evidence, why don't risk managers encourage doctors, hospitals and health care systems to communicate and find resolution with injured plaintiffs? Well, that was a mystery until last June when I presented to the local chapter of the health risk management association.

In my talk, I told the story of how I reached out to a defendant doctor even after years of painful litigation, more painful discovery of how preventable my son's death was, missing medical records, a "negligent but not responsible verdict", and a denied motion for mistrial. I tell of how he and I were able to work through a process of communication through email, then phone, then in person to regain some trust to share in respectful conversation and some understanding. I share how similar the experiences of shame and internal blame are for the doctor whose medical care has less than optimum outcome and the mother who failed in her responsibility to ensure her child lived longer than she did.

I do use names. It is not to continue shame but to begin the work of transparency. Honesty works.

But it was when I finished my talk and the audience was beginning to disperse that some of the risk managers hung back and spoke honestly.

"Do you want to know what we (risk managers) are really afraid of, Mary Ellen?" One asked me point blank.

Before I had a chance to respond she went on, "CMS and DOH." (Centers for Medicare and Medicaid & Department of Health)

The half a dozen other risk managers around us nodded in agreement.

She continued, "I can litigate. I know how to litigate so let me litigate," the local hospital system risk manager shared transparently.
But as soon as CMS or DOH get in there, and see what mistakes are happening, that affects our payment and reimbursements. I can't have that."

I listened. I felt quite grateful for these risk managers to share what challenges they face and how they perceive them. It allowed me, who arrived to the journey for patient safety in health care wearing the glasses of a patient & family member to try on a different lens. I didn't realize that this conversation would change my opinion on a public option for health insurance.

As politicians and activists wrestle with the issue of health care insurance reform, I keep coming back to these words from the hospital risk manager:

"Let me litigate. ...I know how to litigate... We are afraid of CMS and DOH."

But isn't that what many against reforms consider to be one of the biggest reasons for all the costs?

Read the March 2010 Patient Safety Advisory on "Leveraging Healthcare Policy Changes to Decrease Hospital 30-Day Readmission Rates" generated by a government created oversight organization in Pennsylvania.

Whack-A-Mom for Peace in Healthcare

2010-02-26T16:31:00.004-05:00

Someone recently compared me to the game, "Whack a Mole". Affectionately, he described me as a person who kept sprouting up in a variety of arenas, sharing a different skill he didn't know I had or had interest in.

Roaring in laughter, I agreed it seemed a spot-on description and reason why I might get so many headaches.

In sharing a variety of experiences, opinions, successes and failures, I have been beaten around a little bit for them. Including a recent unexpected series of harassing phone calls and emails from a surgeon who seemed to misunderstand (and appeared quite threatened by) my goals for transparency and disclosure in health care. Whether it has been a tragic rift with family & friends because of poor or lacking communication or a medically trained clinician I have never met, my head still hurts from the blows. I never seem to know where they will come from, so like other grievers I go undercover to protect myself.

My assessor explained what he was seeing. A teacher, restorative practices facilitator, consultant, health care advocate and activist, an author, and a freelance writer.

But, I am also, most importantly, a mom. Despite the personal aches, the job description requires me to keep popping up to make sure the children are safe.

Parents are dogmatic in their search for the best for their family - a recipe that will be different for each family. Sometimes we must look back at our history to remember what we are doing in the present as we are working for a better future for our grandchildren.

In searching for some materials for a conference I will be giving tomorrow (Peace building in Preschool Classrooms), I came across some clothes my son James never got to wear (his older brother had pulled them out unbeknownst to me, for his teddy bear).
My body slumped. A release of breath came from my lungs. My heart went concave. And the fight to stave off the tears started. It was another whack and I never know from where they will come. I did realize though, that they despite the pain they keep me awake, alive and engaged.

Tomorrow teachers, parents and I will discuss how to teach conflict resolution strategies to our youngest community members. Our universal hope that when outcomes are not ideal, they will be able to be honest, open, transparent, compassionate, and strong enough to find a peaceful resolve.

Pennsylvania's Infant Mortality is not being Improved with Tort Reform

2010-02-25T13:01:00.002-05:00

Politicians are struggling with bipartisanship and meaningful transdisciplinary conversations over health care insurance. Debate has begun to shift to one of the major factors of steep costs in health care - medical malpractice. Most of the media focus has been on "tort reform" which is symptomatic of the problem, not the problem itself.

Pennsylvania Patient Safety Authority board member and lawyer, Cliff Reiders, wrote in the summer of 2009 how the tort reforms made into Pennsylvania law in 2002 have significantly reduced the number of medical malpractice claims while at the same time the reports of medical errors in Pennsylvania hospitals have increased. These numbers are significant to Philadelphia and its surrounding area as it houses at least 6 major hospitals and health systems - most internationally recognized as leaders in innovative medicine. Though the worst medical cases may end up in Philadelphia's hospitals, there are many simple patient cases that fall below the professionally accepted standards of care and quality.

As recent as yesterday, a regional hospital reported the closing of its obstetric unit. Politicians and health care leadership should not use this as an exhibit for tort reforms. Instead obstetrics is a very good example of how tort reform is the symptom, not the problem. Read more.

Why Patients & Families Have to Verify Medical Licenses Themselves

2010-02-24T15:27:00.002-05:00

Dhamber Ghalley learned from a reporter that the doctor he drove his sister to had previously had his medical license suspended. He learned this during the reporter's investigation into his sister's death after a procedure done by the same doctor, Kermit B. Gosnell. This story is an example of many tragic cases that happen across our city, state, and even the country.

It is commonplace for patients to trust the medical providers they go to. Iatrogenic injury (injury caused by a medical provider) is as taboo as the procedure (an abortion at 19 weeks) Gosnell was performing on Ghalley's sister, Karnamaya Mongar. Regardless of the procedure or the doctor, patients and their families are becoming increasingly aware that they need to educate themselves when making decision regarding health care.

While it is lacking in accessibility and transparency, there are some tools patients and families can use to garner some preliminary information on potential health care providers. In Pennsylvania, you can view disciplinary actions taken by a variety of professional licensing boards

For links to how to check on licensure read more here.

Improving Patient Satisfaction & Health Care - With or Without Legislative Mandates

2010-02-22T19:44:00.006-05:00

President Obama has released a new proposal for a Health Bill to be considered by the House and Senate which will culminate in a highly anticipated meeting on health care reform on February 25.

There are current tools available to hospitals, doctors, pharmacists, nurses, insurers, and others close to improve care NOW - regardless, of the outcome of this summit. One of these tools comes from a well-established customer service industry leader. Two successful tools are the Patient's VOICE (tm) and Patient Satisfaction Skills(tm).

The potential cost of the President's plan is about $950B (the Congressional Budget Office has not yet released a financial analysis of the proposal). This is a scary, hefty price tag. The health care industry has been aware of the out-of-control costs of its industry for well over a decade or more. This is new to many consumers and those outside of the industry. In Pennsylvania, legislators have continued to allow state funding for The Pennsylvania Health Cost Containment Council for over two decades. The data offers insight into how expensive poor quality treatment can be. Just over a decade ago, The Institute for Medicine issued a landmark (highly referenced & trusted) report stating that upwards of 98,000 Americans die from preventable hospital acquired infections (HAI) each year. That doesn't mention the amount of people that survive from an HAI but are faced with the additional unnecessary cost of treating a preventable infection. The Center for Medicare & Medicaid Services even has an incentive payment policy now (also known as "pay for performance"). In educating doctors, nurses, all clinicians and even clinical support team members on best communication practices with programs like The Patient's VOICE & Patient Satisfaction Skills, hospitals have been able to improve their scores that relate to improved payment for services. This usually is a reflection of a more satisfied patient and family as well.

Government and private health care agencies acknowledge the root cause of runaway spending is medical errors. The commonly accepted root cause of medical errors is poor communication (whether between provider & patient; clinician & family; or clinician & clinician; or even, between hardware & hardware).

The President is asking legislators to collaborate and hear the voices of the patients (not just "voters") in America - which is potentially everyone within our borders who currently or in the future may need medical care. The White House website states that this proposal "make health care more affordable, make health insurers more accountable, .....and make the health system sustainable." Implementing tools that concretely train the clinician on awareness of THEIR voice as well as what is within the patient's voice during any interaction closes gaps, lowers barriers, and opens up collaborative treatment plans.

President Obama's current proposals are among the biggest promises ever made to the American public by a president since, well, since President Truman promised to nationalize health care as the troops were returning home in 1945. Truman was successful however in establishing an Instate Highway System.

President Truman wisely observed, "Our unity as a nation is sustained by free communication... The ceaseless flow of information throughout the Republic is matched by individual and commercial movement over a vast system of interconnected highways crisscrossing the country .... Together, the uniting forces of our communication system(s) are dynamic elements in the very name we bear — United States. Without them, we would be a mere alliance of many separate parts."

Companies and organizations from a variety of industries have a stake in health care. As is the American way, some even have solutions. Customer Focus Inc (CFI) offers an innovative health care improvement tool for legislators, hospitals, health care systems, insurers, accrediting agencies. The company is a model for how everyone can help improve the challenge we currently face as a nation in health care. CFI invested its own resources and talent to produce a tool that will benefit the health care system as a whole and improve health care outcomes.

What have you lost in medical malpractice?

2010-02-15T13:04:00.004-05:00

Consider the true impact of medical malpractice.
How does it affect patients, caregivers, siblings, parents, etc?
What is the impact on society at large?
What happens when you lose trust in a doctor? Or your local hospital? Or are a provider and you lose trust in a patient?
What is available to help heal the iatrogenic injured bodies and souls?
How much of a burden does medical malpractice put on our social services industries?
Where do clinicians go to get help? Is there a place for patients and their families to reach out?
Can patients and clinicians impacted help each other?

In working one on one with both parties, each will move forward. What seems more challenging is meaningful healing that brings a sense of understanding and being understood. Absent understanding to bring peace, both impacted parties are stuck in a pattern of anger, grief and denial. Each party leans on whatever they can find available to fill the void left by anger and isolation. Alcohol, prescription drugs, food, gambling, high risk extracurricular activities, etc.

Not just Medicare but food stamps, welfare, low income energy assistance are necessary when people cannot return to their life after medical errors leave them more impaired than their original illness.
This is much more than tort issues; it is the day to day impact of unnecessary hospital acquired infections, wrong site surgeries, surgical errors, misdiagnoses, poor patient-physician communication, and the other sentinel events.
Patients have lost limbs, jobs, dignity, sanity, focus, moments with no pain, friend and familial support and loved ones. Clinicians have lost jobs, practices, dignity, focus, friend and familial support.
Patients lose the ultimate - their life. Clinicians' ultimate is in taking their own life after involvement in a preventable medical injury.
Either way, both lose as does society. Patients and clinicians are members of one community. Our bonds are tied much stronger when we share in a sentinel event than when outcomes are good. It is a mistake to isolate the two parties. They need to be brought together with thought, support, compassion and transparency.

There are pink ribbons, puzzle ribbons, red ribbons, yellow ribbons, blue & pink ribbons, purple ribbons, teal ribbons, green ribbons and rainbow ribbons. Within each one of those supported conditions lies the threat to be injured not by the condition but the medical care employed. Perhaps, it is time to forgo the ribbon cost and invest in clinician & consumer education on the cost of medical errors.

So what have you lost since your involvement in medical malpractice?

Either from the patient's or provider's perspective, comments are welcomed and encouraged.

A Laugh Raiser for Pediatric Safety

2010-01-26T21:22:00.004-05:00

Unfortunately this event was canceled due to the poor weather. We will reschedule when the weather is better! Thanks for your interest. In the meantime, please recognize Heart month by registering as a member at www.splitthebaby.com. Register by Valentine's Day and you will be in the raffle for a free "valentine" :) Thank you!

The STB(Split The Baby) Project and the Congenital Heart Network

invite you to enjoy a night of laughs
at Helium Comedy Club (Philadelphia) on

February 11 at 7:30 PM.

Proceeds from this event will help support C.H.I.N., and the Split the BabyProject (Foundation - 501(c)3 pending), the work of fellow CHIN member MaryEllen Mannix. The project aims to bring pediatric disease specificorganizations together to collaborate, learn, and share information aboutpatient safety and best practices for sick children.

We hope you will join us for a fun night night out!
Tickets are $15.00/each.

Visit here to order your tickets (your receipt will serve as your ticket) online.http://tchin.org/events/helium.htm

Or email maryemannix@ymail.com

Or call 610-299-0478It should be great fun. They have two headliners that night
including Illiza Schlesinger, winner of Last Comic Standing.

Please pass along to anyone who might be interested!

Does the Pennsylvania Patient Safety Authority help Pennsylvania patients?

2010-01-26T20:42:00.001-05:00

Occasionally Pennsylvania patients read or hear about this state government regulated agency. The Pennsylvania Patient Safety Authority (PA PSA) was legislatively created as a result of tort reform in 2002 by Act 52. This organization is charged with collecting, analyzing, and disseminating the resultant learning of sentinel events reported by Pennsylvania hospitals, nursing homes, and clinics.

The PA PSA has maintained its main goal is to work with hospitals and like healthcare institutions in PA to improve safety. They have an innovative program called PA-PSRS through which the healthcare providers can report these events without risk of exposure to liability or media. Consumers can access their website and review “Advisories” that contain general information about some of the challenging issues of PA healthcare providers. This is a great way for consumers to begin to educate themselves on issues and how to best advocate for themselves or a loved one in hospital or institutional health care setting.

What the Pennsylvania patient/family cannot do is to report their questionable care experiences or sentinel events to the PA PSA. All Pennsylvania patients can report any concerns or sentinel events through a laborious process via the state’s Department of Health (DOH). The reporting process at the DOH is limiting as it requires writing and mailing in hard copies. It also does not seem to have readily available the instructions for an illiterate or non-English speaking patient or family member. It would be highly beneficial to put in place a process for patients and families to report a sentinel event to the Advisory. As patients are the one common denominator at all touch points of health care delivery, to not collect their knowledge is to miss an important factor in process improvements for the entire system.

It was legislated that there is consumer representation at the PA PSA. The legislation requires a "governor appointed non-health care worker” sit on the PA PSA board." At this time that seat is held by the VP of Independence Blue Cross, Lorina L. Marshall-Blake. Rounding out the board are 3 nurses, 3 doctors, 2 lawyers, and a pharmacist. As of summer 2009 the PA PSA had received a million sentinel event reports.

The PA PSA is helping Pennsylvania patients. It could be a greater force for improvement if there was a way to accept reports and communicate directly with patients - an idenitfied vital part of health care best safety practices.

Make-A-Wish Supporter

2010-01-12T21:41:00.001-05:00