During the last week of February, 2009,  PULSE of Colorado joined Consumers Advancing Patient Safety (CAPS), The Colorado Patient Safety Coalition and Colorado Citizens for Accountability to launch a united effort to bring attention to healthcare quality and patient safety in Colorado.   The workshop, facilitated by CAPS board members Marty Hatlie and Becky Martins, successfully brought providers and a diverse group of consumers together under one roof to discuss and create a joint mission that will be adapted through the entire state in time.   Participants were oriented to the World Health Organization’s World Alliance for Patient safety by Marty Hatlie and Patient Safety Champions, Jeni Dingman, and all participants were invited to join the World Alliance Patients for Patient Safety program and become Champions themselves.

Four key areas were addressed by all participants and action plans were developed for each.   The four areas are: "Engaging Patients and Families in Quality Improvement, Patient and Family Involvement in Their Own Care, Effectively Responding When Errors Occur, and Establishing a Community Culture of Patient Safety".   The challenge now is for Coloradans to develop each action plan into projects that will advance change statewide.  This was the first time that the topic, "Establishing a Community Culture of Patient Safety," has been a focus of discussion in workshops that CAPS or the World Alliance For Patient Safety have organized..   This innovative idea boldly realizes that the only way to successfully change a culture is to involve all aspects of society.  Consumers are learning how to be engaged, but patient engagement cannot flourish without the full cooperation of the entire medical community.   Consumers must also know exactly why they must be engaged.  These goals cannot be realized unless full community culture is totally synchronized in this area.

Also for the first time, the issue of how the American legal system interferes with disclosure, healing and learning from adverse outcomes was addressed.  This objective was openly and honestly discussed by both providers and several consumers who have actually had first hand experience with filing legal claims, in some instances against organizations represented in this room.  Powerful stories were told of the impact of litigation and the defensive strategies that providers use when they are sued.  Rather then healing or delivering a sense of justice achieved when a settlement is made, workshop participants shared that the process, which can last years in Colorado, actually forces them to constantly relive the pain and agony of an event  that has already changed their lives forever.   No specific reform agendas were agreed upon, and there were participants who spoke to the merits of a legal system that can hold providers accountable and potentially cause change.  But there was a strong sense that the current system doesn’t work well for many patients and disruptive of relationships between providers and patients.  It is hoped that the discussion at the workshop may be a step towards increasing understanding and consideration of  alternatives to the legal system that might someday be pursued in Colorado. 

A new horizon is now visible to the stakeholders of Colorado, and a bright hope of innovation and change will bring with it a new day of change and healing for all of our newest Champions for Patient Safety.