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Transitioning from 'Never Events' to 'Patient-Centered Ever Events'

Susan B. Frampton, PhD, and Patrick A. Charmel, for HealthLeaders Media, October 16, 2008

There has been a considerable amount of attention paid recently to "never events," serious medical errors that should not happen. The Centers for Medicare & Medicaid Services raised the visibility of these events by mandating that when such errors occur, CMS will not pay for additional expenses incurred. Hospitals are currently preparing for implementation of CMS' "no pay" plan and expending tremendous resources in the process.

Never events are relatively infrequent occurrences, but underlying the events are failures in patient-centered care that affect thousands of patients every day. Seven years after the Institute of Medicine identified patient-centered care as one of six aims of a quality healthcare system, hospitals still struggle to consistently deliver care that "is respectful of and responsive to individual patient preferences, needs, and values." The lapses in patient-centered care are documented in the HCAHPS survey results, which confirm that hospitals nationwide are not always listening to patients, communicating in a way that patients understand, being responsive to patient requests, or managing patients' pain.

The quantitative portrait offered by HCAHPS is supplemented by the qualitative stories of patients who experience humiliation, shame, hopelessness, and powerlessness in a system that is intended to help the patients it is inadvertently harming. A recent Picker Institute-funded analysis of more than 100 patient focus groups conducted by Planetree at 35 hospitals of all sizes and locations across the country found disturbing evidence of major failures in the provision of respectful and responsive care. Major themes emerging from the focus groups included lack of caring attitudes on the part of hospital staff, dismissal/trivialization of patients' knowledge and views about their own bodies and their health, and a troubling phenomenon of "reverse caring" in which patients witnessing the stress and strain on caregivers makes them reluctant to inconvenience or aggravate staff by asking for the care they need.

Ultimately patient-centered care is about culture change and must involve not only caring for patients, but also caring for staff members who often feel demoralized and shamed themselves by constant reminders of how they are falling short. In the safety movement, the focus has shifted from individual providers to system solutions, and the patient-centered care movement needs to evolve in the same direction. We need to advance beyond the amorphous public policy goal of patient-centered care to tangible operational objectives. These objectives must reflect and honor the good work done every day by passionate people who dedicate their professional lives to helping others, but work in a system that doesn't always honor that intention.

Expanding focus from never events to the patient-centered "ever events" is a significant step in the right direction. Never events focus on preventing horrific clinical outcomes for a small number of patients, while ever events focus on what should happen for all patients, every time they interact with the healthcare system. Never events are nationally standardized; ever events are customized by each institution. Never events highlight what goes wrong; ever events celebrate what is done right.

The Cleveland Clinic is one of several patient-centered hospitals that are making this leap. The Clinic's Office of Patient Experience is guiding teams of physician and nurse leaders who are defining what actions will create the ideal experience for patients. One initial ever event defined by the Cleveland Clinic is that prior to the induction of anesthesia, all staff members in the operating room should introduce themselves to the patient and explain their role in caring for the patient. This ever event was identified by a patient who called the Office of Patient Experience to report how amazed he was by this approach. In stark contrast to the ever event is the more frequent patient-centered never event of OR staff chatting about their weekend plans, ignoring the patient who is lying terrified on the table waiting for anesthesia. The patient-centered never event will be prohibited, while the ever event is celebrated.

Ironically, CMS' no-pay for never events policy became effective October 1, 2008; the same day marked the beginning of the second annual Patient-Centered Care Awareness Month. This month we call on all hospitals to broaden their focus from "never events" to "patient-centered ever events," and we ask each hospital to identify its own patient-centered ever events. Many patient-centered practices that promote an effective partnership between patients, families, and providers, as well as among all staff members, clinical and non-clinical, are described in a Patient-Centered Care Improvement Guide that Planetree and the Picker Institute will publicly release in late October. Together we can build a future where the never events are more rare than they are today and the patient-centered ever events are not simply something we do, but an inseparable part of who we are.


Susan B. Frampton, PhD, is president of Planetree. Patrick A. Charmel is president and chief executive officer of Griffin Hospital. 
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