Mark Graban opened this session by widening its audience deliberately. The topic, teaming with patients to improve safety, matters to healthcare professionals — but it also matters, he said, to anyone who could become a hospital patient or the loved one of one. That framing is the right one for this session, because the story at its center is not an abstraction about healthcare systems. It is the story of one family, told by the daughter who lived it.
The session brings together three perspectives on the same idea: that patients and families, given practical tools and genuinely invited onto the care team, become a real safeguard against error. Laura Townsend tells the story of her mother, Louise Batz, and the foundation that grew out of her death. Elise Matocha describes what it looks like to put the Batz Guide to work in pre-operative classes at a real hospital. Dr. Carol Wratten describes the leadership and culture change required to make patient partnership stick rather than fade. Graban, who has served on the foundation's board for several years, hosted.
This is a hard session in places. Laura's story is a story of preventable death. But the presenters were clear, repeatedly, about the spirit of the work: this is not about blame. It is about partnership.
Laura B. Townsend is Co-Founder and President of the Louise H. Batz Patient Safety Foundation. She founded the foundation after losing her mother, Louise Batz, to a preventable medical error following routine surgery. Since then she has led the development and spread of practical patient safety guides — including specialty guides and a mobile app — designed to help patients and families become active, informed members of the healthcare team. Her work focuses on building partnership, transparency, and communication between caregivers and patients to prevent harm.
Elise Matocha, BSN, RN, ONC, is a Bone and Joint Care Coordinator at Seton Healthcare Family, where she coordinates care for orthopedic and joint replacement patients. She integrates the Batz Guide into pre-operative education classes, preparing patients and their "co-pilots" to speak up, ask questions, and participate actively in their care. She has helped embed the guide into daily clinical workflows and has seen firsthand how it reduces patient anxiety and strengthens communication at the bedside.
Carol Wratten, MD, MBA, FACOG, is a physician executive, a Batz Foundation board member, and the retired Chief Quality Officer of Seton Healthcare Family. She was the Chief Medical Officer at Baptist Health System when Louise Batz died, and has worked with Laura since then to develop and implement the Batz Guide. She helped lead the cultural shift required to move from paternalistic care toward genuine collaboration with patients and families, and continues to advise healthcare organizations on sustaining that change.
Laura told her mother's story directly, and it is the foundation of everything else in the session.
A little over eight years before the webinar, in April 2009, Louise Batz went in for a total knee replacement. She had done her research. The family is a medical family — five doctors among them — and felt they knew how to navigate the system. Everyone told them this would be no big deal: in and out in three days. The family went in, Laura said, with a false sense of security. Louise was a healthy, strong woman; the last time she had been in a hospital was 35 years earlier, when Laura was born.
The surgery went well. The surgeon came out after about an hour and a half pleased with the result, and the family felt the huge sense of relief that comes when a patient makes it through surgery. Louise was moved to a unit on a PCA pump delivering 2 milligrams of morphine. Around 6 p.m. she felt nauseated and was given a drug for it. Around 10:30 that night, the family — Laura, her father, her aunt — spent about 30 minutes with the nurse, asking questions about how the night would go. They learned Louise was scheduled at midnight for morphine, the anti-nausea drug, and a narcotic, Demerol. That gave the family pause: it seemed like a lot of medication for someone who had never taken anything stronger than Advil. They decided together that Louise should only have the morphine if she needed it, and that she did not need the Demerol at all. The nurse encouraged them to go home so Louise could rest. Laura kissed her mother, told her she loved her, and told her she would be there in the morning.
At 3 a.m. the hospital called: Louise was having trouble breathing, and the family needed to hurry. When Laura arrived, there was a security guard outside her mother's room. She ran. Louise was lying lifeless on the bed. She had been given the morphine, the Demerol, and the anti-nausea drug at midnight. She had no monitoring on her. She went into respiratory depression and suffered an anoxic brain injury. Louise Batz was on life support for 11 days. On April 26, the family had to take her off life support.
It did not take the family long to learn that Louise had suffered a preventable medical error — a phrase they had never heard, despite being a medical family. During the 11 days, Laura did research, wondering whether her family was uniquely unlucky. She found that preventable medical errors were, by the figures she cited, the third leading cause of death in the country, behind heart disease and cancer. She was shocked that a problem that large had never come up, even in a medical family.
The night her mother died, the family wrote the mission for the Louise H. Batz Patient Safety Foundation. They were not going to let other families experience the pain they had been through. Louise's legacy, Laura said, was not going to end with that night.
Laura described what amounted to the family's root cause analysis, done with the support of San Antonio hospitals rallying around them. They identified three reasons Louise died.
The first was a lack of teamwork. The family's framing has stayed with the foundation since: they had a great family, a great patient, a great nurse, a great doctor — but great players don't make a great team, and they did not work as a team that day.
The second was a lack of knowledge. Laura sat with the nurse and asked a thousand questions, and not one of them was the right one. Nothing she asked affected any decision in her mother's care. Looking back at that is, she said, heartbreaking.
The third was a lack of technology. Laura's image: the hospital put her mother in a car going 200 miles an hour with no seatbelt and no helmet and said good luck. Louise was given narcotics she had never taken, with no way to predict how she would react, and no monitoring on her at all. It was, in Laura's words, a disaster waiting to happen.
Underneath all three sits the idea that became the foundation's work: if Laura had known the right questions to ask, her mother might be alive. She often says she wishes she could have six hours back.
Out of that came the guides. The Batz Guide is a practical tool — and a mobile app — that helps patients and families understand common safety risks (falls, infections, medication errors, monitoring), organize their questions and information, participate meaningfully in conversations with caregivers, and recognize when to speak up.
The foundation has built a family of guides: an adult guide available in English, Spanish, and a third language; a pediatric guide; pediatric transplant guides; and a free app for iPhone, iPad, and Android. The guides are distributed not only by the foundation but by partner companies that bring them to conferences and believe in the work. The foundation has also worked with the Head Start program and an "Empower" collaboration involving the University of Texas School of Pharmacy to create English and Spanish tools for thousands of San Antonio families — work aimed at health literacy, at giving families the right questions and a bridge onto the care team. At the time of the webinar, specialty guides were in development for breast cancer patients (with Susan G. Komen), heart patients, and NICU babies. Laura noted that the foundation keeps getting calls — everyone, it seems, needs a guide for their specialty.
Elise Matocha described what the guide looks like in daily practice at Seton Healthcare Family — a not-for-profit system serving an 11-county, 1.9 million population in Central Texas, with Elise's orthopedic unit certified in disease-specific care for joint replacement and spinal surgery.
The guide is introduced in a pre-operative bone and joint class, ideally four to six weeks before surgery. The class is built around preventing complications and patient safety — preparing patients for what to expect in the hospital and at home, and for their rehab. The framing Elise's team uses is the one that matters: the caregivers have a big role to play, and the patient plays a big part too, and a central part of the patient's role is being their own advocate, feeling free to speak up and voice concerns to staff, surgeons, and physicians.
Patients are asked to bring a designated person to the class — a "co-pilot" — and both are told they can speak up. The class gives a brief overview of the guide and the Batz mission and story, walks through the guide's sections, and points patients to the app. Elise's read on the effect: introducing the guide sets the tone from the start for transparency about care and for the patient taking an active role.
Elise was candid about the initial staff concerns, from a few years earlier when the culture was less transparent than it is now. The team worried the guide would make patients suspicious rather than reassured. They worried it would increase nurses' time at the bedside, because more suspicious patients would ask more questions. They worried the guide had too much information and was too unwieldy, and that staff would become defensive.
What they found was the opposite. Patients and families became less anxious, not more. They were encouraged to speak up and to actively engage in their care. Elise's team can watch it happen in the class itself — patients visibly relaxing, body language easing, nodding in agreement as the purpose of the guide is explained. The guide, Elise said, is all about being real and honest and planning ahead. It helps patients become more knowledgeable about their care, and it fits naturally alongside the other things Seton already does — bedside reporting, daily nurse leader rounding, a care board reviewed every shift, a laminated care pathway reviewed with the patient. The guide moved hand in hand with all of it, a tool serving an overall transparency goal.
Elise was honest about a weakness too: the feedback the unit has is subjective. By patient report, roughly a quarter to a half use the guide's workbook to organize questions and medications for visits. Most patients give positive feedback that the information is helpful and that it makes them more comfortable to know the staff is encouraging them to speak up and is comfortable being watched. The unit knows it needs to do more formal data collection. Elise also described how the foundation streamlined the guide based on the unit's feedback — including the suggestions of one patient, a company CEO, who loved the guide and also said exactly how it could be tightened. The foundation made every change he recommended. And the guide is free, which Elise tells patients from the start, so no one feels they are being sold something.
Dr. Carol Wratten's portion of the session was the most pointed about what this actually takes. Her central message: this is a culture change, not a tool rollout, and culture change is neither easy nor quick.
Wratten brought a personal frame to it. As a new healthcare provider, and later as a family member facing serious illness and death in her family, she had been frustrated by the healthcare industry's resistance to bringing the family into the care team — even though she was inside the industry herself. Healthcare, she said plainly, is traditionally paternalistic, and a paternalistic structure cannot keep patients as safe. Patient safety requires patients to recognize and accept their responsibility to be actively involved in every detail of their care, and it requires providers to recognize patients as integral members of the team.
She spent close to a year at Seton understanding the culture and the staff before there was enough traction to implement the guide, and she said it took a year or two beyond that for staff and patients to genuinely accept it.
Wratten laid out the critical steps the work has taught her.
Create a "why" with a real patient story. For Baptist Health System, that story was Louise Batz's story. But each institution needs its own why — one that leadership understands, supports, and actively facilitates. Leadership support and facilitation is critical.
Have champions on the ground. Beyond leadership, there must be champions in the individual units or service areas who believe in patients as members of the care team and who lead the transformation on the unit. Elise has been that champion for Seton's orthopedic unit. For the development of every guide Laura's team has built, Wratten said, it has been champions who brought the guides to life.
Build the tool into the workflow. There must be a reliable process for introducing the tools, with training for patients and staff. And the use of the tool has to be part of the team's workflow. Top-down implementation will not work and will not be sustainable if using the guide is an extra thing piled on top of the team's existing work. Wratten named this directly as a reason the foundation values working with Mark Graban: the idea, drawn from Lean process development, that the tool becomes part of the workflow rather than an addition to it.
Hold the organization accountable, with measures. There need to be organizational goals around patient engagement that hold leadership and staff accountable, and measures that reinforce the desired behaviors. Wratten specifically described a daily management system with leading metrics that assure the patient voice is being incorporated into the workflow and into the unit's goals.
Plan for turnover. There has to be an ongoing process to address staff turnover that keeps the tool part of the workflow and part of the organizational goal — and orienting new staff and residents to the guide, Wratten noted, is itself an innovation.
For sustainability and reinforcement, Wratten pointed to recognition: the foundation developed the "Angel Hero Award," given to staff who have been heroes in bringing the patient voice into care. She shared testimonials from staff and organizations — including transplant safety work — describing how the guide helps keep patients safe. Her framing of why that reinforcement works: healthcare providers are mission-driven people who entered the field to help people, and these tools help them fulfill their own mission, not just serve the patient.
Graban asked the presenters why there is still so little public awareness of the scope of harm from preventable medical error. The answers, from three angles, were among the most candid moments of the session.
Laura, from the patient side, called it the white elephant in the room — a sensitive, touchy issue without enough transparency yet. She was careful to hold two things together: doctors and nurses are heroes who save lives every day, and the guides exist not to accuse them but to work with them. When the family does catch a mistake, she said, that is a good catch. Her father had medication errors caught during several hospital stays after Louise's death — caught, fixed, and it did not end the way her mother's did.
Wratten, from the healthcare side, traced it to the culture of medicine and medical education. Providers go into healthcare to help people, and being humble enough to recognize you don't always do that well — and being open to soliciting help from patients — is difficult. There has been real shaming, and active suppression of error, by the healthcare community. Some of that is a defensive mechanism by providers unwilling or unable to be vulnerable; some is fear of job loss and lost reputation. Partnering with patients, she argued, takes some of that burden away.
Elise added a hopeful note: the culture is changing. Among the surgeons her unit works with, hospital-wide daily safety briefings now discuss near misses and what could prevent them. In her long nursing career, she has seen real change just in the last few years. The work now is getting the message out to the consumer.
Graban added his own perspective, from an engineering background. In engineering, thinking about what could go wrong is a positive act, because it lets you prevent problems and focus on systems rather than telling people to be careful. When he entered healthcare twelve years earlier, he found more of a tendency to blame someone when something went wrong, and even a near-superstition that not talking about errors was a strategy for preventing them. He named what draws him to the foundation's work: it comes from a blame-free perspective — a recognition that healthcare has great people often thrown into bad systems. Laura's own framing closed the point. Her mother's death, she said, did not lie on the shoulders of one person. The system failed everyone. And if the stories of what went wrong are never shared, the problems can never be fixed.
Two exchanges in the Q&A sharpened the connection between this work and Lean thinking.
Graban offered a reframe of the Batz Guide that the audience would recognize. The guide, he suggested, is more than an admonition to be engaged. It functions as standardized work — it gives specifics about what to ask and when. It cannot address every unique situation, but it is designed as a framework to catch most of the common scenarios. Laura confirmed it: the guide addresses evidence-based, proven risk areas — falls, infections, medication errors — the categories preventable errors tend to fall into.
Wratten built on it with a Lean lesson about the power of "why." When a question from a guide prompts a nurse to explain a task — putting on a pulse oximeter, for instance — the explanation clarifies for both the patient and the staff how the system is keeping the patient safe. A caregiver might apply a pulse oximeter almost automatically, not fully cognizant of why. The guide focuses everyone on the why of the task, and the explanation becomes part of the work. Graban called that a powerful Lean lesson — the power of explaining why instead of telling people to do something because we said so.
Laura's most vivid image answered the concern about time at the bedside. She had spent 20 minutes with her mother's nurse asking questions, and not one of them was in the Batz Guide — not one of them mattered. The guide is meant to make the communication between family and caregiver efficient and high-quality: life-saving questions, not "what's for dinner." And she returned to the team metaphor. She was never going to be on the "A team" — she had not gone to medical school for eight years. But she could have been on the B team. She could have come off the bench and made the three-point play, because nobody knew her mother like she did. The guide is what helps a family member be an effective member of the team — to come off the bench. She wishes she had never been sent home, because she never even had a chance to try.
This is a session about people, not software — about a family's loss, a guide, and the human work of culture change. Laura's story stands entirely on its own. But Dr. Wratten's portion of the session named, almost point by point, the conditions that determine whether patient partnership sticks, and several of those are exactly the conditions improvement infrastructure exists to support.
Wratten was explicit that the Batz Guide must be built into the team's workflow, not added on top of it, and that top-down implementation fails when using the guide is an extra task. She named Lean process development as the reason the foundation values working with Mark Graban. The same principle holds for the infrastructure underneath: a patient-partnership practice survives when it is part of how the work is captured, tracked, and reviewed — not a separate initiative competing for attention. Infrastructure that holds the improvement work of embedding the guide, surfaces it in daily routines, and keeps it visible is part of what makes "part of the workflow" operationally real rather than a good intention.
Wratten called specifically for a daily management system with leading metrics that assure the patient voice is being incorporated into the workflow and into each unit's goals. That is precisely a daily-management-and-huddle function. A unit that wants to know, every day, whether patients are being prepared to speak up — whether the co-pilot showed up, whether the guide was introduced, whether concerns raised by patients were acted on — needs leading indicators visible on a board and reviewed in a huddle, not a retrospective report months later. The infrastructure that runs tiered huddles and daily metrics is the operational form of what Wratten described.
Wratten also named accountability — organizational goals around patient engagement that hold leadership and staff accountable, with measures that reinforce the desired behaviors. And she named the turnover problem: an ongoing process that keeps the guide part of the workflow as staff change, including orienting new staff and residents. Both of those are tracking and standardization problems. Standard work for introducing the guide, captured and visible so it survives staff turnover; a record of whether units are meeting their patient-engagement goals; recognition like the Angel Hero Award tied to visible behaviors rather than memory — these are the things infrastructure holds in place so a culture change does not quietly erode when its original champions move on.
Elise's honesty about the unit's weakness points the same way. The feedback Seton has on the guide is subjective, and the unit knows it needs more formal data collection. The case for patient partnership, like the case for any improvement, gets stronger when its impact can be measured and shown rather than described anecdotally. Infrastructure that tracks improvement work and its outcomes is what turns "patients tell us it helps" into evidence a leadership team can act on and spread.
And the foundation's larger ambition — spreading the guides across hospitals, specialties, and patient populations, from orthopedics to pediatric transplant to breast cancer to NICU care — is a spread problem. A practice that works on one unit at one hospital does the most good when other units and other facilities can see it, understand it, and adopt it. Making improvement work visible across an organization so a proven practice spreads rather than staying local is, again, what infrastructure does.
None of this is the heart of the session. The heart of the session is Louise Batz, and a daughter's conviction that the right questions at the right time save lives, and three people's work to turn a tragedy into a practical, blame-free partnership. What infrastructure does is hold the conditions Dr. Wratten named — workflow integration, daily metrics, accountability, sustainment through turnover, measured impact, and spread — so that partnership becomes how the work is done and stays that way.
What is the Louise H. Batz Patient Safety Foundation? A foundation co-founded by Laura Townsend and her family after her mother, Louise Batz, died from a preventable medical error following a routine knee replacement in 2009. The foundation's mission, written the night Louise died, is to spare other families that pain. Its central work is developing and spreading practical patient safety guides — and a mobile app — that help patients and families become active, informed members of the healthcare team, built on partnership, transparency, and communication rather than blame.
What happened to Louise Batz? Louise Batz entered the hospital for a routine total knee replacement. The surgery went well, but that night she was given a combination of medications — morphine, an anti-nausea drug, and the narcotic Demerol — at midnight, with no monitoring in place. She went into respiratory depression and suffered an anoxic brain injury, and died after 11 days on life support. Her family identified three contributing failures: a lack of teamwork, a lack of knowledge (Laura asked many questions but none that addressed the real risks), and a lack of monitoring technology.
What is the Batz Guide? A practical guide — also available as a free mobile app for iPhone, iPad, and Android — that helps patients and families understand common safety risks (falls, infections, medication errors, monitoring), organize their questions and information, participate meaningfully in conversations with caregivers, and recognize when to speak up. The foundation has developed an adult guide in multiple languages, a pediatric guide, pediatric transplant guides, and specialty guides in development for breast cancer, heart, and NICU patients.
How does Seton Healthcare use the Batz Guide? Seton introduces the guide in a pre-operative bone and joint class, ideally four to six weeks before joint replacement surgery. Patients attend with a designated "co-pilot" — a family member or friend — and both are explicitly invited to speak up and be active participants in care. The class gives an overview of the guide, its sections, the app, and the Batz story. The guide is introduced as free, so patients don't feel they are being sold anything, and it works alongside Seton's other practices: bedside reporting, daily nurse leader rounding, care boards, and laminated care pathways.
What concerns did staff have about the guide, and what actually happened? Initial staff concerns included fear that patients would become suspicious, worry that it would increase nurses' time at the bedside, and concern that the guide had too much information. What Seton found was the opposite. Patients and families became less anxious, not more. Their questions became more focused and meaningful. Transparency improved trust. And the guide fit naturally into existing bedside communication and daily routines rather than adding friction.
Why do the presenters describe this as a culture change rather than a tool rollout? Because, as Dr. Carol Wratten emphasized, simply distributing a guide does not change how care is delivered. Healthcare is traditionally paternalistic, and moving to genuine partnership with patients requires a shift in beliefs and behaviors that is neither easy nor quick. Wratten spent close to a year understanding Seton's culture before there was traction to implement the guide, and it took a year or two more for staff and patients to fully accept it. A tool without the cultural work behind it does not produce partnership.
What does it take to make patient partnership stick? Dr. Wratten named several critical steps: create a compelling "why" using a real patient story that leadership understands and supports; have champions on the ground in individual units who lead the transformation; build the tool into the team's workflow rather than adding it as extra work (top-down implementation fails); establish organizational goals and accountability around patient engagement, supported by a daily management system with leading metrics; reinforce the behavior through recognition (such as the Angel Hero Award); and create an ongoing process to orient new staff and residents so the practice survives turnover.
Why is "build it into the workflow" so important? Because, as Wratten put it, if using the guide is an extra thing piled on top of the team's existing work, it will struggle to gain traction and will be very hard to sustain. Top-down implementation will not work or be sustainable on its own. This is why the foundation values Lean process development — the principle that the use of the tool becomes a natural part of how the team already works, rather than a separate task competing for time and attention.
Why is preventable medical error still not openly discussed? The presenters offered several reasons. Fear, shame, and defensiveness are embedded in healthcare culture, and there has been active suppression of error — partly as a defensive mechanism, partly from fear of job loss and lost reputation. Medical culture and education make it hard for providers to be vulnerable enough to acknowledge that they don't always help people well. Patients often feel too vulnerable to question caregivers. And society tends to frame errors as bad individuals rather than bad systems. The presenters were emphatic that the work is blame-free: the system failed everyone, not one person.
How is the Batz Guide like "standardized work"? Mark Graban offered this reframe in the Q&A. The guide is more than a general encouragement to be engaged — it gives specifics about what to ask and when, drawn from evidence-based, proven risk areas (falls, infections, medication errors). It cannot address every unique patient situation, but it functions as a framework designed to catch most of the common scenarios. Like good standard work, it turns a vague intention ("be involved") into concrete, reliable practice.
Doesn't engaging patients this way take more of the nurse's time? It was an early staff concern, but the presenters argued the opposite. Laura noted that she once spent 20 minutes with her mother's nurse asking questions, and not one of them was a question that mattered. The guide is designed to make family-caregiver communication efficient and high-quality — focused on life-saving questions rather than on details that don't affect safety. Dr. Wratten added that when a guide question prompts a nurse to explain a task (like why a pulse oximeter is being applied), the explanation clarifies the safety system for everyone and becomes part of the work — a Lean lesson in the power of explaining "why."
Where can patients and organizations get the Batz Guide? PDF versions of the guides are available at louisebatz.org, and the app can be downloaded from the Apple App Store and Google Play by searching for "Batz Guide." Organizations interested in adopting the guides into their facilities — or community members and employers interested in sponsoring the effort — can contact the foundation directly through louisebatz.org.
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