Patty and David Skolnik were again at the Telluride Patient Safety Summer Camp this week, to lead the discussion after sharing the educational documentary film, The Story of Michael Skolnik, with almost 75 medical students, nursing students and resident physicians. As always, and as quite an understatement, the film illuminates the need for change in healthcare and healthcare education–not only to make it safer for all, but to also cultivate the skill sets that engender meaningful conversations built on honesty and trust between patients and providers. Following are reflections shared by Patty and David today, ten years after losing Michael to medical harm. Thank you, Patty and David, for your continued presence within healthcare, serving as a reminder that we still have much work to do.
David and I feel many emotions 10 years after our son’s death:
- Anger that we have lost our child unnecessarily
- Strange relief that Michael is no longer suffering
- Unexplainable sadness that Michael is gone and his dreams are unfulfilled
- Guilt for making decisions we regret because we trusted the doctor and didn’t look further
- Awe at the courage one young man could manage. Michael was a fighter; he had unbelievable strength to fight back
- Admiration, immense admiration for the love and unstoppable caring he showed through his horrible ordeal
- Appreciation for what we all learned from Michael, he had no room for weakness, failure or lies
- Regret that we lost our best friend and a large part of our souls
- Happiness that we had a child that never hesitated to participate in life or have any goal intimidate him
- A love of Michael’s was sailing. Through sailing he learned: ingenuity, resourcefulness, trust, caution, adventure, discipline, and perseverance
Michael has also taught us many other lessons that I want to leave with you, namely that we all have choices, choices about how we live and how we die. If Michael were here he would tell all of us:
- To smile always
- To laugh daily
- To sing every chance you get, whether others think you can or not
- To dance, even if you have to do it in a wheelchair or bed
- Not to feel guilty if you don’t know what you want to do with your life
- To meet new people and make new friends everyday
- To enjoy your body. Use it every way you can. It’s the greatest instrument you’ll ever own.
- Get to know your family and especially your parents. You will likely discover that they are the best friends you will ever have.
- Do one thing every day that thrills or excites you
- Respect those that earn it
- Be the Best medical professional you can
We are determined to make a difference for Michael’s life. This is what Michael would have wanted–to have his voice still heard and all the others that have no voice. Thank you for what you do and for helping us keep our promise to Michael–that we all leave the medical field better than he found it.
Yesterday’s afternoon discussion at Telluride East was focused on “Transparency”, a buzzword for many in healthcare today, but a concept that holds tremendous meaning for patient safety and caregiver well-being for those who walk the talk. Dave Mayer started the conversation by asking the group to share what transparency meant to them, and then breaking up the larger group to discuss:
- What are the barriers to transparency in healthcare?
- What are the barriers to being transparent with patients?
- What are the benefits to having a transparent culture in place?
In our small group, several themes emerged, and surprisingly, not the least of which revolved around leadership and culture being the primary drivers of the “shades of transparency” experienced by both providers and patients in any given health system. One of our student scholars shared how he feels his excellent intuition, or spidey senses, need to be kept in check so as not to appear a “pain in the butt” to senior physicians–physicians who set grades and can directly impact his medical career. Those same spidey senses activated in the mindful physician during the delivery of care, or as he coined it, hypervigilence, are exactly what is being called for in healthcare organizations seeking to become high reliability systems. Here was someone who clearly was acting in the best interest of a patient, and because of hierarchy and poor leadership, was made to feel as though his intuition was a bad thing.
In a related and revealing post, I’m sick and tired…but far from done, Telluride faculty and colleague, Richard Corder, shares his ire related to watching the bad eggs of healthcare remain in place, to continue to harass and cripple the well-meaning efforts at culture change. While he comes from a position of understanding “the why” of the situation, he’s also sick and tired, as are many well-intentioned caregivers who have chosen to remain silent in the face of leadership that fails to lead–and worse yet–infuses toxicity into a culture and careers of those less tenured. When I hear stories like these I know we still have a long way to go to create a healthcare that is safe for all who work within it, or enter it as a patient.
The silver lining to all this is the medical and nursing students who have chosen to come to Telluride this year. The same medical student mentioned above also stated, “when I’m an attending, I will encourage questions about the care being delivered.” And I believe him, but I also know the real world sometimes takes that passion, that resolve, and turns it into “shades of the self” that if not careful, can turn even the most well-meaning individual into someone who has to rationalize or tone down the goodness within. It’s our job as healthcare leaders to support those young learners in any possible way we can. This is a recurring theme that comes to light at the Telluride Patient Safety Summer Camps…
It has been some time since we have written about the concept of flow on ETY (see What is Flow, and How Can It Improve Healthcare?, Achieving A Flow State in Healthcare: Can We Do It?), and after recently finding Warren Miller Entertainment’s website once again, I was reminded that flow is not far away if one remembers to seek it.
As defined by Mihaly Csikszentmihalyi, being “in flow” means achieving a state of mind, or being, where time stands still and an individual is so in tune with the moment, and so engrossed in the activity, that all awareness of the self or self-consciousness is overtaken by the activity at hand, and a feeling of well-being is experienced. It could be likened to mindfulness at its most intense level–something we are trying to embed within the healthcare culture. We had asked: Could learning to find flow in our healthcare work return the joy and meaning that Dr. Lucian Leape speaks of, and as a result, improve the patient’s experience of care?
As you ponder these thoughts on a summer Friday, enjoy the following peek at Warren Miller’s 2014 annual kick-off to ski/snowboard season–always a visual example of flow in my mind:
Many of you may have already read Josie’s Story. Sorrel King sent me a copy a few months back, and it has sat patiently on my bookshelf, waiting for me to discover the beauty that lay inside. I think I waited to read it because my heart has been filled with Lewis’ story, and Michael’s story and Alyssa’s story…young people I never knew, but who have influenced my professional journey in ways I could have never imagined when planning a course of study or career path. I think I waited to read her story because I wasn’t sure I had room to take into my heart so profoundly, yet another story of loss at the hands of the industry in which I work. But I picked up Josie’s Story last week, and could not put it down.
While the book reads like a fiction novel with well-written, lovable characters moving through the journey of an unthinkable loss, the unfortunate truth is that it is an autobiography. While Josie was here only a short time, I believe she was here to inspire her Mom to tell their family’s story in a way only she could–with honesty, love and a strength that is truly inspiring. Their story is a road map and a touchstone for dealing with grief–a reminder that the only way through something so painful, so unimaginable, is to feel it. It’s also a reminder that grief is an individual journey, but that in time, you can reach the other side and find a life you may have never imagined could be so wonderfully different from what you had planned.
Josie’s Story is also a brief history of patient safety, as the origination of so many Patient Safety programs in place today began as a result of the Josie King Foundation, and Sorrel’s blood, sweat and tears. Care for the Caregiver, the Keystone Capstone, CUSP and a partnership with Peter Pronovost–all of these lifesaving programs have a tie to Josie, Sorrel and their foundation. The book itself is also being used as a foundation for teaching patient safety principles across healthcare, and in book clubs around the country. It’s a must read, and a heart-hitting reminder of the basic reason we go into healthcare–to protect patients first from harm, and then to heal them. It’s a reminder that we must also change our systems to protect the well-meaning, hard-working care providers who often suffer in silence when patients are harmed. From the book:
I realized as I flew home that Josie’s story had struck a chord with the very people who could fix the problem. I could not stop thinking about their reaction, how they listened to me, how they cried and confided in me. They seemed hungry for something, though I wasn’t sure what. Maybe it was the fact that I was coming at patient safety from a different angle. I wasn’t talking about the data and statistics. I didn’t have a lengthy PowerPoint presentation. I wasn’t one of them: I was an outsider with a real story.
I’ve known Sorrel a relatively short time on my own patient safety journey, and have always been inspired by the way she carries herself, her professionalism and especially, her sense of humor. I did not know the details of her family’s story until recently, and having read their story, I have a new level of respect for her as person. The ability to live life authentically, bravely in the best of circumstance is a characteristic I deeply admire, but to do so throughout a time of such trial is a reminder of how resilient each of us can be if we open our hearts to the love and strength within. Thank you, Sorrel, for being here to show so many a path through grief, and for being someone the healthcare industry has listened to. As we continue our journey to make care safer for every patient, I truly believe it is stories like Josie’s that inspire the greatest movement forward. We are after all, humans caring for humans, and it’s our stories that make life worth living.
Confession… I am hooked on three foods – Peanut Butter, Chocolate Chip Cookies and Grilled Cheese Sandwiches. I keep a spoon next to the peanut butter jar in the cabinet and always zero in on the Mrs. Field’s when I get to the mall. Grilled cheese sandwiches, like mom used to make, have been more challenging to find until this year’s Telluride Patient Safety Roundtable and Summer Camp.
While walking through town this year, I came across a grilled cheese cart right on Main Street. It was set up across the street but like Pavlov’s dog, I crossed quickly while beginning to salivate. Dickie, the wonderful woman who owned the cart, offered several different types of grilled cheese sandwiches, and these were not your average grilled cheese either. Dilemma time – what should I pick? Habanero cheese, cheddar and bacon, apricot and brie…I had a big decision to make. I finally settled on the more traditional cheddar and bacon, and with one bite I was hooked.
During the next two weeks, I found myself sneaking out during lunches, skipping the traditional Summer Camp faire, and quickly walking the three blocks to Dickie’s stand to get my fix. By the fourth day, Dickie was letting me sample some of the newer offerings she was considering before adding them to the menu, including a Brie and Tart Cherry sandwich, which quickly became my favorite. I was in heaven.
My noon habit was soon discovered however, and after a couple of days, students and faculty alike started to notice my quick, back door exit as soon as the group broke for lunch. They started to question the grin on my face as I sat in the back of room, eating something out of a paper wrapper. To my surprise, but not before weathering a number of creative cheese jokes, people began to ask if they could join me on this grilled cheese pilgrimage. By the last two days of the Roundtable, we were like lemmings…a line of committed people walking to the grilled cheese cart. We became a “village” with a mission.
So why am I sharing this? Be it grilled cheese or patient safety, it only takes one passionate person to start a village. The mission of the Telluride Patient Safety Summer Camps has been to take passionate and caring young healthcare leaders and show them how to create their own village of like-minded colleagues at their institutions. These young leaders have been creating their own patient safety villages back home, and it is clear this movement is becoming contagious. I am reminded of Margaret Meade’s mantra, a thought I have often returned to on the journey to make care safer throughout my career:
“Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it’s the only thing that ever has.”
For the last 18 months or so, we have been sending out our Monday morning “Good Catch” of the Week. Our initial email list included about 30 associate leaders, and it was a weekly email highlighting a story we had heard about through our Quality & Safety Directors across our health system. Our initial intent was to recognize caregivers at the front lines for all the great work they do every day. Through their mindfulness (sensing something wasn’t quite right) – and their actions (stopping the line), our patients were safer in our environment…and with the knowledge gained, we now had the ability to seek solutions to possible clinical care gaps. Both associate empowerment and recognition, along with greater knowledge about the health of our system, all are instrumental as we continue to seek high reliability at MedStar Health. An additional plus around our Good Catch celebrations is the Joy and Meaning we hope to inspire within our front line caregivers…something that is so badly needed in healthcare today.
And it’s working! Our Good Catch stories have become infectious. Over the course of the last 18 months, our email list has grown to almost 2,000 of our associates–a result of receiving many requests to, “please add me to the list”. Our Good Catch program has taken on a life of its own, and we no longer have to seek out stories from the front lines of care – they are sent proudly by many. Many of our entities also have a Good Catch program of their own in place, which adds a nice “local flavor” to the celebrations. It is truly inspiring to see.
But what has been even more amazing, is that people are now reaching out to us for more good catch stories. Stories that they can use as Safety Moments to start every one of our meetings! As a result, our last Good Catch Monday, put out by Seth Krevat, AVP of Safety, provided some tips on how to find and take note of all the safety moments around us. Seth’s recent email inspired Richard Corder, a fellow Telluride faculty and good friend/mentor, to pen the following after an unfortunate event in his kitchen. Richard’s story highlights the importance of the term “unconsciously competent” – doing certain tasks so often that we take the related risk involved for granted, and begin without thinking while multi-tasking, or with numerous distractions occurring around us. Pilots follow what is called “sterile cockpit” – no personal conversations or distractions during take-off and landing when the plane is below 10,000 feet so they stay focused on the task at hand even though they have done it thousands of times. In healthcare, there are many rote tasks related to the delivery of care and taking even the simplest of those for granted can result in harm to a patient or provider. Richard’s story (Re-learning the lessons of distractions and over-confidence) is well worth the read, and shows how even the simplest of kitchen tasks can present a risk when not staying mindful and in the moment.
Last week, we were humbled to share Dr. Roger Leonard’s story, “Not Retired”– a story that initially began as a reflection by Roger after coming to the aid of a fellow passenger in need of emergency medical care onboard United flight 575. As with many stories and events such as this, details often unfold in the aftermath that illuminate just how impressive human nature proves itself to be. As a follow up to those who have been reading, we do have some good news to report. Roger was able to speak with both the wife of the patient and his cardiologist, who described the event as “the most amazing save he has seen in his career”. Of course Roger is quick to point out that this amazing save is due in large part to many people on board, and on the ground that day. From the passenger sitting behind the patient, who though shaken, alerted the crew of a problem, to the skillful direction by the cardiologist upon receiving the patient in a small Midwestern town in the early hours of the morning, to the professionalism of the airline crew, the paramedics and every hospital team member who contributed to this incredible and successful outcome.
As the story has evolved, it becomes ever more difficult to separate it from a made for television movie. This was a very sick patient who survived cardiac arrest at 40,000 feet, and then was kept alive as the plane diverted to a hospital midway between arrival and departure cities, a total distance of over 1600 miles. And this was only the beginning of his fight for life that evening. Upon arrival at the hospital, the patient was in cardiogenic shock and still had to undergo placement of an intra-aortic balloon pump to help support his failing heart, along with three coronary artery stents urgently placed to open occluded vessels. Hypothermic care was initiated for 48 hours to help protect from possible neurologic damage, and he also survived a number of days on ventilator support. Each procedure individually presents its own survival challenges, but collectively, every cell of even the healthiest of patients is pushed to extreme limits.
When Roger finally had the opportunity to speak with the patient’s wife and cardiologist, the patient was awake, alert and eating a chicken dinner. The wife shared that he gave Roger a thumbs up. Everyone involved in his care believes he will make a full recovery, and while so much of an event like this can be attributed to luck, it was the skill of all involved, along with their commitment to providing the best possible patient care and customer service, no matter the circumstance, that made this luck reality. It also speaks to the beauty of processes put in place on airlines and in healthcare to make luck reality. And the debrief initiated afterward, without knowing the outcome for this patient, shows how committed everyone involved was, and is, in making certain the next patient or passenger has the same, if not better, care.
Roger always say, “It’s all about the patient”. But this story is also continued evidence of the good that happens in healthcare every day by caregivers who truly put patients first. The majority of caregivers will tell you this was all in a day’s work, a very extraordinary day perhaps, but a day you will not find promoted on the front page of any major media outlet. In our book, this was truly heroic—and we hope that in the days to come, more healthcare stories of heroism by these good caregivers are picked up and shared.