Patients' use of care plans: A ten-minute engineering fix

Libby Hoy’s story:

I was brought in as the patient/family advisor for a Lean event, a one-week rapid cycle improvement event addressing the wait times in the outpatient clinic my kids were served in.  I was with the clinicians, nurses, administrators, the assistants who bring you back to the exam room, and the front office staff, so all three of the gears in our company’s emblem were represented on the team.  

We identified some of the deficiencies.  In the middle of the week, a conversation came up about a physician’s frustration with families not following their care plans.  The care plan had made sense, he said, but the family had not called back.  He proposed that the families didn’t really care about their kids.  

I spoke up and said, I’m very invested in this. Sometimes we don’t get the call back either. It’s very frustrating when you can’t get in touch with folks.  Others joined in.

The team realized that in the office’s phone tree, when patients called in, the call was routed to a voice mailbox of nurses and staff members who were no longer with the organization, so our messages were sitting in unchecked mailboxes.

There had been assumptions about miscommunication, with team members thinking that patient education might be needed to emphasize to families the importance of following the care plans.  Instead, there was a ten-minute engineering fix to route the phone calls to the right mailboxes.  That improved follow-up and the continuity of care, etc.  If all of us hadn’t been there, this would have gotten lost in translation.

This is an example of the value of co-design, and representing all the voices in the room, not just the patient’s perspective, but their interaction with clinicians and administrators.  That’s so important.  We’ve worked so hard over the last ten years to get the patient’s voice into the conversation.  The secret is in the interactions together to highlight the opportunities for co-design and improvement.  The pendulum is swinging, but in some ways having just the patient or family’s perspective is of as little use as just having the clinician’s viewpoint.  The interdisciplinary approach is better.

Libby is the founder and CEO of PFCCpartners, based in California.

Read a story of the co-production of medical care.

What We Can All Learn From Michael Jackson's Doctor

Michael Jackson had what most of us think we want:  utterly personal attention from a dedicated doctor, on call all the time for him alone. 

Dr. Conrad Murray is now on trial for manslaughter, though no one thinks Michael's death was deliberate. What went wrong, and what can we learn from it?

Much remains unclear about exactly what happened, but I see three key lessons: Don't assume information about your medications has been communicated from one doctor to another. Keep an updated medication list. Get a family member or professional patient advocate.  

This story, among those of other celebrities, is explored in my book, Getting Your Best Health Care:  Real-World Stories of Patient Empowerment. There, I examine more fully the role of the medical team. This week, more information has been made public, though the conflicting accounts by the prosecutor, defense lawyer, and early witnesses make it hard to know the truth at this time. Still, some useful lessons are already emerging. 

Poor communication among medical personnel

    Michael’s primary care provider communicated some critical information poorly. When emergency medical technicians arrived to try to revive Michael, his primary care doctor did not inform them that he had given Propofol to Michael [according to the prosecutor].  That may have affected the way the EMTs tried to revive him.  Flumazenil was used to reverse the effects of benzodiazepines like the Lorazepam that Michael had been taking.  Miscommunication may have led the EMTs to administer the Flumazenil in a misdirected effort to counteract the effects of the Lorazepam, though it seems that the biggest immediate problem was actually the Propofol. 

The patient's role

Michael himself seems to have played a role in at least two miscommunications. First, Michael had become addicted to another sedative, Demerol, which he regularly received from his Beverly Hills dermatologist, without telling his primary care provider.  The addiction allegedly left Michael unable to sleep, sometimes for days, leading him to beg for Propofol [according to the defense lawyer].  Second, Michael had swallowed an extra dose of the anesthetic, Propofol, while the doctor was in the restroom, unbeknownst to the doctor [according to the defense lawyer].  

The risk of hand-offs

     Such miscommunications of information during medical “hand-offs” among medical personnel like these are common, so patients need to be on guard.  Keeping an updated medication list of each drug, its dose, and the reason you’re taking the drug can prevent errors like this.  During crises, a patient advocate – either a trained family member or professional advocate – can also catch and correct the miscommunication before the patient suffers for it.  

     It’s most likely that a chain of errors on the part of both Michael and his primary care provider, and perhaps another physician, were responsible for his death.  Given the many drugs Michael was taking and they way he received them, it seems there were several wrong-drug, wrong-dose, and wrong-time errors.

Michael Jackson's death also raises two other issues that patients should consider: 

-Behavioral health and substance abuse issues
Michael was relying on many drugs, at least one of which was habit-forming. Ideally, a concerned family member, or even Michael himself, would ask his primary care physician about his dependency, and the doctor would have some training in detecting and dealing with substance abuse. In the absence of that, lacking full knowledge about Michael’s habits, the doctor was flying blind, though neither Michael nor he seemed aware of that. (Michael called the propofol his “milk;” indeed, the drug’s nickname is “milk of amnesia.”)


-Did Michael Jackson choose the wrong doctor?  
In hindsight, it’s easy to say, Yes. Beforehand, it was less clear-cut. If Michael had looked up the doctor’s public quality information in Health Grades, for example, he would have seen the doctor had received only two or three stars on a five-star scale, as rated by a small number of patients on each of ten different dimensions of care, including trustworthiness, communication skills, listening skills, whether they would recommend him to someone else, etc. At that time, the doctor had neither any malpractice activity, nor any actions by the state’s medical board, nor any formal sanctions.


Ken Farbstein, MPP, President of Patient AdvoCare, is a professional patient advocate who advises people on staying safe through healthcare crises.

Read another miscommunication story.

Thanks to Ian Lovett and Timothy Williams of the New York Times, and Anthony McCartney and Linda Deutsch of the Boston Globe, for their source articles this week.