Residents as Sentinels and Change Agents for Safer Care

This coming Saturday, April 26th, the Committee of Interns and Residents (CIR) will be hosting its next QIIQ Conference titled, “How to be a Lead Agent of Change: From Bedside to Transformative Care“, in NYC. Rosemary Gibson, Carole Hemmelgarn, Shelly Dierking and I have the honor of joining leaders from CIR to help facilitate the all-day interactive session. While many faculty will be attending, the major focus of this educational meeting will be on the residents, both from CIR Hospitals as well as other GME programs, and aligns with the “Educating the Young” mission.

Residents can be change agents for safer, higher quality care. There are now numerous examples across the country of this fact–residents leading important quality and safety initiatives that have reduced risk and raised the quality of care provided–and they have done this work despite internal challenges and long work weeks. Those that have followed our ETY blog for the past two years will remember my post on the work of David Leach, the former CEO for the ACGME (see The Canary in the Coal Mine…).  In one of his publications, Dr. Leach shared the most important role of graduate resident physicians was to act as the “moral agent” for their patients. Residents must be the gatekeepers for safe, high quality care–a sentinel on watch for the many unsafe conditions they might encounter while trying to provide optimal patient care, prepared to alert faculty and leadership to these unsafe conditions, and then work with their institutions to find solutions to remove risk from the patient experience. The analogy Dr. Leach used was the canary in the coal mine, taking on the role of guardian and protecting others from harm before it was too late. I loved this “moral agent” concept. It is so simple, yet so important in the quest for safer, higher quality, patient care. In academic medical centers, resident physicians spend more time in the hospital, have more direct contact with patients, and see many more unsafe conditions during days, evenings and weekends than most other caregivers, except possibly nurses. And they do it many times with little, if any, direct supervision. Resident physicians can be those sentinels and serve as excellent change agents for safer care.

We need more conferences like CIR’s QIIQ focused on our next generation of caregivers.  Please help spread the word about the conference. Below is some additional background information with the links to register. The third link is the conference brochure which has additional details.  We appreciate the support and as always, thank you!!

Background Info:
The one-day conference on How to be a Lead Agent of Change will be held Saturday, April 26th in New York City. Given the importance of the patient experience and the desire for more patient-centered care, the Committee of Interns and Residents conference is meant to empower medical residents to develop and execute high-value care projects in their hospitals and health systems, and better equip them with the competencies they need to work in a rapidly changing delivery system.

To register for this conference, please click here. There will also be a webcast, and people can sign up for that here. The agenda and conference brochure can be found here (this includes logistics on location and timing, as well as goals for the day and additional contact information). Please feel free to share this information, as well as the links to register, with your organization and networks.

*CIR has also been tweeting about the conference with the #QIIQ hashtag. Here is a sample tweet you are more than welcome to share with your followers: What’s your #QIIQ? Join @cirseiu & @EinsteinMed in NYC on 4/26 for the next #QIIQ conference. Register now! bit.ly/qiiq426


Teamwork and Thinking Differently: Can Healthcare Leaders Do This?

If you can make it to “When the Shark Bites…” you’ll have already seen what teamwork looks like in this talented quartet. A piano has just 88 keys, yet new music is created every day. How can we take what we have to work with in healthcare and see what has yet to be discovered or apply what has yet to be tried — especially when it comes to teamwork.

Please share creative examples of how your health system is applying teamwork!


Telluride Alumni and “Paying it Forward”

Each day, we are barraged with hundreds of useless “junk” emails. Many have learned the tricks on how to make it through our spam filters and firewalls. However, amongst all that “noise” each week, one can find a few “pearls”. For me, the pearls are the emails I regularly receive from our Telluride Scholar Alumni.

Michael Slade, a second year medical student and Telluride Patient Safety Summer Camp alumni, recently emailed me to share the following reflection on how his Telluride educational experience has translated into further patient safety education at his home institution. It’s this passion and enthusiasm for both patient safety and innovations in medical education that Telluride aims to inspire, in hopes that both will go viral in healthcare environments across the country.

One of the biggest things I took away from Telluride was the power of knowledge. Because of the Telluride conference and the speakers who presented, those of us who attended were able to go back to our home institutions with a transforming set of ideas. The problem is that, quite simply, we aren’t going to be able to make healthcare safer or more effective by empowering a hundred or two hundred providers at a time. We all need to go back to our respective healthcare homes not only as technicians, but also as educators.

When I left DC, that was my goal. The medical school here allows first year students to take several elective courses. With the help of a patient safety champion in the faculty, I spent the fall organizing a 10 hour course that included lectures on many of the topics we discussed at Telluride (HREs, human factors, standardized communication, etc) and attendance at hospital PS&Q conferences. We met our goal of enrolling 15 students in the course and completed it a couple of weeks ago. The feedback from the class was almost universally positive; one student (encouragingly) wrote “These are concepts that every med student can (and should!) buy into without extensive medical knowledge. I got a great snapshot of how things work in the hospital (good + bad), w/o being overwhelmed.” A student from the course is also taking over our local IHI branch next year and applying for Telluride this summer. We’re planning on offering the elective for the foreseeable future.

I just wanted to thank you (and by extension, the entire staff) for investing in me and the other attendees of the Telluride experience. The road to safe, reliable healthcare is not going to be an easy one, but I’m proud to be a part of the journey.

Many of us have spent the last four months preparing for the four Patient Safety week-long Summer Camps that will begin this coming June. As in past years, through the generous support of The Doctors Company Foundation, CIR, COPIC and MedStar Health, over 130 medical students, nursing students and resident physicians have been awarded full expense scholarships to attend the camps.  Like Michael, and the many others you have heard about through ETY the past year, we hope they too will leave with a higher sense of urgency and become change agents, leading safer, higher-quality, patient care in the future. That is how we will eventually reach our tipping point.


Telluride Faculty Member Dr. Kim Oates: On Kindness in Healthcare

Screen Shot 2014-04-04 at 2.49.17 PMKim Oates MD has been a regular faculty member at the Telluride Patient Safety Educational Roundtable and Summer Camps, which is no easy accomplishment given he travels to this remote Rocky Mountain town all the way from Australia. Kim, who is a pediatrician by training, is a medical educator to the core, and is now Emeritus Professor, Director Undergraduate Quality & Safety Education, Clinical Excellence Commission in New South Wales. The following is an excerpt from a piece he wrote on kindness in healthcare for the Royal Australasian College of Physicians, recently reprinted in the Medical Journal of Australia. Please feel free to share with colleagues. The entire abridged piece in MJA can found by clicking here.

Way back in my intern days, it was unusual for consultants to talk with their “public” patients…The hard stuff was often left to us — the interns, young people with minimal life experience, an overwhelming workload and no training in the gentle art of communication.

At my teaching hospital a time was set aside once each week when family members could come to the hospital foyer, page the intern and ask questions about their loved one’s condition. In my third month after graduation I assisted at a laparotomy on a fit, active 54-year-old man who presented with a hard lump at his umbilicus. The laparotomy showed widespread cancer with multiple metastases. The surgeon closed the wound. There was nothing to be done…It was my job to tell his unsuspecting wife when she came to the foyer to ask about her husband’s operation. I told her the truth as kindly as I could. Her eyes welled up with tears. So did mine.

Afterwards, I felt embarrassed about my show of emotion.  Why couldn’t I be “more professional” like my consultants? I wondered if I was really suited to do medicine. Later, I realised that it may have helped her. She may have seen that even though the news was bad, I cared…In subsequent years, as a consultant, my eyes would sometimes moisten when I had to tell a parent that their child would not survive. And sometimes it happened when I had the pleasure of giving unexpected, but joyful news.

Was this behaviour “unprofessional”? Or is there is room for families, junior doctors and medical students to realise that we, the more senior doctors, do care? To realise that there is more to it than striding the narrow catwalk between aloofness and over-familiarity, that there is a place to show humanity and that it is not unprofessional to let people know we care…

…Of course, there are some professional boundaries which we must always respect…these well accepted boundaries are different from really caring about our patients and doing something about it…We don’t have to take off our compassion, or our ability to show it, when we drape a stethoscope around our neck. The need for doctors to be professional is not synonymous with being emotionless. There is more to this than just being nice to people. It is about being kind. It also has implications for the quality of patient care…

Powerful recommendations — listen to patients; model transparency; model trust; keep on learning.


Top 10 Takeaways from #SXSW2014: Part Two

As promised, here are the remaining five of my Top 10 from this year’s SXSW marathon! If you haven’t been, I think it’s still worth going but the meeting itself is changing as  this year SXSW seemed to play host to a much larger big business presence than just past years. Innovation is contagious, and I believe those who jump in overcome common objections rooted in fear fairly quickly. “I’m not creative,” “Where’s the research?” and “I’m too old for change,” many be voiced silently or outwardly by leaders–in healthcare and elsewhere when it comes to the change associated with trying new approaches to common practice, but the fact that so many large organizations, from Blue Cross/Blue Shield to Deloitte & Touche, had a presence leads me to believe those fears are being overcome by opportunity realized.

  1. Screen Shot 2014-03-16 at 9.24.29 AMShare ideas-In Show Your Work, repeat speaker and tribe leader, Austin Kleon (author Steal Like An Artist ) shared the value in making your work public early, in a non-promotional way, and how that leads to being noticed. Sharing what you’ve discovered or what you’ve created allows for others to comment and build upon your work too, moving ideas forward faster. In healthcare, this idea remains a challenge, as Steal Like An Artist takes on a whole new meaning. But crowdsourcing for change has proven to work wonders in many industries, including healthcare–think FoldIt-a computer game enabling anyone to contribute to scientific research. Why not give it a try?
  2. Identify Pain Points-For software developers and more, this apparently is a common refrain. But this year at SXSW, I heard the phrase used more than ever before. In healthcare, we may know what our pain points are, but do we have a working strategy and action plan in place to actually move beyond them? Do you really know what your pain points are, and do you have a strategy in place to mitigate or move beyond?
  3. 3D Printing-3D Printers were everywhere in Austin this year. Last year, I saw only one exhibit throughout the meeting with a 3D printer in action. This year even Deloitte & Touche had a 3D printer putting out chachka for those who stopped by to visit. With Grey’s Anatomy using a 3D printer to save an infant, healthcare will undoubtedly see the maker movement invade our space.
  4. Anyone Can Create A Start Up-This follows the next takeaway: Do What You Love! While many of the keynote speakers made it sound easy to achieve their level of success, I’ve come to see that what these folks have in common is courage, passion, resilience and an unwillingness to settle for anything less than what they want. The cost of starting almost any online business is within reach of almost anyone, removing one of the greatest barriers to taking that first step. What do you have to lose?
  5. Do What You Love-This should be number one on the list. If you’re not doing what you love, change things today. Life is short!

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An Addendum to Annie’s Story

Following is additional information from our team who helped share Annie’s Story, led by RJ (Terry) Fairbanks (@TerryFairbanks), MD MS, Director, National Center for Human Factors in Healthcare, MedStar Health, Tracy Granzyk (@tgranz), MS, Director, Patient Safety & Quality Innovation, MedStar Health, and Seth Krevat, MD, Assistant Vice President for Safety, MedStar Health.

We appreciate the tremendous interest in Annie’s story and wanted to respond to the numerous excellent comments that have come in over YouTube, blogs and email. The short five minute video sharing Annie’s story was intended to share just one piece of a much larger story–that is, the significant impact we can have on our caregivers and our safety culture when the traditional ‘shame and blame’ approach is used in the aftermath of an unintended patient harm event. At MedStar Health, we are undergoing a transformation in safety that embraces an all-encompassing systems science approach to all safety events. Our senior leaders across the system are all on board. But more importantly, we have nearly 30,000 associates we need to convince. Too often in the past, our Root Cause Analyses led to superficial conclusions that encouraged re-education, re-training, re-policy and remediation…efforts that have been shown to lack sustainability and will decay very shortly after implementation. We took the easy way out and our safety culture suffered for it.

Healthcare leaders like to believe we follow a systems approach, but in most cases we historically have not. We often fail to find the true contributing factors in adverse events and in hazards, but even when we do, we frequently employ solutions which, if viewed through a lens of safety science, are both ineffective or non-sustainable. Very often, events that are facilitated by numerous system hazards are classified as “nursing error” or “human error,” and closed with “counseling” or a staff inservice. By missing the opportunity to focus on the design of system and device factors, we may harm individuals personally and professionally, damage our safety cultures, and fail to find solutions that will prevent future harm. It was the wrongful damage to the individual healthcare provider that this video was intended to highlight.

In telling Annie’s story, we chose to focus on one main theme–the unnecessary and wrongful punishment of good caregivers when we fail to cultivate a systems inquiry approach to all unfortunate harm events. This is the true definition of a just culture…the balance between systems safety science and personal accountability of those that knowingly or recklessly violate safe policies or procedures for their own benefit. Blaming good caregivers without putting the competencies, time and resources into truly understanding all the issues in play that contributed to the outcome is taking the easy way out. We wanted our caregivers to know we are no longer taking the easy way out…

You will be happy to know that the patient fully recovered, that Annie is an amazing nurse and leader in our system, the hospital leaders apologized to her, and all glucometers within our system were changed to reflect clear messaging of blood glucose results. We believe we have eliminated the hazard that would have continued to exist if we had only focused on educating, counseling and discipline that centered around “be more careful” or “pay better attention”. We also communicated the issue directly to the manufacturer, and presented the full case in several venues, in an effort to ensure that this same event does not occur somewhere else.

This event, which occurred over three years ago, gave us the opportunity to improve care across all ten of our hospitals. It also highlighted the willingness of our healthcare providers to ask for help because they sensed something was not right and wanted to truly understand all the issues–they also wanted to find a true and sustaining solution to the problem using a different approach than what had been done in the past. Thanks to everyone for sharing your thoughts and for asking us to tell the rest of the story. We have updated the YouTube description as well.

And, thanks to Paul Levy for opening up this discussion on his blog, Not Running A Hospital, and to those of you who continue to share Annie’s story.

For those who have yet to see the video, here it is:


Taking the Easy Way Out When Errors Occur

Historically in healthcare, when an error occurred we focused on individual fault. It was the simplest and easiest way out for us to make sense of any breakdown in care - find the person or persons responsible for the error and punish them mostly through things like shame, suspension or remediation. Re-train, re-educate and re-policy were the standard outcomes that came out of any attempt at a root cause analysis.  Taking that route was easy because it didn’t require a lot of time, resources, skills or competencies to arrive at that conclusion especially for an industry that lacked an understanding, or appreciation of systems engineering and human factors.  High reliability organizations outside of healthcare think differently, and have taken a much different approach through the years because they appreciate that it is only by looking at the entire system, versus looking to place blame on the lone individual, that they can understand where weaknesses lie and true problems can be fixed. James Reason astutely said “We cannot change the human condition but we can change the conditions under which humans work”.

The following short video is about Annie, a nurse who courageously shares her own story…a story that highlights when we didn’t do it right, but subsequently learned how to do it better by embracing a systems approach that is built on a fair and just culture when errors occur.  A special thanks to Annie and to Terry Fairbanks MD MS, Director, National Center for Human Factors in Healthcare who helps us make sure our health system affords the time, resources, skills and competencies necessary to do it correctly.


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