Kentucky Hospital Engagement Network One CEO’s Story from the Other Side: when you are the dot on the run chart Michael L. Collins, FACHE with Donna R. Meador, K-HEN Project Director

Objectives: Demonstrate the power of story-telling in patient safety and quality work Discuss the difference that genuine patient and family engagement makes in an organization’s culture Describe how adverse drug events can impact patients and their families 2

The Power of a Story We know the work we are doing is important, but how do we make it real to our staff? And sometimes to our leaders? Stories go way back, even before YouTube 3

Patient Safety Heroes 4

5 Adverse Drug Events

ADE’s continued “You can’t improve what you don’t measure.” 6

ADE’s cont’d. Opioid Safety Anticoagulation Management Glycemic Management mine that data! 7

Meet Michael Michael L. Collins, FACHE President, Jewish Hospital Shelbyville (also Poppy ) 8

and Meet Alexandra! 9

My Story 10 I was born a couple weeks early on July 22, 2010 to Kevin and Michelle Collins. I weighed in at 6lbs, 12oz and 19 inches. I spent 1 month at Kosair Childrens Hospital's NICU after I had some pulmonary issues shortly after birth. Since then I have been soaking up my parents love and attention at home. On Jan 5th, 2011 I was diagnosed with an incredibly rare and serious enzyme deficiency disease known as Hurler Syndrome or MPS1. Join my team by praying for me and my family as we need your help to face the challenges ahead.

A few facts about Hurler’s Syndrome Hurler syndrome is a rare, inherited disease of metabolism in which a person cannot break down long chains of sugar molecules called glycosaminoglycans (formerly called mucopolysaccharides). metabolism Hurler syndrome belongs to a group of diseases called mucopolysaccharidoses, or MPS. Hurler syndrome is a disease with a poor outlook. Children with this disease develop nervous system problems, and usually die young. 11

Errors happen even at “the best” University of Minnesota Amplatz Children's Hospital 12

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Our Own “Alex’s Lemonade Stand” What have we learned? How can we make the best possible out of a bad situation? What can we do moving forward? 14

Learnings Errors can happen to anyone Even at the “Best Places to Work” Errors can be handled in many ways. 15

My best recommendations?  Open culture, staff free to report without fear of punishment  Errors need to be properly investigated, RCA, etc. to determine how to avoid in the future  Communication and disclosure to patient/family  Apology and remediation  Commitment to system improvement  Data tracking and performance evaluation  Education, training, and coaching 16

Thank you! Questions? Happy Halloween from our Pumpkin 17