By Yukiko Takanashi and Hiroaki Ishihara / Yomiuri Shimbun Staff WritersGunma University Hospital is working to reform itself after a number of patients died following liver or pancreatic surgeries. A year has now passed since a third-party committee tasked with investigating the situation published its findings in a report, and the hospital presented its reform initiatives to the committee at a debriefing session on Sept. 1.
The committee concluded that some issues remain, but its overall evaluation of the hospital’s efforts was positive. We asked three people who were involved in the matter, both inside and outside the hospital, for their opinion on where the reforms are headed.
(From The Yomiuri Shimbun, Sept. 20, 2017)
Families’ concerns still need to be addressed
Ayako Kawada / Executive director of Iryo no Ryoshin wo Mamoru Shimin-no-kai (Association for honesty in healthcare)
In 2003, I lost my mother when she underwent surgery for valvular heart disease at Tokyo Medical University Hospital. Afterward, I found out that several other patients of the physician who had operated on my mother had also died. News of the deaths broke for the first time in December of the following year.
Ten years later, media reports about Gunma University Hospital broke out. When I read an article, I was shocked. I thought: “It happened again. Has the nature of university hospitals not changed?” I began to have regrets. “Had I not clamored loudly enough for measures to prevent the recurrence?”
To prevent these accidents from reoccurring, we, the bereaved families, submitted a 10-point proposal to Tokyo Medical University Hospital. It included a proposal for establishing a memorial day focused on medical safety — something that would provide an opportunity to reaffirm the importance of medical safety every year. For more than 10 years, the hospital has held a lecture about medical safety on the first Saturday of August every year. I participate in that meeting every year, and it is now open to the general public as well.
I also became involved in civic activities to promote medical safety, and I have continuously made efforts to encourage dialogue between patients and medical staff, so I was all the more shocked when I heard that medical accidents similar to the one that killed my mother had happened at Gunma University Hospital.
In August I had a chance to talk with the bereaved families of the Gunma University Hospital patients when they held a press conference in Maebashi after their interview with the surgeons involved. My eyes filled with tears when they told me about their feelings. It was just like when I lost my mother.
Feeling that the surgeon and the former professor involved have not shown proper regret for their actions, the families of the patients who died at Gunma University Hospital have sought administrative punitive measures against them, such as their suspension from medical practice. With no signs of regret or proposals for measures for improvement, the families likely had worries about the doctors continuing to practice medicine.
After the accidents at Tokyo Medical University Hospital, the Japanese Society for Cardiovascular Surgery took the initiative to retrain the surgeon involved. That surgeon returned to the operating room after two years of retraining. As a family member of a victim, I felt that this measure gave me a sense of security. I think it would be good if the cases at Gunma University Hospital also led to similar kinds of initiatives from expert groups.
In June, I gave a lecture to doctors and nurses of Gunma University Hospital after I was asked to talk to them about my experience as a family member of someone who had died in a medical accident. This lecture took place in the middle of a “medical safety week” that was being organized to help people learn from the series of accidents that had happened. The hallways of the hospital were lined with panels displaying the safety initiatives that each department was taking. I felt that little by little, it was moving toward reforms.
I very much hope that it will continue taking initiatives to realize reforms, and the hospital will serve as a model of medical safety for other medical institutions.
[After her mother died after undergoing surgery at Tokyo Medical University Hospital, problems were discovered with the abilities of the surgeon, as well as the medical treatment system of the hospital. After giving a lecture at the hospital as a representative of the bereaved families in 2009, she has continued to work as a medical safety activist. She is 46.]
We are cultivating an environment of communication
Yayoi Nagai / Head of the Medical Quality and Safety Management Center at Gunma University Hospital
We at Gunma University Hospital are working on a patient-centric system that focuses on what we need to do to ensure safe, secure medical treatment.
Previously, we left discussions on informed consent to individual medical departments. Today, all discussions use a template that aggregates the necessary information based on the nature of the treatment involved. We have created about 750 templates. To better support patients, we increasingly have nurses attend the discussions, and we’ve made sure that patients’ responses — questions and so on — can be recorded in detail in their medical records. We’ve also introduced questionnaires that aim to determine whether patients understood the content of the discussions.
Another problem we had was that serious post-surgery complications were not reported to the Medical Quality and Safety Management Center. In fiscal 2016, we received about 800 reports from doctors about medical incidents, including the complications. These also include ones that could have been severe accidents. That is four times more than in fiscal 2013, when we received about 210 reports. Reports by doctors made up 14 percent of the reported incidents, which is a lot.
We also make sure that staff members who hold various positions in different departments participate in conferences, or case study meetings. This aims to tackle the problem we were alerted to of closed environments — the fact that departments in the hospital did not know what other departments were doing. For example, every week, a joint meeting of sections in the Integrative Center of General Surgery spends three or four hours discussing all surgical patients.
Each staff member believes we have to change and that we can’t carry on just providing our usual level of medical care. People are becoming very conscious of the need for reform.
In June, we organized a medical safety week, during which we held a lecture meeting with the family members of victims of medical accidents other than the problematic surgeries invited to attend for the first time. Around 330 doctors and nurses participated, and many of our staff members were greatly moved by the words of the bereaved families. We want to continue organizing this kind of event next year and beyond.
Some patients still have criticism for us, but recently, we’ve also been hearing expressions of gratitude, such as doctors or nurses who tried to spend time with the patients and kindly supported them.
After the accidents were uncovered, the number of surgeries carried out at our hospital decreased, but recently we have seen a slow but steady increase. This increase also occurred in the Hepato Biliary Pancreatic Surgery Division, where a series of patients had died. We hope we can continue to fulfill our role as a university hospital, meeting the expectations of the community while taking care not to place excessive burdens on our doctors and other staff.
At information sessions and the like, I have spoken with the families of patients who had died in a series of medical accidents. I realized that patients find it very difficult to say what they want in front of doctors. We have to create an environment where patients feel able to speak freely.
Medical safety is a project that can never be stopped. I believe it is important for the hospital, as a whole, to continue implementing initiatives aimed at establishing safe systems.
[After graduating from Yamagata University, Nagai began working as a dermatologist at Gunma University Hospital. In 2010, she became an associate professor at Gunma University. In 2014, she began an internal investigation into a series of patient deaths that took place in the former No. 2 surgical department. Since then, she has been in charge of a series of inspections and medical safety reform initiatives in the hospital. She is 53.]
Continuous, steady reform efforts remain essential
Yuichi Ueda / President and CEO of Nara Prefecture General Medical Center
One year after the investigative committee submitted its report, the committee had the opportunity to observe the status of reforms that are being implemented at Gunma University Hospital. Of all the medical care-related problems that we identified, 80 percent are all but solved. We believe that this progress in only one year is commendable.
Early in the morning before a debriefing session, I walked into the hospital earlier than planned because I wanted to observe how things were going. The atmosphere had changed significantly from the one I had experienced before. Compared to when I visited the hospital around the time the investigation started, the young doctors and nurses I saw seemed lively and motivated. My questions were answered energetically. I could feel the confidence of people who had worked as hard as they could and made great progress in just one year.
I also attended a conference with people who held various positions, regardless of their job category or clinical department, and observed lively discussions there. As a university hospital is also a place where students train, letting them see people work in this way is an important part of students’ clinical training.
I also heard people say that now they were conducting informed consent discussions more meticulously, they were so busy that they were short of time. However, that is a problem that must be overcome with some applied ingenuity, such as by dividing responsibilities within medical teams and making easy-to-understand pamphlets. It needs to be solved to restore trust in the medical care they provide.
When it comes to encouraging patient participation, the hospital’s efforts are still insufficient in some ways. But this is not a problem that is limited to Gunma University Hospital. We see it in other hospitals as well. I think this is an issue that the entire medical community will have to deal with from now on.
Another thing that concerns me somewhat is whether the hospital will be able to continue building on the improvements that have been made. Establishing an ideal system is easy, but actually implementing it is very difficult — and implementation is more important. I hope that mid-career medical staff who played key roles in reform efforts and young staff who were trained in this new environment will be the driving force to promote this continuous implementation.
When you throw a stone into a pond, the ripples spread fast. Ideally, the reforms implemented in Gunma University Hospital will also spread to related medical institutions in Gunma Prefecture and have a positive influence on the quality of medical care. Support from the prefecture is already in place, so I think medical institutions are ready for change.
Medical treatment is something that we do for patients, not for medical personnel like doctors or nurses. That means medical professionals should provide, or aim to provide, the kind of medical care that they would want for themselves or their families. A university hospital should have the strength to recover even from significant social backlash. Since Gunma University Hospital has come this far, I want it to aim even higher now.
[Ueda is the president of the Japanese Society for Cardiovascular Surgery and a professor emeritus of Nagoya University. He heads the Quality and Patient Safety Department at the university. He served as the chairman of the third-party committee tasked with the investigation of problematic deaths after operations at Gunma University Hospital. He is 65.]