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https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/86bf3f30efc4c930adb7bff96e00b8b5.pdf?Expires=1712793600&Signature=gnp2GJfIcqlbraLm-f8t9fA0NCIyL-hWtJQ1267g5Pl8sj4uarCy0ID45JLIxDt5RLALqkQfXVTIjbiuPqPg43JZ4Rk2%7EAtzPjNIxATqvUfB4hh17PoTvuwg3V2JYcY4oHK9bY1cwoAv4Cl6qGptHPLvLLT6PGADq8fmSA1zmNpXMu5KULBW7KlLp4nUQTekweel0q9bh9ZMhUOxRtaUGM5xr3X6SmfVjIWuiwb8b-CYVK4itEbOg3L-fSLFH6ykmoDqsk664xl2E8ieeE22mQA9olOHTPbIhDGIEuqwV7msiDzOKg2SPOdc7oKlJGPjIXgl5SzE7nqyTSNYaq6HZw__&Key-Pair-Id=K6UGZS9ZTDSZM
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Preventing Harm with “The Practice of Respect”
Introduction/Problem
Consider these real stories from BIDMC:
A patient wearing her wedding ring is taken to surgery, but when she awakens
post-operatively, the ring is missing and is never found.
A transgender woman patient is addressed as “Mr.” at the reception desk.
When she corrects the staff, she witnesses them giggle and roll their eyes.
A Facebook post on our website reads…“Ok…I have surgery scheduled today
and the paperwork says check in @ 5 am. I wake at 3:30 to make the 1 hr.
drive from [far away] only to learn that no one can ever check in B4 6 a.m.??
The staff here states it is a little trick they do?? Hope my surgery doesn’t have
any little tricks or surprises!”
Results/Progress to Date
PREVENTABLE HARM AT BIDM C
FY16
Q1 16
Q216
Q3 16
Q4 16
DIGNITY & RESPECT RELATED
Dis r e s pe ctful Com m unication (Se ve r e )
Language Related
0
0
0
0
Etiquette/ Rudeness
1
0
0
0
Failure to be Patient-Centered
0
0
0
0
Insensitivity
3
7
1
2
Uncoordinated Care
4
9
9
3
Prejudice or Discrimination that Af f ects Care
0
0
0
0
6
5
1
1
0
0
1
0
Minimization of Patient Concerns (incl. Pain Management)
Failure to Conduct or Incorporate Advance Care Planning
Adverse Event Related
0
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0
Prolonged unclean conditions – Environment
0
0
1
0
Prolonged unclean conditions – Personal
0
1
0
0
Body Mismanagement
1
0
0
0
Bereavement Related
0
0
0
0
Failur e to Car e for Pe r s onal Pos s e s s ions (Se ve r e )
1
0
1
0
Othe r Dis r e s pe ct Caus ing Har m to Dignity (Se ve r e )
0
0
0
Failur e to M aintain an Envir onm e nt that Pr e s e r ve s Dignity (Se ve r e )
At BIDMC these events are now all considered to be preventable, severe,
emotional harm.
Aim/Goal
For the past 2 years, BIDMC has been practicing a different approach by
considering these experiences as examples of emotional harm from disrespect
and applying the rigorous processes we have successfully used to prevent
physical harms.
Privacy Violation – Auditory/Inf ormation
Privacy Violation – Physical
Visitor Mismanagement
Failur e to Pr ovide Appr opr iate Car e afte r De ath (Se ve r e )
16
23
15
6
TOTAL R&D Eve nts Re vie w e d
45
57
51
28
36%
40%
29%
21%
Pe r ce nt Se ve r e
Our aim is to improve the patient experience by understanding the cases where we
did not meet the standard expectations for our patients and then designing
improvements to prevent these types of events from happening again.
The Team
Pat Folcarelli RN, MA, PhD; Lauge Sokol- Hessner MD; Barbara Sarnoff Lee
LICSW; Lindy Lurie LCSW; Carolyn Wheaton RN, MS; Debra Barbuto RN,
BS; Andrea Branchaud MPH; Katie Annas JD
0
TOTAL
Lessons Learned
Emotional harm from disrespect is common, and the reliable practice of
respect depends both on individuals and the system of care.
Institutional management of emotional harms can fit seamlessly within
existing patient safety operations.
This work is also raising important conversations about other aspects of
disrespect – particularly episodes of disrespect between staff, as well as
disrespectful treatment of staff by patients or families.
The Interventions
Next Steps
We have continued to improve our processes for detection, categorizing, and
analyzing events
We have integrated the review of these cases into our QA/PI processes
We held a “Respect and Dignity” convening with 30 key leaders from many
organizations
We are conducting a modified Delphi consensus-building process to identify
the recommendations, strategies and tactics that will help other
organizations engage in the practice of respect.
We are also conducting a scoping literature review to learn how best to
recognize and describe the disrespectful actions and their impacts that
constitute these “non-physical” harm events.
For more information, contact:
Pat Folcarelli RN, MA, PhD pfolcare@bidmc.harvard.edu
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Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
Patricia Folcarelli (<a href="mailto:pfolcare@bidmc.harvard.edu">pfolcare@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Health Care Quality
Location or Affiliate
BIDMC
Project Team
Pat Folcarelli <br />Lauge Sokol- Hessner<br />Barbara Sarnoff Lee<br />Lindy Lurie<br />Carolyn Wheaton<br />Debra Barbuto<br />Andrea Branchaud <br />Katie Annas J
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Preventing Harm with "The Practice of Respect"
Date
A point or period of time associated with an event in the lifecycle of the resource
2017
Format
The file format, physical medium, or dimensions of the resource
pdf
Equality
Patient and Family-Centeredness