I think big and dream bigger but have been told many times in my life to stop doing so. My grade 10 careers advisor told me to aim lower when I expressed an interest in studying medicine, a male physician once told me that training a woman was like training half a doctor and I’ve even had a family member tell me that women joining the workforce are responsible for the downfall of modern society. Despite this, I’m now in medical school and will one day soon achieve my dream of becoming a doctor.
Over the last few days I’ve been given the skills and knowledge to undertake projects that improve outcomes for all patients; I’ve been empowered to make a change. Unfortunately these things take time, you need to carefully plan, analyse, monitor and assess. You need a specific problem to tailor your specific, well researched solutions and I am sure in the months and years to come I will use the things I’ve learned and the frameworks provided to make change happen. However, at this point in time, my goal is big and broad, it’s in no way specific and while I’m prepared to to do my due diligence and execute some high quality, quality improvement projects once I find my focus, right now I just need to do something. Improvements to patient safety education shouldn’t have to wait for me to specifically define the problem in a measurable way or wait to get ethics approval. It can’t wait, not while I know there are things I can be doing that will have some impact right now.
Don’t get me wrong, I know we need to improve patient safety, safely by following the right processes and procedures but today I am going rouge, I am not going to wait. Like a hungry Roundtable delegate on the hunt for a burrito I am going to take action. Tonight I will email my contacts and state my case to ensure that patient safety is on the agenda of every student-run educational conference in my state this year. Additionally, I will push to have a safety moment at the beginning of each event my medical society hosts. Lastly, because I can’t be everywhere at once, I will make a time to train others in my medical society so they too can be safety coaches and start getting the word out about this important issue.
One day soon (when step 1 is behind me), I will start the research and do it the right way but I won’t sit ideally by in the mean time. Watch this space.
Each of our Telluride Scholars adds their own voice and passion to the patient safety movement that continues to need attention. The following are most likely words of unintentional inspiration from Anna Elias who shows what one individual can accomplish when they care deeply about a cause, and dare to dream they can make a difference. Anna is absolutely right — Watch this space! — her space, because she is on her way to great things!
You can also link to the Telluride Blog where Anna originally posted this piece.
As in Doha, SolidLine Media was along to capture the stories being told at The Telluride Experience: Sydney! Thanks to Greg, Michael, John, Ali and team for pulling this short video together utilizing movie magic across the continents in time for the Minister of Health herself to view it live in Sydney, at the Clinical Excellence Commission’s reception for students and faculty before we returned home last week.
Truly a great team effort by all to bring the reflections and voices of change to life.
Taking the Telluride Experience global continues to equally educate our faculty on what both the delivery and culture of healthcare around the world is really like. While many cultural differences exist, it is the similarities in our human experience throughout that connects us all. The local challenges may create the obstacles, but returning to the patient, no matter the locale, grounds every care provider in “how to proceed”. Reflections from yet another impressive group of Academy for Emerging Leaders in Patient Safety alumni follow:
I work in emergency medicine. A buffer for the undifferentiated, where time-poor workers battle a “controlled” chaos. It’s also where patients come. Patients who have a stubbed toe, sprained ankle, a cough or a heart attack. By practicing the virtues of patient-centred care we can appreciate that these aren’t patients who have presented to be an inconvenience, but have come because there was nowhere else to go. Ask why. Why did they present. There are many reasons why they present including health literacy and healthcare infrastructure. The truth distills down to the fact that, in their mind, we are their only hope.
Viet Tran, Emergency Medicine, Registrar
It was very important today to see face to face the huge impact that medical errors can have in a person/family’s life; it has certainly touched me and I wish that every health professional I work with got to experience and see the testimonies I have been able to experience today. Seeing a mother with two children who suffer from chronic illness and how their lives have been shaped by this, and how a mother who lost a child in a way that could have been prevented has the courage and strength to re-live this painful experience in order to teach and change in some way how we practice and how we deliver care. This for me was the highlight of the day. Anyone can make mistakes, it can happen to any of us, but we never think that in reality we are going to be in that position. I have been touched by Susan’s and Carol’s talks, they have been just life changing.
Lina Belalcazar, Medical Student
We talk and even joke about aha moments but the past is marked by many such moments that go on to spark movements and eventually change the face of history. In years to come we will look back on the negligent attitudes towards patient safety the same way we look back on segregation and gender inequality, in disbelief. Doctors of the future simply wont believe that patient safety was not always highly valued, well taught and at the forefront of everybody’s mind during each patient encounter.
I am so pleased to have met the leaders in this field and feel privileged to be one of the first followers. Now let’s not stop till everyone is dancing with us.
Anna Elias, Medical Student
I will continue to strive for excellence in patient safety and I will utilise whatever means on hand to achieve our primary goal. A safe and highly satisfactory patient journey. We cannot perform without our patients and they should be central to what we do. This I feel we as a cohort of professions fail to achieve. I am a professional. I am an expert. These excuses create barriers which have become ingrained in our culture. I hope that as evidenced by this conference with the Australians bucking the trend we can continue to do so and continue to strive towards excellence and truly take place as advocates and global leaders in healthcare.
Ben Gross, Nursing
Today another lived experience was shared. It was that of a widowed husband, this time from the UK, who shared the experience of his wife, undergoing what was a routine surgery but ended up not making it to surgery and having a fatal consequence as a net result of an adverse event and subsequent accrual of system failures, particularly those of a human factor nature. This brings to the light the many human factors that we continually witness in practice, which may be harmful especially when aligned in particular contexts, notably in situations that are unfamiliar or deviate from the norm. One of the things I particularly reflected on is how we as humans are fallible to task focus and makes us become situationally unaware. It is something we need to keep in mind when retrospectively analysing incidents. Even I have to admit that I have been unaware on occasion. It is important to be conscious that we can become like that. This emphasises the importance of teamwork, communication and dynamics, which are able to overcome authority gradients and their pertinence to allow goals to be met.
Kym Huynh, Pharmacy
It was only a matter of time before the Telluride Experience, which began as a labor of love by healthcare leader, Dave Mayer MD, almost twelve years ago came to Sydney, Australia. Kim Oates, MD, a local healthcare leader, Telluride faculty member and another who leads with love in the healthcare workplace, championed the experience for young healthcare professionals on the third continent this year.
Dave and Kim are two healthcare leaders who know what it means to put the patient first, what patient centered care really means, and they put that knowledge to the test in real life practice. Another gift both leaders possess is the ability to gently teach and guide, without sacrificing principles. They understand how hard it is for healthcare learners to rise above the medical culture because they have lived it. Today, Kim shared that the three hardest words in medicine are, “I don’t know,” and “Please help me.” Dave openly shares his own experience of being on the wrong side of medical harm when he was a resident physician. They both care deeply about patients. They also care deeply about educating young healthcare professionals to not only protect patients, but to also ensure these well-meaning nurses and doctors stay safe as well.
Healthcare needs more leaders like Kim and Dave, who lead with love. They never have to question the right and the wrong of a situation. Their hearts are their true north.
For more information on how to learn alongside healthcare leaders like Dave and Kim, as well as take home the lessons of the Telluride Experience, go to www.telluridesummercamp.com.
The Telluride Experience faculty has arrived at Q Station Sydney Harbour National Park, an idyllic Telluridesque location in Manly, Australia. The Telluride Experience: Sydney faculty and students will be tucked into this retreat location in Sydney’s National Park just across the water from the lights and cosmopolitan city of Sydney. Q Station and the National Park has a little bit of all Australian terrains, including Manly cove beachfront, bush land and the protection of a canopy of rainforest-like red gum trees.
These spectacular trees serve as home or rest to 150 different types of birds, and resemble our collective efforts at changing healthcare culture by also renewing themselves each year, as they shed their bark presenting a fresh, new salmon colored skin to the surrounding environment.
An old Quarantine Station protecting Australians from smallpox or other contagious disease potentially carried by those seeking to become citizens during the 1830s through 1984, this could not be a more fitting location to host what will be the epicenter of local of patient safety learning over the next four days. Last night, the group shared conversation, introductions and local food and wine to start the week, welcoming one another to yet another intimate and
International patient safety Telluride Experience. Join the conversation on social media, using #AELPS16.
After a very successful Academy for Emerging Leaders in Patient Safety: The Doha Experience (#AELPS16) workshop in Qatar last month, our faculty will now head to Sydney, Australia mid-April to continue sharing our Telluride Patient Safety Summer Camp curriculum with future healthcare leaders from around the world. Through the years, many Australian patient safety leaders, such as Cliff Hughes, Peter Kennedy and Kim Oates, have been regular attendees and teachers at our patient safety workshops in Telluride CO, Washington DC and Napa CA. The Clinical Excellence Commission (CEC) in New South Wales has also supported a number of young Australian physicians to attend our US patient safety immersive workshops. These young physicians have then gone on to assume quality and safety leadership roles at their institutions upon returning home.
Kim Oates, emeritus professor and Director, Undergraduate Quality and Safety Education at the University of Sydney and Carrie Marr, Chief Executive, at the CEC are the visionary leaders bringing the Academy for Emerging Leaders in Patient Safety: The Sydney Experience program to Australia. The Sydney Experience team includes fellow CEC and Australian healthcare leaders such as Telluride Alum Sarah Dalton MD, and first time attendees, May Wong and Teresa Mastroserio. Thanks to the generous support of the Avant Mutual Group, the major medical defense group in Australia, the Division of Midwifery and Nursing, New South Wales Health, and the CEC, over thirty young medical and nursing leaders will be able to attend #AELPS16: The Sydney Experience, an immersive, four-day patient safety education program. The program has also received significant support from Minister Jillian Skinner, New South Wales Minister for Health, who will attend the last day of The Sydney Experience, and will address both learners and faculty.
We are both honored and energized by the opportunity to distribute our patient safety education curriculum to those at home and around the world who have similar passion of finding new and better ways to deliver the highest quality, safest care to patients. In just two months time, we will welcome Qatari and Australian healthcare professionals into our now global Telluride Experience Alumni network. In 2016 alone, over 700 future healthcare leaders will attend one of many Telluride Experience Patient Safety Summer Camps around the world and become part of this growing network of dedicated and caring patient safety leaders.
On day three of our Academy for Emerging Leaders in Patient Safety…the Doha Experience, Dr. Seth Krevat, AVP for Patient Safety at MedStar Health, led discussions on the importance of in-depth Event Reviews, Care for the Caregiver, and Fair and Just Culture approaches to preventable harm events. Seth shared the event review process used at MedStar Health which was designed by experts in patient safety, human factors engineering and non-healthcare industry resilience leaders. This event review process has been adopted by AHRQ and AHA/HRET, and has been incorporated into the upcoming CandOR Toolkit being released shortly to US hospitals.
The young learners engaged in deep discussions around Fair and Just Culture – the balance between safety science and personal accountability. This topic followed interactive learning the previous day on human factors and system/process breakdowns. Similar to challenges we have in the US, the culture in the Middle East blames the individual first without a thorough understanding of all the causal factors leading up to an unanticipated event. After Seth showed the video, Annie’s Story: How A Systems Approach Can Change Safety Culture, and shared other case examples demonstrating how a good event review can disclose system breakdowns versus individual culpability, the young leaders gained a new appreciation of effective error reduction strategies. In the short clip that follows one of our young leaders, so empowered by the short three days with us, explains how she used what she learned to try to change her parents point of view on patient harm:
The passion and commitment of these future leaders to patient safety was inspiring for our US faculty, as well as for the leaders from the numerous Qatar healthcare institutions that participated in our sessions. I have no doubt this next generation of caregivers will be the change agents needed to achieve zero preventable harm across the world. We have seen many examples of their work already.
It was exciting to be in Qatar working collaboratively with others who are committed to “Educating the Young” as a powerful vehicle for change. Next stop for the Academy for Emerging Leaders in Patient Safety…The Sydney Australia Experience!