Partnering with Patients to Reduce Medical Errors
Patrice L. Spath (Ed.)
AHA Press, www.healthforum.com, 2004, $75, 198 pages, ISBN 1-55648-314-7
Audience: Administrators, CEOs, healthcare consumers, healthcare managers, nurses, physicians, risk and quality managers, safety managers
Key words: Best practices, collaboration, communication, continuum of care, consumer/advocacy, consumer satisfaction, medication errors, organizational behavior, change/development, patient safety, performance improvement, rights of patients/residents, risk management, safety and security

From the dawn of patient care through tomorrow’s treatment methodologies, the most powerful statement any healthcare professional can understand is, “Healthcare leaders carry an awesome responsibility, because patients entering our doors are placing their lives—their most precious gift—in our hands.” This statement is the backbone of this brilliant book edited by Patrice L. Spath. She explains that the 1999 Institute of Medicine report To err is human shows clearly we, as healthcare professionals, are deficient in our duties as caretakers. Why? Because we make and execute patient care plans. In return, we expect the patient to accept everything and not question how or why it is done. We remove the patient’s concerns from our agenda, and this, according to the editor, has been the main reason for our shortcomings in medical error prevention.

This easy-to-read volume describes the changes urgently needed to improve patient safety. The most radical change requires patients, families, or significant others to be involved in their healthcare. These parties should establish a dialogue with providers, and healthcare providers should solicit and welcome this involvement. Examples of this involvement include a complete understanding of the diagnosis and prognosis. These consumers should also ask questions like the following: What is the overall treatment and healthcare concern? What medications have been provided and why? What are the side effects of the medication prescribed? Spath even suggests that all parties do double checks to avoid mistakes. This includes such simple practices as asking the patient whether the name on his arm band is correct or if the patient has been scheduled for the correct procedure. This book is filled with many such useful questions that will help eliminate patient error.

In this text, Patrice L. Spath collaborates with many well-known authors in the healthcare field, and they pose very perceptive questions. It is not just a matter of how the patient is cured, it is also a matter of how the patient is kept safe while hospitalized. The last chapter is devoted to one particular hospital’s commitment to involving consumers in medical error prevention. The key, in this instance, is providing a supportive culture and opportunities for education and partnership.

Reviewed by Linda Brandt-Comer, MSN RN CPHQ CHRM

Patient Safety Principles and Practice
Jacqueline Fowler Byers, Susan V. White
Springer Publishing Company, www.springerpub.com, 2004, $89.95, 562 pages, ISBN 0826133460
Audience: Healthcare consultants, hospital administrators, hospital board members, medical directors, quality management professionals, risk managers, university faculty
Key words: Patient safety

From the overview of concepts and the history of patient safety issues, to the specific guiding strategies for different healthcare settings and populations, to the Web resources provided at the end of each chapter, Patient Safety Principles and Practice is a timely and superb resource on the topic of patient safety. Multiple authors contributed to the breadth and depth of information that make this book not only appropriate for a broad audience, but a must read for hospital governing boards. The authors have succeeded in developing an excellent and well-researched compilation of information for healthcare professionals and a book that would serve as an excellent text for students of both clinical and administrative programs. The chapters do not need to be read in sequence, although for those new to this topical area, the introductory chapters should be read first.

The historical chronology gives the reader an overview of the evolution of patient safety awareness and ties together the establishment and roles of a number of private and government groups, giving meaning to the development of The Leapfrog Group, the Agency for Healthcare Research and Quality, and the federal government’s role in patient safety with such initiatives as a bar code proposal. It is rich in detail and abundant in tangible strategies for those involved in and responsible for making system change within their organization. The editors and authors discuss applied safety strategies including quality tools and techniques, evidence-based practice, considerations for patients and their responsibility in healthcare safety, the role and importance of risk management, nurse staffing and medical errors, and the relationship between the nursing work culture and adverse events in healthcare. Technology is addressed as an approachto improving medical error reduction and increasing safety. In addition, the authors address the human factors that contribute to errors irrespective of technology. Patient Safety Principles and Practice pulls it all together nicely to create an extraordinary reference all in one.

Reviewed by Mary S. Savitsky, MHA RN CHE CPHQ

The Quality Handbook for Health Care Organizations: A Manager’s Guide to Tools and Programs, 1st Edition
Yosef D. Dlugacz, Andrea Restifo, Alice Greenwood
Jossey-Bass, www.josseybass.com, 2004, $48, 256 pages, ISBN 0-7879-6921-4
Audience: Healthcare quality managers, administrators, and interdisciplinary practitioners
Key words: Healthcare quality management, data collection and analysis, clinical quality assessment

The Quality Handbook for Healthcare Organizations is a primer for both newcomers or seasoned professionals in performance
improvement. It is designed to be a practical guide to quality management and to give information about the principles and basic tools necessary for success in today’s complex healthcare industry. This book provides managers with practical techniques and methods needed for making decisions. The reader will be supplied with techniques to help plan, direct, coordinate, provide, and improve healthcare services. This text provides explicit information on performance improvement methodologies and the tools most useful for assessing and analyzing a variety of situations faced by managers in healthcare settings. The main purpose of the text is to provide practical information to assist in setting appropriate goals and implementing strategies in organizations striving to continually improve their overall quality of care.

The text reflects the authors’ combination of technical know-how, years of experience, and enthusiasm for their work. It is organized according to topic or subject, with theoretical issue outlines and practical tools explained in each chapter. At the end of each chapter is a section titled “Things to Think About,” which provides thought-provoking questions. These are designed to personalize the material and may also be utilized as exercises for providing quality management training to staff. It includes examples from the authors’ experiences and provides illustrations using the Plan-Do-Check-Act (PDCA) methodology. The central theme is “the power of data” as a tool for evaluating care, establishing best practice, and developing guidelines for service areas. It demonstrates utilization of a quality management framework to establish accountability and better facilitate communication among staff at all levels of the organization.

Each chapter of the book has a specific focus. Chapter One defines the role of the manager in the current healthcare environment. Chapter Two briefly sketches the history of quality management and how it has evolved within healthcare. The third and forth chapters discuss how to use quality data for evaluating care and criteria confirming preidentified goals. It also addresses how to define indicators and develop databases for reviewing the interrelationships between different aspects of care. Chapter Five provides information on basic statistical tools used for data management and analysis. The remaining five chapters describe in detail all aspects of quality management in healthcare.

This text is a treasure of information and could be utilized in a variety of ways, such as a required reading for students in health administration or a review for new managers or administrators. The examples and format of the book make it easy to read, and the summaries at the end of each chapter and the illustrations are great to use for staff education. It is exactly as the title states, a handbook for quality and is highly recommended for use by managers in today’s healthcare industry.

Reviewed by Anita Gottlieb, MA RNP CPHQ

Escape Fire: Designs for the Future of Health Care
Donald M. Berwick
Jossey-Bass, www.josseybass.com, 2003, $30, 315 pages, ISBN 0-7879-7217-7
Audience: Healthcare consumers, healthcare providers, quality directors, healthcare administrators
Key words: Consumer/advocacy, culture, decision making, outcomes, patient safety, performance improvement, performance measurement, performance monitoring, process improvement, public relations, quality assessment, quality of care, quality tools, rights of patients/residents

This compilation of speeches by Donald Berwick provides a compelling look at a decade of healthcare quality from one man’s perspective. Dr. Berwick is a physician, the President of the Institute for Healthcare Improvement, and an informed commentator about the healthcare system. In these speeches, given to the National Forum on Quality Improvement in Health Care from 1992 through 2002, it is apparent how much, and how little, healthcare quality has changed. Dr. Berwick’s engaging style and wonderful analogies offer a glimpse of how healthcare could and should be. He addresses the inequities of the current system—but more than that, Dr. Berwick offers tools to help address the problems.

The speeches transcribed in this book are about making a revolution in healthcare by fundamentally changing the system. Dr. Berwick repeatedly stresses that the people are not the problem—healthcare workers in general try to do the right thing. It is the system that needs an overhaul—the players simply need to be given the tools to do what needs to be done. Dr. Berwick outlines several tools for changing the system. Some of these include the following: naming the problem (i.e., admitting that there are problems with the current system), building on successes, taking leaps of faith (e.g., believing that the impossible is possible), looking for answers outside of the medical field, setting specific goals and working toward those goals, understanding how systems work and why the current system is so “broken,” taking action to reduce waste and reduce demand on the system, learning to cooperate, and, perhaps most important, keeping the patient as the central figure in the healthcare system.

This collection of speeches will undoubtedly make you wish you had been there to hear them. However, reading these selections should also inspire. If a healthcare facility can buy only one book this year to make others aware of why a quality department is so critical, make that one book Escape Fire: Designs for the Future of Health Care. Entertaining and thought provoking, this is a book to read, share, and make a part of quality improvement work.

Reviewed by Eileen Johnson, MSN RN BC CPHQ

Resolving Patient Complaints: A Stepby-Step Guide to Effective Service Recovery, 2nd ed.
Liz Osborne
Jones and Bartlett, www.jbpub.com, 2004, $79.95, 256 pages, ISBN 0-7637-2622-2
Audience: Risk and quality managers, patient representatives/advocates, healthcare managers and leaders
Key words: Consumer satisfaction, government regulations, JCAHO, rights of patients/residents, organizational behavior

Resolving Patient Complaints provides a model for win-win results for the patient and the institution when complaints arise. The successful institution addresses complaints by taking care of the patient’s feelings first, then looking for systems problems and correcting them to avoid future problems of the same kind. Apatient who is satisfied with the way a complaint was addressed will feel valued and will likely remain loyal. As a consequence, the frequency of such incidences and the associated regulatory and legal costs will be reduced. Following the principles of service recovery in today’s cost containment environment is a very important component of maintaining a viable institution.

The author defines key attributes that the patient uses to evaluate the service. These same attributes are used for “customer-oriented problem-solving,” or service recovery. In this service recovery model, staff is empowered to resolve complaints within certain limits. By providing education and resources to staff, the institution helps staff become more comfortable with the service recovery role. Tools for staff include standard protocols to address the most frequent complaints, mentors with service recovery skills, cards listing the service recovery steps, scripts, and identification of “decision zones” (i.e., who can make decisions at each level).

For those initiating a service recovery program or attempting to make a current one more effective, the author clearly explains necessary steps. She also provides sample forms, tables, documentation, protocols, and scripts that may be easily adapted. This book is an excellent resource for anyone in healthcare who interacts with the patient.

Reviewed by Marie C. Ruckstuhl, RN CPHQ

Consumer-Driven Health Care: Implications for Providers, Payers, and Policymakers
Regina E. Herzlinger, (Ed.)
Jossey-Bass, www.josseybass.com, 2004, $55, 892 pages, ISBN 0-7879-5258-3
Audience: CEOs, healthcare leaders, third-party payer leaders, marketing professionals, six sigma, and quality professionals
Key words: Administrative and management, cost containment and management, consumer advocacy, consumer satisfaction, third-party payers, outcomes, innovation, healthcare productivity, public policy

Although this is not a how-to book, it provides the reader with exhaustive research, interesting theories and numerous examples on the subject of consumer-driven health care. Herzlinger, a compelling and entertaining writer, delivers a revolutionary and moving vision about how to empower consumers. This heavyweight tome noticeably points to the fact that success is shaped by a potentially tedious journey, which requires innovative thinking and actions, to fuel the massive changes needed to overhaul current traditional and bureaucratic structures.

Throughout the book Herzlinger emphasizes that the consumer must be taken seriously by listening to what they want and acting on their needs. This will bring much needed accountability to all aspects of the healthcare sector. When the consumer defines the quality expected, fewer failures are experienced, which, in turn, lowers healthcare costs.

The first eight chapters of the text cover why consumer-driven healthcare is needed. Herzlinger then engages numerous expert contributors such as Denton A. Cooley and Dean Ornish to help describe how productivity may be enhanced if consumers are key drivers in critical decision-making processes. Early adopter models include descriptions of U.S. and international initiatives. All points of view are taken into account, whether from top business executives, the insurance industry, higher learning settings, or medical experts.

In summary, this book is rather lengthy, but it is filled with much useful information. All 81 chapters may not appeal to every reader, but content will hold the attention of any industry leader or healthcare professional interested in consumer-driven healthcare.

Reviewed by Carole S. Guinane, MBA RN

JHQ welcomes the opportunity to review various media that could potentially be of benefit to healthcare quality professionals and the people they serve. Reviews are published in every issue of JHQ. To have your product reviewed by a healthcare quality expert, please send a nonreturnable copy to:

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