Most of us go about our daily lives with the attitude that becoming a statistic is something that happens to other people. We’d be too paralyzed with fear to function any other way. But then when something does happen to us, whether we are ready or not, we must figure out our response. Vonda Vaden Bates faced such a situation when her husband, Yogiraj, died from a hospital-associated venous thromboembolism (HA-VTE) after his 13-day hospitalization for a traumatic brain injury. She responded by drawing on her experience in organizational and personal development to become an advocate for patient safety.
For Vonda, CEO of the boutique consulting firm 10th Dot, patient safety was so much of an assumption she didn’t realize it was an assumption on her part when Yogiraj first entered the hospital. But then a series of disconnects with hospital staff, who had otherwise been very attentive to Yogiraj’s treatment, set off alarm bells.
First, a member of her husband’s surgical team was dismissive of her serious concerns about recurring symptoms following the surgery. A short time later, when a nurse inadvertently poked herself while drawing blood, the staff seemed only concerned about the nurse receiving an AIDS test and not the patient.
Upon confirming the cause of death was a deep vein thrombosis (DVT), which resulted in a pulmonary embolism (PE), or VTE, she began to understand that her husband had died of a hospital associated condition, the third-leading cause of death in the United States. She suddenly had the same feeling as she did during the 1980s and 90s when someone she knew had died due to AIDS. It was no longer something happening to other people over there. “This was impacting to us.”
After spending some quiet time for deep personal reflection, she started investigating to see if Yogiraj’s death could’ve been prevented. Her alarm bells were set off again while trying to engage the hospital in a conversation about the incident. Months would go by between calls with the hospital; she felt like she wasn’t being heard.
“That’s when I started getting even more concerned about issues of patient safety—even beyond the situation of Yogiraj’s experience. It started to become evident that Yogiraj’s hospital caregivers may have also been left to experience his death without administrative support. I knew they would be deeply impacted. I began to understand why this is the third-leading cause of U.S. deaths, if this is how it gets handled—shrouded in secrecy and defensiveness. My perception was that the moment my husband took his last breath, he also ceased to be a person the hospital cared for; he immediately became a risk to be managed. There was insensitivity throughout our family’s attempt to understand what happened, ultimately leading to a complete shutdown.”
Vonda soon began to look at the broader scope of the problem, realizing that her background and experience made her uniquely qualified to address the bigger issues of healthcare safety as opposed to just focusing on the specific event that resulted in her husband’s death.
Some of the behaviors at the hospital she witnessed during her inquiry into Yogiraj’s death were exactly the behaviors that Yogiraj had dedicated his entire life to helping people move past. The guardedness she saw in particular is an important aspect of their coaching and consulting work, which seeks to create an unguarded self to be in better relationship with others.
Her next step was to learn all she could about VTEs and familiarize herself with organizations like the Patient Safety Movement Foundation, Leapfrog Group, and CANDOR. She felt the PSMF’s highly inclusive and collaborative approach was most aligned with her own.
“I went to the Mid-Year Meeting in 2016 and was impressed with the collaborative process that encouraged me, a newcomer, to show up and express my desire for the organization to prioritize HA-VTE as an APSS for 2017. I took notice of the openness and sincerity I encountered. When I heard that sharing medical device data was also at the core of PSMF’s mission, I knew instantly that PSMF was where I wanted to direct my attention moving forward.”
Vonda’s current work in patient safety involves sitting on the VTE and PFE (Person and Family Engagement) workgroups, sharing Yogiraj’s story, and leading collaborative assemblies to intervene in healthcare, education and governance. She recently led a four month cohort that included physicians, policy influencers, artists, communication experts and a former medical director. This set the stage for increasing her organization’s focus toward hospitals since everyone interfaces with healthcare at some point in their lives.
To that end, Vonda offers support to both individuals and systems, instilling her organization’s fundamental approach of taking beneficial pauses to create sound attentiveness during day-to-day interactions, as well as seminal events.
“We just started a pilot program with Intermountain Healthcare to support their caregivers to make more effective use of the great processes already in place for using an intentional pause. Our focus is on helping caregivers gain skills that support their focus, which often means de-focusing with practices like meditation, breathing practices, or a simple walk in nature.”
Seeking ways to engage the patient and family, Vonda is sending a letter of intent for PCORI funding to increase utilization of sequential compression devices (SCDs.) “Keeping SCDs on longer decreases VTEs. This could make a significant contribution to PSMF’s 0X2020 goal.”