3/3/07 - Working Toward Positive Change: Dan Ford, a CAPS Feature Story.

By Jeannine Gluck, CAPS Correspondent

"I see myself as a sower of seeds," Dan Ford told me, hoping to sow enough that a few might find fertile ground. The "seeds" are his efforts to raise awareness of patient safety within the medical community. This goal is rooted in his family's own experience with medical error, which began over 15 years ago.

Diane Ford checked into an Illinois hospital in May 1991 for a hysterectomy. She and her physician believed it would offer relief from the bleeding she had been experiencing. Tragically, the surgery marked a beginning, rather than an end, of troubles for the 47-year old graduate student and mother of three teenagers. A series of errors resulted in brain damage, manifested as severe short-term memory loss. Her family was devastated to see the quality of Diane's life changed so suddenly and severely. As a result, Dan, her former husband, has become very much involved in patient safety. He works primarily towards elimination of medical errors. Changing the way people are treated after such an error occurs is another important goal.

Dan has spent many years as a hospital executive search consultant, and so feels comfortable in the world of healthcare. Even after enduring very negative treatment at the hands of the hospital’s risk managers, his faith that the great majority of doctors and hospital administrators are good people remains unshaken. They try every day to do the best they can for their patients, Dan believes, yet his family's experiences led him to realize that there was plenty of room for improvement.

Dan rejected the approach of bringing his family's story to the newspapers. He realized that he was uniquely positioned as an "insider," to reach the most important audience—healthcare providers themselves.

His lawyers advised Dan against his public activity in the patient safety movement during the years the family's lawsuit was ongoing. He wanted very much to be involved, and had been encouraged by a friend and professional colleague with whom he had shared his story. Once he was able to begin, an opportunity came soon. ASHRM, the American Society for Healthcare Risk Management, called one day in late 2002, to invite Dan to join a new Patient Safety Task Force. Dan's friend would co-chair the group. His door to the patient safety movement had opened.

The Task Force strongly encouraged Dan to begin telling his story. The Institute of Medicine had published "To Err is Human," in late 1999. The report attracted a great deal of attention, but had not yet engendered much action. Perhaps hearing the Ford's story might jump-start the patient safety efforts of some hospitals, the group reasoned. One prominent member asked Dan to co-present with her. Each time he spoke, someone asked if he would be willing to speak to another group—and another. Dan co-presented five talks, and has now done 25 on his own, to date. Audiences include management and physician staff and board members from health systems, hospitals and risk management groups; quality and patient safety executives, medical group managers, and other healthcare providers.

Most of these presentations begin with an explanation that he feels far more comfortable talking about the job search process, interviewing, resume writing, and careers. Yet he continues, through his unease. Dan shares lessons learned with these groups. He encourages hospital professionals to always do what they know is right; tell the truth; take responsibility for actions; be accountable to patients. Understand the human side of events and what he calls "the deer in the headlights syndrome," and realize that what you are saying to patients & families may not be really heard until you have met with them a few times. Realize that the honesty and integrity espoused in your values statements applies even in the face of adverse events. He encourages hospitals to include patients and families on the Root Cause Analysis teams.

Many individuals have contacted Dan, most with very positive comments, after hearing him speak. Those who find his ideas more difficult to accept are less vocal. Dan knows that business has been lost; that some health systems may have simply hired another search firm.

Dan has also been a member of many patient safety groups. He is a "safe" consumer participant, he likes to say. Because he is a healthcare industry insider, and has articulated his beliefs in many presentations, Dan feels that others trust him. He also sits on the quality committee of one provider health system. They count on him to bring a new point of view to the table, and to ask objective questions. "I do," he says. "Some are dumb. Some are dumb like a fox." He realizes that he is somewhat of a token consumer participant, but is happy that at least the door to these meetings has been opened a crack.

It has taken several years to reach this point, and the slow pace of change is one of the biggest challenges in this endeavor. Each physician or risk manager who tells Dan that they have taken his message to heart is a small step towards wider change in attitudes of the industry. There have been other positive outcomes along the way, as well.

THE MEDFORM is a tool that Dan helped to create, and he was the first consumer in Arizona to ceremonially fill it out at a press conference in Phoenix in 2005. This form gives people an organized, convenient way to record all their medications. It fits in the wallet, easy to pull out at the doctor's office, pharmacy, or hospital-anytime or anywhere one is asked for a list of prescriptions. This simple form directly aids patient safety efforts. Physicians can more easily determine whether a drug they are considering for a patient might interact with one prescribed by another specialist. At the end of a hospitalization, this record of pre-admission meds can help ensure that a patient returns home on the same prescriptions he was taking, or that there's a good reason why not. This process during patient hand-offs, called medication reconciliation, is one of the National Patient Safety Goals of the Joint Commission.

Dan's national and regional patient safety activities led to a speaking engagement on the role of the patient in safety in Geneva, Switzerland at the World Health Professions Alliance Leaders Forum in 2006. The talk was published in World Hospitals and Health Services in 2006.

In that article, Dan offers recommendations to patients, gathered from his colleagues around the globe. Among them:

• Document and update medical history and medications taken
• Let our healthcare providers know if we have literacy issues
• Ask plenty of questions about our medical care, and don’t be afraid to speak up
• Bring a friend or family member with you to doctor’s appointments or the hospital, to act as your advocate
• Expect respectful and honest treatment to be the norm

Dan has presented his story to many provider audiences, and has participated on many committees and work groups concerned with patient safety. It is a role he never expected, and one which will probably never feel entirely comfortable. Dan explains why he continues on: "I am told this is a compelling story....if no one speaks up, then change is slow to happen, if at all....I share this to help others, and to encourage constructive ideas. This is not about me. My only goal is to cause positive change so others do not experience what Diane and our family is experiencing."