April 18, 2001 8:00 — 8: 30 AM: Opening Remarks
The Commonwealth’s Perspective
The Honorable John Hager, Lieutenant Governor of Virginia

Good morning ladies and gentlemen. It is a great honor to be here with you at this conference of Virginians Improving Patient Care and Safety. I appreciate the invitation and I want to thank John O’Bannon for including me. Thank you, Tom Snead, for such a nice introduction.

This has been an interesting week at the Capitol, as the General Assembly works on redistricting. There is a lot of maneuvering on both sides, much of which is related to the budget. There is a lot of activity going on behind the scenes in an attempt to resolve the budget and car tax issues. It looks like there are enough people here to sit down and work out a solution.

And, of course, this afternoon many people will be going to Wakefield for one of the biggest political events in the Commonwealth: the Shad Planking. So it’s a busy week.

I am here, in the Governor’s absence, to bring you greetings from the Commonwealth. And I am certainly well-qualified and pleased to do that.

But I have some other qualifications for speaking to you: As lieutenant governor, I have studied health care issues and advocated passage of related legislation. I also have experience in the field of health care…as president of Children’s Hospital, as chairman of the Virginia Health Care Foundation and, of course, as a patient!

So I hope I can add some insight to your deliberations today.

It is so great to see all the people involved here today. I mean that sincerely. Having representatives from so many segments of the industry here to discuss the problem, analyze it and brainstorm solutions…This is the way to get things done.

Virginians Improving Patient Care and Safety has the challenging goal of reducing human error in the treatment of patients. You have taken on an important and admirable mission. I don’t need to elaborate on the obvious fact that everyone involved in health care strives for the best treatment and best possible outcome for each and every patient.

But your proposal to study mistakes in treatment in a methodical way and then design ways to minimize the occurrence of those mistakes is truly exciting. The promise of reducing errors in the treatment of patients holds the promise of saving lives, changing lives and, of course, freeing up resources for other health care challenges.

And I know that you will be successful in reducing patient errors or "adverse drug events."

I know all about patient error... I am one. I got clobbered by a vaccine that was out of spec.

I was a young executive with a big promotion, moving to New York, when I suffered a week of pain in my legs. I was working lying on the floor. Finally, I ended up in the emergency room of a hospital, where misdiagnosis and lack of technology led to an operation that, quite literally, almost killed me.

I had a long recuperation, during which a fellow patient in rehabilitation counseled me, "You’ll get used to it…you can take lots of naps." Well, that didn’t really cut it with me.

I had the opportunity to sue after I had polio but I decided to try to use the leverage to get the drug companies to change their protocols. I took advantage of that situation to help prevent it from happening to others.

But let’s not talk about the bad things. Let’s talk about the good things. Let’s talk about finding an approach that helps solve the problem and protects people. Protecting the patient is of course the highest goal here. But we don’t want to attack professionals in order to save patients. We are all interesting in finding ways to study the problem of human error and develop strategies for minimizing its occurrence.

You will hear from others today who have worked in this field, and they will have specific technical suggestions. I’d simply like to offer some generalized suggestions.

1. We need to level with people about what’s involved with medical procedures. This is undoubtedly a labor-intensive approach. It will require more training and more personnel, but educating people about their own health will help avoid some mistakes. For one thing, patients will have more confidence to speak up if they have questions about their treatment or symptoms.
2. There are many readily-available uses of technology that would surely avoid costly mistakes. The development of VIPC&S comes at a good time, when you can take advantage of technological developments to reduce human errors and improve care. For instance, doctors should enter prescriptions and drug treatment schedules on a computer. Then nurses and pharmacists won’t be wondering whether the doctor’s hen scratching called for a narcotic or a diuretic.
3. In a related development, there are recent efforts by the medical and pharmaceutical community to monitor Oxycontin use and abuse. This is being done elsewhere -- and soon perhaps in Virginia -- by establishing a data network linking pharmacists, so they can check and see if there is a suspicious pattern of prescriptions being filled for the drug. There are other applications for such a network.
4. The health care industry needs to adopt and adapt some of the business world’s quality control programs. I spent 30 years in industry, and we used various tools to improve performance…programs like Total Quality Control and performance-based management. We engaged in re-engineering. Sometimes the medical community has been slow to adopt business practices that have been demonstrated to be successful. It involves every employee and lots of investment and training, but it pays big dividends.
5. We need a system for resolving patient error cases that is people-friendly. Litigation only addresses a certain error in a certain place at a certain time. It doesn’t foster a long-term solution, a reordering of the circumstances that led to the error in the first place. I’m speaking as a layman here…I’m not taking sides.
6. Certainly, if you expect to change the culture and reorder the circumstances in which human errors are likely to occur, you have to be able to identify those "red zones." That means the collection and analysis of data relating to potentially actionable instances of human error.

The legislature has shown a willingness to care for the victims of "adverse outcomes" without penalizing the health care professionals who act in good faith. I’m talking about the Birth Injury Fund, which has been in the news recently. This little-known program provides lifetime care for people who are severely injured during birth, provided they waive their option to sue the medical community.

Nevertheless, any legislation to protect the medical community while also allowing for data collection would have to be carefully written. I believe such a balance can be struck, a balance that would give us the opportunity – ultimately – to institute life- and health-saving measures.

As the details of such a proposal are developed, I hope you will keep me informed.

I also want to point out that legislation is not always the answer. However, it can help to facilitate various actions and to promote strategic partnerships.

You have an outstanding team of capable people gathered to work on this project. I am truly and deeply impressed by the list of organizations who are united here and by the names of talented individuals who are actively involved. The synergy created by such a group will produce a measurable improvement in the health and lives of all Virginians.

You will hear many presentations today from people who are far more qualified in this field than I, but I hope my humble words will contribute to your success. You have so much potential for achievement here today.

I want to thank you for all the fine work you have done in establishing this organization and putting on this conference. You are a credit to the Commonwealth, and I am proud to be here with you.

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