"I'm responsible, as CEO, for creating the environment in which every staff person prioritizes proper hand hygiene, and mourns the human consequences of failure. That's my job, more so than the clinical staff who provide care."
Although some healthcare organizations have provided case studies for the paper, others told Conway they don't want to talk publicly about their experiences—even though they're experimenting with the responses that he espouses. At least not yet.
The paper includes tips on how to talk with the media, how to respond to events that happen in other facilities, and what the process of disclosing facts cases should be.
Conway is in a position to know about the impact of an adverse event on a hospital, as well as on patients and family members. He was COO of Boston's Dana Farber Cancer Institute in 1994 when Betsy Lehman, a 39-year-old Boston Globe health reporter died of complications after a chemotherapy overdose she received while undergoing breast cancer treatment there. The incident received an enormous amount of media attention.
As he watched what the horrible error did not just to the patient but to the Dana Farber staff, Conway decided to spend the rest of his career working on error prevention.
The whole idea, he says, is to help everyone move through the event rather than force it to drag out. The patient, family and loved ones, and the hospital staff "need to move on, and healing can begin when they know what happened. And that's clearly a point we're making in this paper.