The importance of listening

“When [going into] an examining room,” said Dr. David Ruben, Chief of Geriatrics at UCLA, “you’ve got to be ‘out there’ for the patient. It’s very much like going on stage. It’s not that it’s insincere, but you have to be optimistic for patients. You need to engage them completely with your attention and be observant of everything that’s going on with them.”

That comment is from a story broadcast recently by National Public Radio. “On stage” was the phase that struck me because, although we are not “acting,” we in health care certainly are at center stage for patients and family members. Patients and family members study us, as if we were performing at a recital, giving a reading at our place of worship, or making a speech in front of our social group.

They watch closely to discern clues about what’s going on with their care or with their loved ones. Are we excited about something? Are we confident? Distracted? Are we sensitive to the patient’s discomfort or anxiety? This is the way we human beings communicate, by closely watching others to see if actions match words. And the more important something is (such as hospital care), the more closely we observe.

This year the federal government will start observing us – through the eyes of our patients. Surveys will be mailed to the patients of CGH and all other hospitals across the country. This is called the HCAHPS survey (pronounced “h-caps” and meaning “Health Consumer Assessment of Healthcare Providers and Systems”). The results of these surveys will be reported publicly, starting in 2007, by the federal Centers for Medicare and Medicaid Services (CMS). Eventually CMS intends to use the hospital patient satisfaction scores to determine how much they pay us for the care of Medicare patients.

CGH will voluntarily participate in a test run of the new HCAHPS survey this summer. The official survey process begins this fall.

Press Ganey Associates, a professional polling organization that already surveys CGH patients, has worked with the HCAHPS survey to determine what patient values are most correlated with high hospital satisfaction. According to Press Ganey, patients who give hospitals high marks well feel they have been listened to by the nurses and other staff.

“You need to engage them completely with your attention and be observant of everything that’s going on…” is the way Dr. Ruben put it, an excellent definition of effective listening.

The experts say that how we perform our jobs is as valued by patients as what we do in the jobs. “Scoring highly (on patient surveys) does not require [hospital staff] perform any additional tasks or duties but simply conduct their existing activities in ways that build relationships with [patients and families],” according to the experts at Press Ganey. Examples? Greeting the patient by name, and asking for help to pronounce the name correctly. Making eye contact with the patient and family members when speaking with them. Asking about a patient’s comfort and helping make the patient comfortable. Explaining what you are doing – and why. Using those most-important words consistently: “excuse me,” “please,” and “thank you.” Before leaving the room, ask, “Is there anything else I can do for you?”

Health care workers are hardly actors in any theatrical sense, but we are clearly stars to our patients when we listen to their needs, when we show concern for their comfort, and when we demonstrate courtesy in the many things we do every day.

I had no idea

Two months ago we heard shocking reports about several individuals who were arrested for illegally harvesting body tissue in New Jersey funeral homes. [1] The tissues were provided to a legitimate medical supply company where they were properly processed and distributed to hospitals around the country – including to Community General Hospital.[2] The investigation into these matters is continuing, most recently with a probe of a Philadelphia funeral home.

We saw an entirely different kind of story in our local paper recently. For the 26th consecutive year, students from SUNY Upstate Medical University gathered at Weiskotten Hall for a memorial service to honor individuals who donated their bodies to science.

All of us benefit directly or indirectly from the gifts of bodies and body parts from voluntary donors. For many years the New York State driver’s license has included a short form allowing each of us to “make an anatomical gift to be effective upon my death.” This prompts a story about anatomical harvesting at CGH several years ago.

A young adult died in our Emergency Department as the result of a neurological event, and the spouse agreed to organ harvesting. The couple had been married only a few years, and they had discussed with each other their willingness to donate their bodies “to help others if something should happen.” When the patient was pronounced dead, the spouse readily gave consent, and the deceased patient went to the OR for harvesting.

Six months later the surviving spouse called me one morning and asked to meet with members of the Emergency Department and OR teams who cared for the patient who had died. “I want to thank them,” the spouse said, “and I have some unanswered questions, some things I am wondering about that I would like to ask.”

I did not know what to make of this request. The spouse was certainly heartfelt, but what were the “unanswered questions?”

Working with the Nursing Division, I arranged for a small reception in the Personnel Lounge for the spouse at mid-morning one day. I invited those who had cared for the patient to stop and introduce themselves to the spouse. It was voluntary, and I told the spouse that CGH people were busy, and I could not be sure how many would be able to attend.

Many did. Employees shook hands with the spouse and introduced themselves. They said, “I cared for your [spouse] in the ED,” and “I was with [the patient] in the OR.” They said, “I am sorry for your loss.” The spouse said, “Thank you so much for all you did,” and “Thank you for coming this morning.”

One nurse from the OR had done homework. She arrived with a small piece of paper that had numbers written on it. “Let me tell you about some of the people who benefited from [the patient’s] gift,” she began. “There was a 15 year-old girl in [a Southern state] with bone cancer. She received your [spouse’s] long bones. There was a middle-aged man in St. Louis who received the heart. I was there when the harvest team arrived from St. Louis. A few hours later, as we continued to work on your [spouse], there was a phone call that was put over the OR speaker. The caller said, ‘The heart is in the patient, and it is beating.’ And we all cheered.”

The nurse continued, “I tried to count the number of patients who were helped by [the patient’s] gift – the eyes, the kidneys, the skin, the bones, the heart. There were more than 150 individuals who were helped by some part of your [spouse]. The harvesting took many hours, and at the end we were all exhausted. We all said a prayer for your [spouse] in the OR.”

I don’t think there was a dry eye in the room. “I had no idea,” the spouse said. “I had no idea that so many people were helped. Thank you for telling me this. You have no idea how much this means to me.”

This story has stayed with me all these years as a reminder of the good that we do – and how powerful it is when we explain what we do so others may share its meaning.

This CGH story – along with the annual memorial service at SUNY – are antidotes to the revulsion we feel at learning of the tissue scandal in New Jersey.

Please take out your driver’s license. Have you signed permission to be an anatomical donor “to help others if something should happen?”



[1] Two CNY patients got tissue linked to indicted supplier ,” Post-Standard, February 23, 2006
[2] “CGH opens info line on body tissue scare,” CGH Family Letter, February 25, 2006

Thank you, 95%

Community General Hospital has seen an increase in the percentage of hospital people (that includes doctors and employees) who comply with proper hand hygiene. In the first three months this year, we are averaging 95% compliance, compared with a 90% average in the past two years.

Three weeks ago I quoted a newspaper obituary for David Williamson Milne, a man who died in Kingston, Ontario on October 30, 2005. “The surgery was successful,” read the obituary.

Dave’s recovery was preceding well, thanks to the care of the [hospital] staff. Unfortunately, a series of hospital-acquired infections set back his progress and ultimately caused his premature passing.[1]

According to the Hand Hygiene Resource Center, “two million people become ill each year as a result of a hospital-acquired infection,” at a cost of some $4.5 billion. This week the Wall Street Journal reported “the rising alarm” that 90,000 hospitals deaths occur each year from these infections.[2] That translates to about 250 patient deaths each day! To put that number in perspective, last year CGH had an average daily census of 192 patients.

A review of 34 studies shows that “hand washing adherence among health care workers…varied from 5% to 81%” – with the average “only 40%.” Yesterday Sue Chamberlain, CGH’s Infection Control Program Director, told me there is a 1999 study by the Centers for Disease Control (CDC) that shows an average 54% of health care workers wash their hands as required. From this I conclude that the average hospital’s compliance is in the 40-50% range.

“‘It is no longer tolerable to accept noncompliance rates of more than 50% when we are dealing with critically ill patients,’” according to Dr. Don Goldman of the Institute of Healthcare Improvement (IHI) who was quoted in the Journal article. Dr. Goldman noted that computer-chip makers have better hand-cleaning performance than some hospitals.

At CGH nothing we do is more important than keeping safe the patients entrusted to our care. So I thank you for the increased vigilance that has boosted our hand hygiene compliance to 95%. We are at the very top of nationwide performance, ]something we should be proud of – and something very important for patients.

I do have a nagging question about the remaining 5%. Who would fail to wash hands and raise the risk of a potentially life-threatening infection for a patient in the next room, a colleague in the cafeteria …or for that matter, a loved one at home?



[1] “A Tipping Point,” CGH Family Letter, March 18, 2006.
[2] “Hospitals Get Aggressive About Hand Washing,” Wall Street Journal, April 5, 2006

A tipping point

“Some day, we may look back at this and say it represented a tipping point in public consciousness.”

That is a message I received yesterday from my colleague Peter McGinn, PhD, who is the President and CEO of United Health Services in Binghamton, NY. Peter copied me on an e-mail that he sent to his staff about an obituary that appeared in a Canadian newspaper five months ago.

In reprinting the obituary, I repeat Peter’s words to his staff: “Please read this very carefully – all the way through.”

On October 30, 2005, David Williamson Milne passed away at Kingston General Hospital after a battle with hospital-acquired infections. He was loved and is deeply missed by many.

David Milne was the kind of person that you got to know, and like, quickly. His friends were among society’s small and society’s great, and he treated each with equal respect and appreciation. His Scottish humor and laugh were infectious. Even in his last days he could make us laugh.

His family was the joy of his life and sustained him throughout. As the youngest of a large Manitoba farm family, he was his mother’s joy and primary recipient of her loving largess. He wedded his first love and childhood sweetheart, Catherine, who followed him from posting to posting, with one and then two children, Catherine Jr. and Jacqueline.

As a long-service pilot in the Canadian Armed Forces David Milne’s life was not without risk, but risk balanced in an equation with skill. His heart surgery was a risk, but it was balanced against the outstanding skill of Dr. Hamilton at Kingston General Hospital. The surgery was successful and Dave’s recovery was preceding well, thanks to the care of the KGH staff. Unfortunately, a series of hospital-acquired infections set back his progress and ultimately caused his premature passing.

Every year hospital-acquired infections cause or contribute to the death of more people than breast cancer, heart disease, and car accidents combined. Most of these infections are initiated by otherwise caring healthcare workers who forget or neglect to clean their hands.

And for each of those who, like our friend David, succumb to one of these unnecessary infections, there are many more who ache for their loss. These are not numbers on month-end reports. These are our fathers, our mothers, our children, and our dear friends, who are dying prematurely because of unclean hands. The little bit of extra time that it takes for healthcare workers to wash or to use an alcohol sanitizer is pittance compared to the waste of so many productive, loved and loving lives.

In honour and memory of David Williamson Milne a donation will be made in his name to the Community and Hospital Infection Control Association of Canada. His family and his extended group of friends openly urge those at Kingston General Hospital as well as healthcare workers everywhere to clean their hands before and after every patient contact. It is absolutely a matter of life and death.

Farewell to a dear husband, father and friend.

Whatever became of bedside manner?

The New York Times ran a series of letters to the editor last month under the heading: “What ever became of bedside manner?” [1]

The nine letters were mostly from doctors, who offered their own advice for improving doctor-patient communications. The doctors recommended good manners, such as making eye contact, remaining seated while a patient recounts symptoms, washing hands in the presence of a patient, returning phones calls and accepting appointments promptly for established patients. [2]

Some letters also pointed out a patient’s responsibility for effective communications. “So often patients come to us without organized information or prior records,” one wrote. [3] Another physician noted that patients can waste time by speaking of irrelevant things. He wrote about a recent example where a patient recounted a lengthy medical experience from the Korean War. The physician said,

I listened patiently as the minutes ticked by, wondering what the story had to do with his eye condition or general medical history. It eventually became evident that it was simply an interesting anecdote that the patient felt like sharing…[4]

Several weeks after the first set of letters, the Times printed more letters on bedside manners. Several suggested that better communications training is (or should be) available for health care professionals. One writer suggested that health care workers “ask themselves, ‘Is this how I would want my family member to be cared for? Is this how I would want a family member to be addressed?’” [5]

I have been in the hospital field for over 30 years, and I am still amazed at how much we sometimes talk past each other. We must all have examples of people misunderstanding one another – not because they were not listening, but because they applied different frames of reference to what was being said.

Messages we think we are sending may not be the same messages the other is receiving. We have different training, different experiences. We cannot automatically assume that our own perspective is shared by another. Sometimes our different frame of reference may cause us to make assumptions about another’s motivation. We may not even know we’re making an assumption, but what we think about the other fellow can affect the way we listen to – and accept or dismiss – what is being said.

I can imagine, for example, that the gentleman who rambled on about his Korean War experience (in the example above) may have done so because he was nervous at seeing a doctor – and his nervousness prompted too much talking. Or perhaps his long-winded story was an attempt to establish a relationship with the doctor before he brought up an embarrassing problem or a scary health complaint.

The point is, we may not know what motivates the other party, but our communications can improve if we imagine reasons why the other party might say or do something that is otherwise inexplicable. Keeping an open mind about the other person can help get past distracting or annoying communications. How might the caregiver’s communication with the Korean veteran have changed if he had considered reasons for the patient’s story other than mindless prattle?

When communications prompt an emotional reaction in the caregiver or the patient the focus can move away from what is being done or what has to be learned. If we’re thinking “How rude!” or “Who knows what she meant by that!” we’ve already changed the focus of our attention. When the focus moves away from the communication process, we risk not hearing something, forgetting to say something, not paying attention to something.

Good manners in health care communications are not just the “extra” that we bring to the bedside. They are an important part of the caring that we do, facilitating unambiguous understanding and reducing the chance for a mistake.


[1] “What’s Become of Bedside Manner? (Nine Letters),” New York Times, December 4, 2005.
[2] “Some Simple Guidelines for (seeing) Patients,”, Sharon Lewin, MD, New York Times, December 4, 2005
[3] Allan B. Ettinger, MD & Deborah M. Wesibot, MD, New York Times, December 4, 2005
[4] Mark Melamed, MD, New York Times, December 4, 2005
[5] Judith A. Erlen, New York Times, January 17, 2006

"A classic example”

Earlier this week an employee raised a concern about patient privacy after she saw a provider interviewing a patient about her health history in a way that could be overheard by others.

Yesterday John Conner, our HIPAA[1] Privacy Officer, sent an all-department e-mail to remind us how important it is to use only the minimum necessary information when communicating about patients.

He wrote about a situation involving a department that produces a list of patients to be treated each day. The list is used to check-off names as patients arrive for their appointments. Last week a patient reported being able to see information on the list, such as the diagnoses or treatments associated with other names.

John called the situation “a classic example” of not following the minimum necessary standard.[2] In other words, more information was included on the patient list than was necessary. A second problem was that the list was visible to others. Patient information must be protected from unauthorized access, including casual access by others.

“The event provides a valuable learning opportunity for us,” John wrote, and he asked employees to bring similar situations to the attention of their supervisors right away.

I responded to John with an e-mail, saying that his message reminded me of another situation that dates from pre-HIPAA days. The mother of a patient called me to complain about a lack of information privacy. Her son, who had been a patient the prior week, had left his blue jeans in the room when he was discharged. She called Security, which promptly contacted the nursing unit, and the lost jeans were found.

When the mother stopped at Security to pick up the clothing, she saw that they were stored in a clear plastic bag, marked “patient belongings.” The bag also contained the printed half-sheet with the patient’s name, address, age – and diagnosis.

“Why, Mr. Quinn,” the mother asked me, “did the security officer have to know that my son is HIV positive?” It was a good question, and as a result, CGH changed its then-policy of including the half-sheet to identify patient belongings.

I’d like to thank the employees who showed their interest in (and sensitivity to) patient privacy this week. Confidentiality is a subject we take very seriously, and – as is apparent – one we need to remind ourselves about constantly.[3]


__________________

[1] HIPAA refers to the Health Insurance Portability and Accountability Act of 1996, a federal law that limits how hospitals and other health care providers may use health information that identifies an individual patient. The rule does not restrict the ability of doctors, nurses and other providers to share the information necessary to treat patients.

[2] HIPAA requires providers to use or share only the minimum amount of protected information necessary for a particular purpose. Information on HIPAA is available on this federal website: http://www.hhs.gov/news/facts/privacy.html

[3] For CGH policies on patient confidentiality, go to “Public Folders” on the CGH intranet, find “Manuals” and select “Hospital Policies.” “Hospital Policies” will take you to a number of headings. Select “09 Management of Information” and go to the subsection on “Confidentiality & Security.”

We have to take you in

On rounds this morning, I witnessed the life of our hospital as always. Nurses attended their patients. Doctors were at the bedside and at the charts. A technologist pushed a bed toward Radiology. The Emergency Department accepted its next patient. A maternity patient went upstairs for evaluation. The laboratory staff was busy testing fluids. In the kitchen, breakfast trays were being prepared for upstairs. Security was on alert.

It is a holiday, and our patients need us.

There is no elective surgery, and all our patients are those who cannot be anywhere else. As a hospital, we care for the acutely ill every day and all night.

There is an often quoted line of poetry by Robert Frost:

Home is where, when you go there,/ They have to take you in.[1]

The line applies to hospitals too – “we have to take you in.” What a responsibility we have, and what a privilege!

[1] “The Death of the Hired Man,” North of Boston, New York: Henry Holt, 1915

A most difficult heroism

In the aftermath of Hurricane Katrina, words fail. The scale of the Gulf Coast disaster is truly massive, and the situation in New Orleans is a natural disaster compounded by a human one.

I have been thinking about those New Orleans hospital workers who left their families last Sunday, fully expecting to ride out the approaching hurricane while caring for the patients who needed them. By week’s end, however, the patients and caregivers of one hospital had become “almost indistinguishable,” according to the Los Angeles Times. [1] The newspaper reported the hospital had become “a chamber of horrors” with sewage backed up in sinks, its basement morgue under water, and a body bag in the ED. One employee was quoted as saying, “Workers are to the point of collapse.”

When the hurricane intensified Sunday night, hospital staff moved patients into hallways to protect them from the shattering windows. When the power failed, the hospital’s generators came on, but the rising water stopped the generators, and the hospital was without the electricity that runs ventilators, CT scanners, computers and air conditioning. Patients used 02 tanks to smash windows for fresh air. An internal evacuation moved patients to an upper floor. By Thursday hospital staff were in the third day of hand-ventilating patients. The National Guard started, then stopped an external evacuation because of sniper fire. Other rescue workers eventually followed, and aluminum boats were packed with patient stretchers and IVs as nurses accompanied patients to the Superdome and to the airport, which served as staging areas for evacuation out of the area. By Thursday 1,800 patients had been evacuated from New Orleans hospitals – with another 3,000 waiting for evacuation.

Hospital staff have families too – were they safe? With so many communications problems, the hospital staff were unable to talk with their loved ones. What must have been the worry, the fatigue, and the demands on doctors and hospital employees as they remained with the sick in those wasted facilities without the ability to provide sanitary or adequate care?

There have been many dramatic photos of the Coast Guard rescuing hundreds of people from rooftops and attic windows. The helicopters worked, allowing such heroic action. But medical equipment did not work. Indeed, the buildings themselves failed. That required a different kind of heroism by the caregivers of New Orleans. They struggled without rest to keep patients as safe as possible without equipment that is basic to proper care.

I have not seen any dramatic photos of life saving within the hospitals, comparable to the photos of Coast Guard rescuers. But the work of hospital people represented a different kind of heroism, one of the most difficult kind.




[1] “Hospital Descends into Misery,” Los Angeles Times, September 2, 2005.

EMR promise and reality

It was standing room only in the POB-South classroom at Community General Hospital on May 27 when several presenters discussed the promise – and the reality – of electronic medical records (EMRs). The forum was organized by health care advisers to New York State Assembly Member Jeff Brown (121st Assembly District).

Dr. David Wormuth, a thoracic surgeon, opened the discussion by reviewing office-based medical record systems, such as the one he uses. This was followed by a discussion of hospital EMRs by Mitch Rozonkiewiecz, CGH vice president of information technology, and Chuck Fennel who has the same position at St. Joseph’s Hospital.

Mitch talked about the importance of linking separate CGH systems (such as radiology, pharmacy, and patient access) through a common “portal” that is easier for clinicians to use and that improves patient safety by reducing multiple data entries and patient look-ups. He also talked about a discussion by the Manufacturers’ Association of Central New York (MACNY) about possibly forming a regional health information network (RHIO). A RHIO would permit physician offices and hospitals with EMRs to exchange test results and other patient information, no matter where in our region a patient had tests.

Such connectivity is the promise of electronic medical records, although the discussion quickly focused on some barriers to that promise.

Several physicians in attendance talked about the difficulty of using EMRs that include lengthy narrations or formulaic sentences, making it time consuming to locate relevant information about a patient. Chuck Fennell said that, despite all the talk about records portability, “the health care industry is underserved because commercial products are not readily available for implementation in community hospitals.” There are some 300 vendors who provide systems with differing components, making it difficult for medical practices to select a vendor or commit to the cost of a system that might not survive all the market and regulatroy changes to come.

Mitch Rozonkiewiecz said that forming a local RHIO would be a formidable undertaking requiring the community to provide the “brains, the investment, and the standards for use.” Where, he asked, would the necessary resources come from?

One person attending the forum was Nasir Ali, the Chamber of Commerce vice president responsible for new venture development. He said the health care system is not a single process – it acts more like an ecosystem. He speculated the lack of a single, large customer makes it difficult for the information technology industry to focus on a single standard for connectivity. Mr. Ali suggested that the formation of RHIOs might provide a sufficiently large customer base to help the information technology industry develop the systems and standards necessary for connectivity, similar to that of the internet.

It was a fascinating discussion, full of promise and caution in equal measure.

Assemblyman Brown deserves thanks for arranging such a briefing on this important subject, and CGH was pleased to serve as host for the meeting.

Motality & hospital report cards

Two years ago I was concerned about pneumonia cases. A large insurance company released an updated version of its report card on hospitals, and for the second year in a row CGH statistics were good in all areas – except pneumonia. According to the insurer, the death rate from pneumonia at CGH was more than it should be when compared with the Central New York region.

What was the cause? Were CGH patient records properly coded?[1] An outside review of our records showed that we were accurately coding them.

Was CGH care being provided properly? Yes, it was. We reviewed every single case.

Were pneumonia patients at CGH somehow different from those at other hospitals? We looked at the numbers of patients transferred to CGH from nursing homes. We looked at the average age of pneumonia patients. CGH pneumonia patients were somewhat older than those in other hospitals. On average the CGH patients were 75 years old. The average age of pneumonia patients at other hospitals ranged from 50 to 69 years. Still, age alone did not explain it. We were puzzled.

The quality committee that was reviewing our pneumonia care focused its attention on advance directives.[2] One form of advance directive is a DNR order (“do no resuscitate” order). Patients with DNR orders request not to have cardiopulmonary resuscitation (CPR) under certain circumstances.

When we examined the records of patients with pneumonia who died at CGH, we found that that 90% of them had DNR orders. In other words, most deaths were by patients who did not want aggressive efforts to resuscitate them if their conditions seriously deteriorated. Of the hundreds of non-DNR pneumonia patients cared for at CGH, the death rate was less than one percent.

This distinction was apparently not reflected in the analysis used by the insurance company for its hospital report card. This point was clearly demonstrated last year when Dr. Dan Carlson, Vice President – Medical Affairs, and I attended a meeting on hospital report cards with about a dozen upstate hospitals. The large insurance company showed pneumonia mortality rates that it prepared for hospitals attending the session – and, sure enough, CGH appeared to have an above average mortality rate. Next to present was a national company that also produced quality comparison data. In this case, however, CGH was shown to have a lower mortality rate than the other hospitals when adjusted for more patient risk factors. Both presentations used the same data to generate different hospital rankings, based on their different statistical methods.

I was reminded of our pneumonia investigation when I read “Informed Choices For Better Care,” a recent story in the Post-Standard. The story said that for many years patients and families were “kept in the dark” about hospital comparison information, but report cards are now letting “consumers shop for health care much the same way they do for cars.”[3] The article also quoted the publisher of one hospital report card as saying that “hospital special interests” may no longer claim that “those poor dumb yokels (the general public) couldn’t possibly decipher how to use hospital data.”[4]

That report card publisher apparently sees hospitals as an adversary, but CGH has supported the development of report cards for many years (and we never disparaged the public as “dumb yokels”). In the 1990’s CGH was the first and only upstate hospital to publish its own comparative quality report card.[5] In doing so, CGH consulted the literature on quality reporting, used available data from national studies, and conferred with state government, local health maintenance organizations, and national organizations on the design and data used in the CGH report. This was before insurance companies and the federal government developed their hospital comparison websites.

Hospitals are not perfect, and neither are report cards, as the above pneumonia example suggests. I would argue, however, that website report cards educate both the public and providers, and they encourage competitive hospitals to get better. These are important tools in helping the health care industry make continuous improvements in quality management.

The pneumonia example demonstrates how seriously CGH investigates itself. I believe all hospitals take variations in quality seriously, and as the tools for measurement get better, hospital results will improve too.



[1] The government and payers look at the disease codes assigned to each patient record – this forms the basis for analysis.
[2] Advance directives are the written instructions patients give to doctors and hospitals specifying the type of care the patients want to receive (or don’t want to deceive) in the event they cannot make future medical decisions for themselves.
[3] “Informed Choices for Better Care,” Post-Standard, May 9, 2005.
[4] Post-Standard, May 9, 2005
[5] CGH’s self-published Quality Report Card started in 1996. It was posted on the CGH website and was issued annually until 2000, when the internally-prepared documents ceased when CGH joined the Health Alliance of CNY. In 1999 CGH’s report card cited with approval the Report of the President’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry (1998): “A widespread and ongoing consumer education strategy should be developed to deliver accurate and reliable information on quality when choosing health plans, providers, and treatments.”