I want to begin by saying THANK YOU for sending me to Telluride to learn from some of the nation’s pioneer leaders in patient safety and quality improvement. I have been so moved that I want this to be my “niche” in medicine as I continue on to become a pediatric hospitalist. I am hoping at some point to sit down with all of you to discuss the processes CMH has in place to reduce error and at the same time acknowledge human factors. I have not yet made it to error prevention training due to scheduling conflicts, but I am excited CMH is taking this step towards becoming a high reliability organization. Nick Clark (a previous Telluride Patient Safety Summer Camp alum) has done a great job of incorporating patient safety moments into many of the meetings he has led, and I hope to carry this forward in some way.
We watched a variety of videos and heard multiple stories of near-misses and unfortunately, preventable patient morbidity and death. Carol, one of the representatives from the patient perspective, shared the powerful story of the loss of her daughter who had been diagnosed with leukemia 9 days before she died from a hospital acquired (and too late recognized) C. diff. infection. A C. diff. infection! This year has been particularly hard for Carol and her family as her daughter would have gone to senior prom this previous April and then graduated from high school in May.
In order not to make this email too long, I want to just make 2 more points and then, hopefully, I can discuss my thoughts with all of you in person at some point.
1) John Nance, writer of “Why Hospitals Should Fly,” said during his talk: “You have been trained to be the center of your own universe.” I do feel as if I was trained in medical school to practice “independently.” On rounds as students and many times as residents, we are expected to diagnose a patient (even if we are completely wrong), come up with a firm plan…and then present it confidently. Our goal is for everyone around us to nod their heads in agreement with the plan we have made. We hope no additional input is needed. However, this erases the team-based approach to medicine we MUST have in place in order to create the most safe environment for our patients. Our plans may be acceptable plans, but others’ ideas should be elicited EVERY time and considered EVERY time, so that we can ensure we have considered all options.
2) I want to begin my own QI project, but I’ll need a mentor. I just don’t know yet what I want to focus on. Sometimes it’s better when I write or talk about my interests or concerns, and then a person outside of my head points out the obvious to me. I appreciate all thoughts any of you have to offer.
Joy Solano, MD PGY-1
It is happening…and it is growing. A newer generation of caregivers – young physicians, nurses, pharmacists and other allied health professionals – are stepping up and starting to make a difference. Many of them understand and appreciate they will soon be the gatekeepers for high quality, low risk, high value patient care. They seem to be taking this responsibility seriously – more seriously than I and my older generation colleagues did at their age. They stay connected reading new information shared through social media outlets. They are doing regular literature searches for new articles on quality, safety and value. They want to learn and understand.
The reflective post shared below by Rajiv Sethi is just one of many similar posts that come from our Patient Safety Summer Camps. These young learners don’t just write reflections…they take their reflections and use them to research and learn best practices related to the topic in question. They want to learn, they yearn to learn.
There are days when many of us feel we are slogging uphill, going nowhere and will never live to see the changes so badly needed in healthcare. Working with these young caregivers revitalizes the faculty, just as much as the students are energized and educated around patient safety. Spending time to both educate and learn from the young is so important to the future of healthcare, but also our future and the future of every patients.
Published July 28, 2015 | By Rajiv Sethi
Having only been at Telluride Experience: #AELPS11 for a day, I hadn’t imagined I would have learned so much. We covered a variety of topics with important patient safety learning points. I am so grateful for the opportunity to be here and share the experience with so many motivated individuals keen to be change agents.
I wanted to focus on one of the key moments for me: The Story of Lewis Blackman (http://qsen.org/faculty-resources/videos/the-lewis-blackman-story/). We were very lucky to have Helen Haskell (Lewis Blackman’s Mother) with us and I am so grateful to her for sharing her story. So many issues were raised during the video and I was able to draw many parallels to health care in the UK. For example, the issue of reduced staffing levels on the weekend (see link). The consequences of this can be severe as was found in a study published in the BMJ, Day of week procedure and 30 day mortality for elective surgery… where patients undergoing planned surgery were more likely to die if they have their operation at the end of the week. The new plans proposed by Jeremy Hunt (Health Secretary) to increase staffing provision at the weekend in the UK are causing much controversy, recently culminating in the hashtag #IminworkJeremy (staff posting pictures of themselves at work at the weekend).
Another issue I wanted to focus on may seem rather obvious, but as a student I believe is one of the easiest things to incorporate in daily practice; the importance of health care professionals and students introducing themselves fully to patients. In the story of Lewis Blackman, there was a lack of communication and identification of the team involved in the care of Lewis. As a result his family were unaware of who best to raise issues with.
There is so much to learn from this story but I want to end reflecting on Dr Kate Granger’s hashtag #HelloMyNameIs campaign. On her blog she describes herself as a doctor and terminally ill cancer patient musing about life and death (Click here for story). She has done remarkable work in encouraging health care staff to introduce themselves to patients, with support from over 400,000 staff in over 90 health organizations including many NHS trusts. Only recently did I see a lot of the standard hospital name badges at Guy’s and St. Thomas’ NHS Foundation Trust (where I train as a medical student at King’s College London) being replaced with bright and colorful #HelloMyNameIs name badges. Although it may sound simple, the impact on the patient experience is phenomenal.
Our final session of the 2015 Telluride Experience kicks off in Napa, CA this week. Once again, the learning began by sharing the Lewis Blackman story, and we were fortunate to have Helen Haskell as part of the faculty to lead discussion after the film, along with Dave Mayer. Having been part of the team who created the film, and having viewed it more times than I can count, I am always in awe of the new ideas each viewing inspires. A large part of that inspiration arises from the conversations and stories that are shared by attendees after they hear the story.
Today, there were many excellent comments but it was something Natalie B, a nurse practitioner and educator, mentioned about the fear junior healthcare professionals hold of getting chewed out by healthcare leaders that often prevents them from speaking up when they are unsure. (See her post Transparency and Vulnerability=Scary! on the Telluride Blog). The second inspirational comment came from our newest faculty member, Kathleen Bartholomew, also a nurse, who pointed out the need for a greater sense of urgency around adopting a culture of safety above all else. She continued by pointing out that 900 similar case like Lewis’ occurred in the single day and a half since our group arrived at this meeting.
This begs the question that, shouldn’t delivery of care always be about putting the patient first versus the care provider’s ego or fear of jeopardizing a career? This phenomenon is far from limited to trainees too, which is of even greater interest. Perhaps an interesting model to consider would be to have medical and nursing schools recruit, train and accept only the most courageous students versus those with the best MCATs or test scores. It would be nice to weed out those who would/could put their own professional well-being before that of their patient at any level.
The reminder of the need for a greater sense of urgency was both valuable and validating. There have been times when it has been hard to watch Lewis’ story yet again, knowing errors related to healthcare hierarchy and culture continue to occur again and again. Helen shared that on November 6th, it will be 15 years since Lewis died–was killed–if we’re being honest. She pointed out that all too soon he will have been gone from her life longer than he was alive. This is a hard fact for all of us to hold.
One of the greatest values to the Telluride Experience is infusion of the mindfulness and ire into the minds of young healthcare trainees that comes from hearing these stories. It is both that will be needed for real change. We need providers at all levels of training who are more afraid of harming a patient than of being chewed out by a dysfunctional healthcare mentor. I would challenge those going into healthcare, as well as those already in healthcare, to be prepared to put the patient first, always. Those who are unsure this is something they can do might want to consider a different career path.
One of the highlights of our Telluride East Patient Safety Summer Camp each year is our trip to Arlington National Cemetery. The cemetery serves as a burial-place for “laying our Nation’s veterans and their family members to rest with dignity and honor.” Numerous daily honors remind visitors of the service, sacrifice and valor displayed by those in the military protecting our freedoms.
Again this year, our group hiked up the hill and to a spot just beneath Robert E. Lee’s House where Rosemary Gibson provided a touching “eulogy” on the history of the cemetery and lives lost due to preventable medical harm. She concluded by asking all of us to share the name of a patient or family member we knew who died from a medical error so we could all remember them…many names were shared and honored.
As we stood on the hill at the end of the ceremony reflecting on those lost to medical error along with those who gave their lives for our country, we looked out upon the white gravestones that could be seen in all directions. Gravestones that seemed to go on forever. The informational brochure says the cemetery is currently the final resting place for more than 400,000 people.
The irony of the 400,000 laid to rest in Arlington hits me each year, as this is the same number of patients who die every year due to preventable medical errors according to an article published in September 2013, A New Evidenced-based Estimate of Patient Harms Associated with Hospital Care in The Journal of Patient Safety. All the white tombstones that stretched to the end of the landscape and seemed to go on forever also represented the same number of patients who die each year from preventable medical harm. We fill an Arlington Cemetery every year.
After our collective remembrance of those we knew who gave their lives to medical errors, I broke from our group and walked over to the Tomb of the Unknown Soldier. As I walked up to the white marble sarcophagus, it was easy to see the words inscribed on the back:
Here rests in honored glory an American soldier known but to God.
Wanting to know more, I began reading additional information I found at the Tomb…
On Memorial Day, 1921, four unknowns were exhumed from four World War I American cemeteries in France. U.S. Army Sgt. Edward F. Younger, who was wounded in combat, highly decorated for valor and received the Distinguished Service Medal in “The Great War, the war to end all wars,” selected the Unknown Soldier of World War I from four identical caskets at the city hall in Chalons-sur-Marne, France, Oct. 24, 1921. Sgt. Younger selected the unknown by placing a spray of white roses on one of the caskets. He chose the third casket from the left. The chosen unknown soldier was transported to the United States aboard the USS Olympia. Those remaining were interred in the Meuse Argonne Cemetery, France.
The Tomb sarcophagus was placed above the grave of the Unknown Soldier of World War I. West of the World War I Unknown are the crypts of unknowns from World War II, Korea and Vietnam. Those three graves are marked with white marble slabs flush with the plaza.
Maybe it was because I had just seen David Classen at our Telluride Patient Safety Summer Camp in Colorado, but at the exact moment I finished reading the pamphlet my mind flashed to his global trigger paper that concluded adverse events and deaths from medical errors may be ten times greater than what is reported. [See‘Global trigger tool’ shows that adverse events in hospitals may be ten times greater than previously measured Health Aff (Millwood). 2011 Apr;30(4):581-9. doi: 10.1377/hlthaff.2011.0190. Classen DC et al]
Standing in front of that Tomb, I couldn’t help but think that each of those unreported adverse events and medical error deaths that Classen and colleagues are referring to are the unknown soldiers of healthcare. In our own Telluride East ceremony at Arlington the last three years, we have paid tribute to those we knew had been lost to medical harm, but we failed to remember our own unknown soldiers. They say that what is seen cannot be unseen. What is felt or experienced first hand, or even vicariously through the experience of others, also leaves a lasting impact. Knowledge of the magnitude of our losses due to harm through study, along with the sharing of their stories firsthand through family members at Telluride ensures that next year, we will make sure to also remember the unknown soldiers of our own.
I attended the Patient Experience, Empathy and Innovation Summit hosted by the Cleveland Clinic in May. Sessions covered a wide range of topics, including insight into how technology such as wearables, apps, and greater access to information about patients is influencing the delivery of care, and with it, the experience of care by patients. At the end of the day it was clear, engaging with patients honestly and with empathy, and inviting them to participate in the care they are to receive will never go out of style. It is encouraging to see the renewed focus and importance placed on the power of what have long been viewed as the “soft skills” of medicine. There are many of us, including an increasing body of research, who understand the healing properties of touch, a smile or a kind word to help reframe a healthcare encounter. What truly made the content shared in Cleveland come to life, however, was viewing it all through the lens of a conversation I had with a close friend who recently went through treatment for breast cancer.
I am most happy to report that my friend is now almost two years cancer free. With a family history that is all too weighted in favor of a recurrence, she is taking each day as a gift while at the same time remaining vigilant of every new ache or pain. When she was first “discharged” from treatment last year, she expressed dismay at how quickly and easily her “care team” said goodbye and good luck. With no more follow up visits to an oncologist or surgeon, and no more chemo or radiation appointments to attend, she also had no one regularly monitoring a disease that had taken the life of both her sister and mother. With no one holding some type of medical authority to give her a reassuring touch on the arm, or an all-clear from regular blood work, she has been left to wonder what the future holds alone. And I was left to wonder how post-cancer care can be so lacking in empathy for a patient, a person, who just experienced one of life’s most challenging events.
In the last six months, my friend moved from the often cold, unfriendly confines of the Chicago area for the warm, inviting sunshine she had left five years prior. When she arrived back in her adopted home town, she also needed a follow-up surgery as a result of infection from her implant resting on radiated breast tissue after the double mastectomy she had opted for in hopes of beating her odds of recurrence. This immediately put her in contact with a new breast cancer care team–one I can talk about without quotation marks because she is giving them high marks. She loves her new hospital, surgeon and everyone she has had to work with to get through this next health and life milestone. When I asked her why the care was so much better in her new environment, she shared the following:
They just seem to care so much more. It’s as simple as the gowns. Here the gowns are warm, soft and pink. When I would go to put a gown on at the old place, is was scratchy, cold and old, barely covered me and often tied in knots. I would sit there trying to untie knots in the gowns and get frustrated.
The image of my friend sitting alone, uncovered, frightened of what her future holds, and struggling to untie these knots brought tears to my eyes. Someone easily could have been mindful of making sure the gowns were easy to put on and take off; that they brought comfort instead of more anguish. Admittedly, it is a challenge to turn healthcare culture around on a dime, but can’t we at least hit the mark with the simple things? Couldn’t we try to make the entire experience of care feel like putting on a warm, soft, pink gown, even if we struggle to fix bigger system’s issues?
As her care continues at the new facility, she is also learning more about the way health systems work because people who work within this system are taking time to talk with her, explain things and put her mind at ease. She also feels more comfortable and welcome within in the new system, and is asking more questions. For example, she learned that her oncologist back home was not necessarily ignoring her by sending in a mid-level practitioner to talk with her. In fact, it was a signal that her recovery was going well because she did not need the oncologist’s time. Wouldn’t it have been nice to know this as a patient in their care, versus wondering about the quality of care being received as well as one’s prognosis?
At a recent surgical follow-up visit, my friend’s new surgeon took time to explain the procedure he had performed in detail, describing what he had done and how he thought she was healing. Not only did he take time to talk science, he asked her how she was feeling, and told her “it was his pleasure” to be of service to her. He used phrases that real customer service focused industries use, and my friend picked up on this because she works in the hospitality industry and notices things like this. And she notices when the simple niceties of customer service are lacking.
Do you know who your patients are? If you haven’t asked, it might be a good idea because they have skills and they are paying attention. Maybe just these few patient engagement/experience tips could be bullet-pointed and handed out at white coat ceremonies, or posted in hospital break rooms across the country. I’m hoping my friend will choose to become a patient advocate at her new location, as she has much to offer. Her first agenda item is to become well, and perhaps then she will share the wealth of knowledge she has acquired over the last two years about good and bad healthcare delivery. And while the new system is far better in her experience, she still has experienced bumps in the road. There is so much patients can teach us about what we do well, and where we need to improve, but they need to be invited into a conversation. Start today by asking a patient how he or she is feeling, if there is anything they need. or if you can be of greater service.
For the last six years, health science students and resident physicians have inspired our Academy for Emerging Leaders in Patient Safety faculty as much as they report we have inspired them to become patient safety leaders within their medical centers. Each year, our faculty receive numerous emails sharing the safety projects they have been leading to make care safer for their patients. We hear about how the Telluride Experience has re-focused their purpose within medicine, sometimes even keeping them engaged at a pivotal point in their own careers when the burden of the current culture of medicine seems too much to bear. Bringing close to two hundred passionate and committed learners and future healthcare leaders to Colorado, Maryland and California each summer to work with our faculty from around the world is what keeps me excited and wanting to come back each year.
This post was inspired by the following reflection, Email I sent to my program leaders, posted on our Telluride Blog by Joy Solano, MD-PGY1. Thank you Joy! And thanks to all our Telluride Patient Safety Summer Camp Alumni (close to 500 strong now) for working to make healthcare safer for our patients, families and our caregivers.
Email I sent to my program leaders. Published June 19, 2015 |
As we reflect on our continued commitment to eliminating preventable medical harm, it is important to never forget the lost loved ones that help keep us focused on our important mission. On this Father’s Day, as a proud parent and even prouder grandparent, I can’t help but reflect back this morning to last year’s Telluride Patient Safety Summer Camp and the personal story Caitlin Farrell shared with all of us on Father’s Day last year. Her story is also featured this weekend on http://runningahospital.blogspot.com/ It is one story I will never forget…
Published June 16, 2014 | By CFarrell
Yesterday was Father’s Day, 2014. I woke up before everyone else in my room. Rolling out of bed, I padded down the stairs and brewed a cup of much-needed coffee. Pouring my face over the steaming cup, I looked out my window to the inspiring landscape of endless white-capped mountains. This year marks the ninth Father’s Day that I have spent without my dad, but the mountains and my purpose this week made me feel as though he were standing there with me, sharing our cup of morning coffee, just as we used to.
After taking the gondola ride into Telluride, the students and faculty plunged into our work of expanding our knowledge in the field of patient safety. We watched a documentary outlining the tragic case of Lewis Blackman, a 15-year-old boy who died due to medication error, miscommunication, and assumptions made by his medical team. The film explored the errors in Lewis’s care that have become far too common in our medical system: the lack of communication between providers and families, the establishment of “tribes” within medicine who do not collaborate or communicate with one another, the lack of mindfulness of the providers, and the culture in which all of these errors were permitted to happen.
But what resonated with me the most were the feelings described by Lewis’s mother. She defined her experience as one of isolation and desperation. “We were like an island”, she said. There was no one there to listen to her concerns. Ironically, Lewis died as a result of being in the hospital, the one place where he could not get the medical care that he so desperately needed.
A pain hit my stomach as she said these words. My family also shared the feelings of isolation, uncertainty, and loss throughout my father’s stay in the hospital. After Lewis’s death, his mother was not contacted. Instead, she was sent materials about grieving and loss in the mail. After an egregious error occurred during my father’s medical care, a physician did not give us an apology, but a white rose by a nurse.
An interesting discussion arose after the film. Our faculty emphasized the need for physicians to partner with the families of the patients. This will create not only a team during the course of treatment, but will cultivate compassion, empathy, and trust in the case of a terrible event. I know that despite the growing number of “apology laws” that protect, and even mandate, physicians to apologize to families after catastrophic events, few physicians actually do apologize. This results in families feeling like the events were there fault. I can say from experience that this is a burden that you can carry with you for years to come.
As I got back to my room and put down my books, this conversation mulled in my mind. The death of my father has given me the fuel to pursue medicine and patient safety as my career. It has instilled in me passion, energy, and determination. Yet the one thing that I have not found in the nine years since my father’s death is forgiveness. Although I do not hold any one doctor or nurse responsible for the detrimental outcome in my father’s care, I have not been able to forgive the team for what happened. I have not been able to go back to that hospital. And as I sat on my beautiful bed in the mountains, I realized that I also harbored another feeling: fear. Fear of becoming a physician who does not practice mindfulness, who does not partner with my patients, who does not apologize for my mistakes. I am afraid that despite my best intentions, I will only continue the vicious cycle. A fear that I will allow my patients to feel as though they are “on an island”.
I put away my computer and got into bed. Lying awake, I took in the gravity of the day. I am so grateful to be here at Telluride among students and faculty who share my passion in patient safety. I could not have imagined a more perfect way to spend Father’s Day.