Health Affairs

Dr. Jonathan Welch’s Narrative Matters essay in the December, 2012 edition of Health Affairs, regarding the cascade of errors and omissions he witnessed in connection with the care provided to his mother, should raise profound questions about how the hospital allowed those failures of care to happen. Dr. Welch, an emergency medicine physician, watched helplessly as his mother received indifferent care from various nurses and doctors and ultimately died. Despite having classic signs of evolving sepsis, she was not closely monitored by the nursing staff which ignored alarming signs, was not put on a sepsis treatment protocol by her oncologist, and was not put in an intensive care unit where she could receive more intense monitoring and aggressive treatment from specialists.

While it is tempting to blame the nurse (for not taking vital signs frequently enough and not reacting to abnormal vital signs) and the oncologist (for not following the patient closely enough, not initiating appropriate treatment, and not involving other specialists), Dr. Welch’s story suggests that there were more deeply rooted systemic problems at the hospital that went beyond the shortcomings of the individuals involved in his mother’s care.

As health care attorneys who represent hospitals and physicians, we believe there are some fundamental questions which should be asked by this hospital’s administration, medical staff leadership and governing body to ensure Dr. Welch’s experience is not repeated. Those questions, which the leaders in all hospitals should consider, include the following:

In the Narrative Matters essay in the April Health Affairs issue, Laura Blinkhorn and Mascha Davis write about how working with an obese woman in a Gabon hospital led them to seek solutions to obesity and its related health problems in the developing world. “Public health campaigns, government regulation, and improved education are necessary to bring about real change,” write Blinkhorn, a fourth-year medical student at the Pritzker School of Medicine, University of Chicago, and Davis, a registered dietician and public health professional who lives in Addis Ababa, Ethiopia, and works for Catholic Relief Services.

On April 3, 2013, the Department of Health and Human Services released proposed regulations establishing standards to govern navigators and non-navigator assisters in the federally facilitated exchange as well as clarifying standards on the role of navigators and on who can serve as a navigator in all exchanges.

In today’s Q and A on Patient Engagenment, we feature Rachael Fleurence, a Senior Scientist at PCORI where she leads the research prioritization initiative to help identify important patient and stakeholder generated questions and establish a rigorous research prioritization process to rank these questions. (Also, check out her recent blog post and follow the link to her February Health Affairs article here.)

For those of you who enjoyed the Q and A with Jessie Gruman last week, we’ll post the next in our series with patient advocates next week. This time our featured advocate will be Rachael Fleurence, a director at the Patient-Centered Outcomes Research Institute (PCORI). To learn more about her work and recent Health For those of you who enjoyed the Q and A with Jessie Gruman last week, we’ll post the next in our series with patient advocates next week. This time our featured advocate will be Rachael Fleurence, a director at the Patient-Centered Outcomes Research Institute (PCORI). To learn more about her work and recent Health Affairs article, visit this blog by Dr. Fleurance’s on PCORI’s website.

Now is your chance to ask questions of Dr. Fleurance.


Just go to Health Affair’s facebook page and post your question. We’ll post the answers on Health Affairs’s blog early next week.

Editor’s note: The February issue of Health Affairs was a thematic issue focused on patient engagement. In conjunction with the Patient-Centered Outcomes Research Institute (PCORI), the journal has launched a new initiative inviting questions from patients and others via Facebook for Health Affairs authors on patient-centeredness and patient engagement. Questions are then answered on Health Affairs Blog.

In the first installment of this series below, patient advocate and cancer survivor Jessie Gruman answers questions submitted to her last week. (You can also read Jessie’s Health Affairs Narrative Matters essay and watch her presentation at the briefing for the February issue.) In addition, watch for a Health Affairs Facebook post today soliciting your questions for PCORI’s Rachael Fleurence, who will answer her favorite questions next Wednesday here on HA Blog.

Q1: “Jessie, your Engagement Behavior Framework demands a lot of patients as well as caregivers. In my research, I have heard so many people express worry and even fear of retribution if they try, especially in their interactions with clinicians, to ask tough questions and volunteer conflicting opinions. My question for you is this: What is the most crucial support that patients and caregivers have to get from their clinicians to support their engagement with their health care?” – Shoshanna Sofaer, Professor of Health Care Policy, School of Public Affairs, Baruch College

Health Affairs readers may have noticed something a little different about the Narrative Matters essay in January’s issue. The essay, “To Fight Bad Suga’, Or Diabetes, My Neighborhood Needs More Health Educators,” by Joseph West of Sinai Urban Health Institute, is the first to include the Policy Checklist, a new feature that will accompany all of our Narrative Matters essays going forward.

The feature points readers to related readings, enacted or proposed legislation, current or planned governmental and private initiatives, and other resources that can help to round out perspectives on a given health policy issue. In the case of the checklist accompanying West’s essay, about the need for more community health workers to serve residents in one poor Chicago community devastated by diabetes, the checklist points to Affordable Care Act grants for outreach to medically underserved populations, community-based diabetes management projects like the CDC’s Project DIRECT, and Health Affairs papers on a national diabetes prevention strategy and on the measured benefits of community health workers.

“Back when I was training to become an emergency physician, I’d worry about the day I’d be involved in a medical error,” Jonathan Welch writes in the December Health Affairs Narrative Mattes essay.

It seemed inevitable. With land mines everywhere—the possibilities of missed diagnoses, delayed treatments, miscommunication—it felt like almost anything could lead to catastrophe. I imagined attending the in-house case review afterward, chastened as my hospital colleagues dissected my decisions. Yet I also thought—and hoped—that something positive would come from the process, that lessons from an error would sharpen my clinical skills and improve care in the hospital.

But when I was entangled in my first medical error, I played an unexpected role: I was a thirty-three-year-old son trying to save my mom’s life.

Welch describes what happened after his mother received poor hospital care for an infection. He also discusses his efforts to ensure that something positive comes of his mother’s experience, and he explains what hospitals can do to prevent cases like his mother’s from happening again.

“Because early identification is a key to every prevention activity, every child in America should be screened for mental illness as a part of well-child examinations,” former Connecticut state legislator Paul Gionfriddo writes in “What Funders Can Do in the Aftermath of the Tragedy in Sandy Hook, Connecticut.” Gionfriddo’s post was published yesterday on GrantWatch Blog, the sister site of Health Affairs Blog.

Gionfriddo also stresses that most violence is committed by those who are not mentally ill, and is often directed at those who are. “Now more than ever, we need anti-stigma campaigns to disassociate mental illness from violence in the minds of so many people,” he states.

No other presidential election in American history has been freighted with such significance for health care as was last month’s vote. Uncertainty over the future of health policy dominated the discourse, and we all waited with bated breath for clarity from the voters.

Thirty-six days ago, we got just that. In one night, much of the uncertainty that had marked the past few years faded into history.

But now we all face a different and urgent kind of uncertainty — a pressing question: How, with this newfound certainty in the policy environment, can health care stakeholders best move forward on problems of high costs and suboptimal quality, of poor coordination and preventable medical error, soon enough to meet the social need?

Time is running out to find answers. Health care costs, much of them waste, continue to climb, and too many patients are not getting the high-quality care they need. If we do not act — and act quickly — to transform health care, we will face blunt cost cutting and declining access and quality, particularly for the poorest among us.

Following her husband’s stroke, it fell to Beth Ann Swan, a registered nurse and nursing school dean, to coordinate her recovering husband’s care and manage his transitions among several hospitals and home. Swan writes about her experience in the Narrative Matters section of the November Health Affairs.

A patient in his nineties and in decline chooses the only legal way in most of the United States to hasten his death: He stops eating and drinking. His doctor wonders whether that is just or compassionate.

This is the situation David Muller writes about in his Narrative Matters essay in the October issue of Health Affairs. You can read the essay yourself, or you can listen to the author read it. Doctor Muller is the dean for medical education at the Mount Sinai School of Medicine in New York City, where he works in Mount Sinai’s Visiting Doctors Program.

Earlier this year we marked the first anniversary in a landmark collaboration that is already achieving major milestones on the road to better care through sharing electronic medical records (EMRs). The collaboration involves five leading health systems, each of which is in the forefront of using such records and is committed to the secure exchange... Read the rest of this entry »

Patient registries collect data for the scientific assessment of patient outcomes for particular conditions, devices, and treatment protocols. The Agency for Healthcare Research and Quality is currently developing a catalog of all such registries around the country. In his August Health Affairs Narrative Matters essay, Kerry O’Connell observes: “I often wonder why, in a country... Read the rest of this entry »

About a year ago, some medical symptoms that I’ve experienced for several years suddenly got worse.  Nothing really severe, but I was concerned enough that I wanted to know if this was just a flare-up of a condition I’ve had for quite a while or if it represented a new health problem.  I went to... Read the rest of this entry »

On April 29, 2012, four days after his 74th birthday, Larry Lewin (pictured below) died from complications of an underlying cancer. The funeral was May 1 and his wife, Marion asked me to speak briefly about his professional life. What follows is adapted from those remarks. It will be obvious that anyone who knew Larry... Read the rest of this entry »

A belated tip of the hat to Hank Stern’s  Health Wonk Review at Insure Blog. Hank offers a nice collection of posts, including Diane Meier’s Health Affairs Blog post on Amy Berman’s Narrative Matters essay and overcoming barriers to palliative care. Happy reading!  

Editor’s note: You can hear Amy Berman discuss her April Health Affairs Narrative Matters essay at the recent release event for the April issue. You can also join Amy tomorrow (May 1) at noon for live online chat hosted by the Washington Post, which will also be publishing an abridged version of her essay. In... Read the rest of this entry »

You are increasingly being held accountable for the outcomes of the health care you deliver. Pay for performance; shared savings in ACOs; public report cards…the list of strategies to monitor and measure the effects of your efforts is lengthening. Many of you seem dismayed by the increased weight accorded to the patient experience of care... Read the rest of this entry »

Over the past decade, it has become popular to invoke the term “strategy” in global health.  For many NGOs operating in developing world contexts, strategy is synonymous with “vision.”  For others, strategy is the set of operating activities that meet a defined goal.  And for others, still, strategy represents the ex-post principles invoked to justify... Read the rest of this entry »