Woodstock in Kissimmee: IHI's National Forum Leadership Summit

In November 2000, a very pregnant woman entered a Boston teaching hospital to have her labor induced. "Suzanne" experienced a series of medical errors that resulted in the loss of her fetus and the rupture of her uterus. This required a hysterectomy and an 18-day stay in the surgical intensive care unit.

Five months later, after the insurer, Harvard's Risk Management Foundation, had settled with the family, and after the hospital's public apology, RMF approached the hospital, asking them to adapt Crew Resource Management to safeguard obstetrics. Physician leaders did so. In fact, the medical staff was so successful at bringing this form of team communication to the Obstetrics unit that the number of high-severity adverse events fell by 62%.

This is a case in point of how tragedy can sometimes ultimately lead to improved patient safety. That may not happen often, as it requires brave and dedicated leaders at the top and middle levels of a hospital, and a particular type of dedication by clinicians. Most hospitals lack leaders like Jim Reinertsen, Paul Levy, and Stephen Pratt. Their leadership was key and their receipt of the John Eisenberg Award was well deserved.


Two weeks ago, at the National Forum of the Institute for Healthcare Improvement near Orlando in Kissimmee, Florida, I had the pleasure of meeting Paul Levy and Dr. Pratt, and seeing Dr. Reinertsen again. Along with the heads of the Cautious Patient Foundation, Paul had charmed his fellow hospital CEOs into sponsoring 50 patient activists from around the country to participate in the Forum. I was one of the lucky ones who'd been chosen to attend the Leadership Summit.

For we patient advocates, it was our Woodstock, a mass intoxicating love-in that convened widely scattered like-minded young-at-hearts who are critical of the Establishment. I expect to tell many of our intense and redemptive stories in this blog over the next few months. Many of us hope to turn our tragedies into improvements as solid, life-giving, and lasting as the use of CRM in Obstetrics.

I'd like to salute the leaders of Boston's Beth Israel Deaconess Medical Center, and the doctors who joined us in the Leadership Summit, including some who have harrowing stories as patients: Carl Flatley, Julia Hallisy, Kevin Kavanagh, Gil Mileikowsky, Cari Oliver, Kavita Patel, and Stephen Pratt.

Read another crew resource management story, or read Stephen Pratt's article of Dec. 2007 in the Joint Commission Journal on Quality and Safety.