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!
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.
Kim 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.
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.
- Share 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?
- 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?
- 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.
- 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?
- 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!
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:
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.
As I did in 2013 for SXSW, here are five of my Top 10 Takeaways from #SXSW2014 that can be applied to healthcare! Stay tuned for the remaining five later this week…
1) Storytelling for Change-From Storytelling for Change: A Decade of Impact put on by Participant Media (Waiting for Superman, The Help, Food, Inc.) to The Secrets Behind Addictive Storytelling to A Conversation with Jon Favreau (@jonfavereau) on the release of his new movie Chef (trailer below), brand builders and filmmakers shared tips and success stories throughout the week on projects that have gone viral, and others that have entertained audiences around the globe. As a writer and believer that good stories move mountains, I gravitated to those who told their own authentic stories versus those using story to move products. While many have been using story to sell and manipulate, good storytellers, filmmakers and change organizers know that the real movement occurs when we write from the heart to the heart.
2) The Doctor’s Office is Changing-In the session, Doctors Offices on Their Deathbeds, Dennis Schmuland MD from Microsoft and Gautam Gulati MD (@drgautamgulati) among others led a panel looking at what can be accomplished when providers and patients collaborate to stay well versus treat illness. The idea of flipping the clinic in light of data acquisition and transfer via wearable technology (think FitBit) and better designed health IT systems will put pertinent information about patients in the hands of providers before they enter the clinic. This will allow clinic time to be spent developing a better understanding by both of how to stay well, treat chronic illness and stay out of the healthcare system. In the future, that provider may be a virtual physician or an avatar according to the panel in the session, The Avatar Will See You Now.
3) Wearable Tech-Fitbit, Nike and Jawbone all had a presence at SXSW and everywhere you turned, a different developer was trying to slap a new device on your wrist, touting the benefits of “owning your own data” and “the quantified self”. While I’m the first to admit I love my Fitbit–a constant reminder that I’m sitting at the keyboard too long each day–wearable technology is here to stay and entrepreneurial physicians, health tech start-ups, the government and computer scientists all see the opportunity these devices hold. Whether health IT infrastructure develops the flexibility to communicate with the rest of the world or not, a multitude of data points are already being collected by the innovative organizations openly embracing what consumers/patients want. Look for this movement to gain traction, driven both by consumers/patients and those involved in the redesign of healthcare.
4) Patient Engagement/Ownership-Following on the wearable tech movement, all health panels I attended mentioned the need for patient engagement and ownership of their health and wellness. Those with a FitBit or FuelBand are already on the band wagon, and most likely aren’t the ones taxing the current healthcare system. But as the over-arching healthcare model shifts to one where providers are paid to keep patients out of the clinic, where will that leave those with literacy challenges, or a chronic illness that affects motivation and cognitive capacity? These are two sides to this same coin, and as we move forward by placing increased responsibility on patients, how will we ensure we don’t leave the less engaged for whatever reason behind?
5) Develop A Content Strategy-In Go Home Marketing, Your Drunk, Kristina Halvorson (@halvorson) led a hilarious session, educating and entertaining a ballroom spilling over with fans and followers. Wanting to move to the next great thing in content development is great, but do you have a strategy? In her experience, many clients come to her looking to run before they can walk. Fix your sh@#! was the takeaway here. Know what you have, develop a plan and then embrace all the innovations in content design and development. For those who couldn’t attend, her book, Content Strategy for the Web, could be a good substitute. If nothing else, I highly recommend downloading a copy of her slides from slideshare here.