Telluride Alumni Building Their Own Patient Safety Baseball Diamonds

Screen Shot 2015-03-23 at 9.44.12 PMIts that wonderful time of year for baseball fans when spring training is winding down and opening day of baseball is just two weeks away. If you are a baseball junkie like I am, Field of Dreams has to be an all-time favorite baseball movie. It is my favorite, and when our Telluride alumni reach out with a new patient safety program they have initiated, I can’t help but think of the classic line, “If you build it, he will come,” that encouraged lead character Ray Kinsella to plow his corn field and turn it into a baseball diamond. Our Telluride mission, generously funded through the years by The Doctors Company Foundation, COPIC, CIR and MedStar Health, has been a similar leap of faith…”If you teach them, they will lead”.

The following post is by Telluride Alumni and Guest Authors: Byron Crowe, M3, Michael Coplin, M4/MBA Candidate, and Erin Bredenberg, M4 at the Emory University School of Medicine. Their work is another wonderful example that our Telluride mission is catching fire, and that the next generation of physician leaders are making a difference by building their own patient safety baseball diamonds.

Student-driven quality improvement initiatives are growing at Emory University, and the three of us – Erin Bredenberg, Michael Coplin, and Byron Crowe, all medical students at various stages of training – are using our experiences at Telluride to guide us as we create new learning opportunities for fellow students and improve care through QI projects.

We come from diverse backgrounds; prior to medical school, Erin was a Peace Corps volunteer, Michael spent time in investment banking, and Byron worked in hospital administration. Our personal experiences with the shortcomings of our healthcare system drove a shared interest in QI and patient safety, and we each eventually found our way to Telluride at some point during the last three years.

Telluride has shaped our trajectories at Emory in unique ways.

  • For Erin, now in her final year of medical school, the impact of the connections she made with other like-minded students inspired her to use the skills learned at Telluride while completing an MPH to educate others. She joined her local IHI Open School chapter as Director of Education where she organizes workshops and events to teach students key concepts in QI and patient safety, skills she honed working at the Atlanta VA hospital on a major falls prevention project.
  • Michael has become a key advocate for QI education within the medical school and has been integral in pulling together faculty and students to explore developing a longitudinal QI curriculum. He is currently earning an MBA at Emory and is channeling his interest in health systems efficiency into his work on a QI project in the emergency department.
  • Byron, now entering his third year, continues to lead the IHI Open School chapter at Emory and organize students around local QI projects. In the community, he is coordinating an ongoing partnership between a local safety net clinic and the Open School to improve care for diabetic patients.

We all agree that one of the most important aspects of our time at Telluride was the empowerment we felt from meeting other students who wanted to use their careers to make care safer and more effective through QI. Moreover, our experience at Telluride did not end once we returned to Emory–in addition to working together at school, we have remained connected to the amazing students we met at Telluride from other institutions.

Attending the Telluride conference taught each of us new things, whether about the healthcare system, our patients, communication, and ourselves. But it also enabled us to join a growing community of faculty and students who have attended Telluride and who share a commitment to improvement. Having a small piece of that community at Emory has been a formative and unforgettable part of our medical school experience.


On Grief, Choices and Being Mortal

The stories shared during this year’s Patient Safety Awareness Week (#PSAW2015) were inspiring! In ETY’s Why Patient Safety Week Matters, Carole Hemmelgarn, Patient Advocate, shared for one of the first times her feelings of grief related to a series of medical harm events that took her only daughter, Alyssa. She wrote that “grief is her twin”, a twin that at times brings comfort and sorrow. Thanks to the power of social media, her message was carried like a gift to many around the world. The following comment confirms yet again that our stories matter to others–and our willingness to share them when ready can ease not only our own, but another’s suffering:

Your story is so important. I never thought of my grief also bringing solace. I lost my father and thought that was bad but 10 years later I would lose my sister and mother in the same year. I have cried (for a few minutes) every weekend since August 2013 when my sister died and I thought somehow I needed to stop because this is not normal. After reading what you wrote maybe I should stop trying and just rejoice in the memory of my loved ones a few tears is a small price to pay to remember them.

And from @MichaelDFranklin:

Do we realize that such a quote, “grief is my twin” is not specific to loss from medical errors, but to life itself?

Dave Mayer’s ETY post, Caring for Caregivers…, later in the week, served as insight into the grief felt by those administering care–even when that care goes as planned. He referred to an opinion piece in JAMA entitled, “What I Learned About Adverse Events From Captain Sully – It’s Not What You Think,” that discussed the stress involved in caring for others requires many to side-step a recovery process for the self that could revive and encourage positive coping skills for future stressful events. Caregivers are often expected to jump back into the next case without taking time to recover. This equaling of the patient-caregiver grief playing field reflects the silent suffering that can be occurring on both sides of the healthcare encounter when a simple conversation could be the bridge to healing. Grief multiplies in isolation–it can be lessened in the right company when ready. And as Carole did last week, the sharing of our own grief can also be a gift to a complete stranger. How beautiful is that?

Screen Shot 2015-03-18 at 12.33.23 PMHow can we help multiply these gifts; stories of our selves by both patient and healthcare professional? Especially when medical training has only begun to consider the healing power of listening with the heart, as well as the head. This winter, I had the pleasure of hearing Atul Gawande speak at the IHI Forum where he shared insights gained while working on his latest tome of wisdom, Being Mortal. Of all the thoughts he shared that day, the one that has stuck with me four months later is the differing views he and his wife hold for end of life comfort. Atul said he is “down with Stephen Hawking”, and if he is simply “a brain in a jar and we can still extract his thoughts” let him live on! His wife on the other hand (and I summarize) has shared that if she even looks as though she can no longer enjoy life or share in the moment, pull the plug. This take home message is a reminder that individual choices related to how we live and die can be very different, even from those we love most. Unless we choose to talk about those choices–with one another, and with our healthcare teams–we remain a mystery to one another.

In the introduction to Being Mortal, Gawande reflects on how far our current approach to care as we age is from where we once were, or even where so many will find real comfort, including those delivering care. He writes:

I learned a lot of things in medical school but mortality wasn’t one of them…our textbooks had almost nothing on aging, or frailty, or dying…when I came to experience surgical training and practice, I encountered patients forced to confront the realities of decline and mortality, and it did not take long to realize how unready I was to help them.

There are many in healthcare–patients and caregivers–who also understand there is a better way. I recently found out that a good friend’s Mom was given 6-12 months to live at the younger-every-day age of 71. The choices she made throughout her life most likely have influenced the way it will end, but they are hers. She has found a doctor she likes to see her through treatment, and he is encouraging her to continue to make the choices that bring her comfort and as much joy in the remaining time she has with friends and family. She has found a healer, as well as a physician–someone who can sit with her and listen, hear with the heart and share experiences that might prove healing even though he cannot treat the disease itself.

Atul Gawande is on to something in Being Mortal. In fact, it could be one of his most important works to date. The suggestion that instead of being taught to diagnose, to treat, and to protect the hospital assets, a greater amount of time could be spent teaching healthcare professionals how to share in grief, to share stories of the self and to explore more deeply what is truly meant by the art of healing is an idea that each of us–patient or caregiver–can carry with us into care environments if we choose.


Josie King Foundation: Picking Up the Pace for Patient Safety

2015 is well under way and our friends at the Josie King Foundation are determined to increase awareness and action around their mission of keeping patients, and providers, safe from medical harm. So determined, in fact, that Sorrel King is sacrificing her joints to run the Boston Marathon in April to raise awareness and funding for the cause. If you are going to be in the Boston area on Monday, April 20th — or running yourself — be sure to reach out and join the mission.

For more information or to make a donation, you can go directly to the Josie King Foundation website, or click below to read more!

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Read more…


Caring for Caregivers During Patient Safety Week

Over the last few years, we have written about the vital importance of Care-for-the-Caregiver programs when unintended patient harm occurs from a medical error. As caregivers, the willingness to admit our humanness, as well as our ability to make an error, helps us reframe the recovery and learning process when these events tragically occur. All too often, we have turned away from our fellow colleagues, or worse, blamed them at a time when they needed our support the most. We all know of stories where good, caring healthcare professionals have taken their own lives after unintentionally harming a patient. As a profession, we need to do better.

Sully_Sullenberger_SkilesBut what about the impact a highly stressful event, even with a good outcome, can have on our care teams? And could that stress impact the safe care of the next patient?

I encourage everyone to read an outstanding two-page opinion piece in JAMA titled “What I Learned About Adverse Events From Captain Sully – It’s Not What You Think”. Written by Marjorie Podraza Steigler, a fellow anesthesiologist, the article should cause all of us to stop and rethink this important question. An emotional toll on physicians and nurses may occur even when no error was made, and the care team responded with precision during a major patient care crisis. As a cardiac anesthesiologist, I think of emergent, high-risk cases that went for hours, and while the outcome may have been good, the team was physically and emotionally drained afterwards. All of us, however, were usually expected to immediately return to the operating room for the next case often without time to process what had just occurred.

As Dr. Steigler correctly points out:

The contrast between the immediate removal from duty for those involved in the Miracle on the Hudson and the expectation that permeates our hospitals is stark. In both cases, the safe care of the next “customers,” whether they be travelers or patients, is at stake.

We have to do better for ourselves if we ever expect to do better for our patients.


Why National Patient Safety Week Matters

Today’s post is by guest author, Carole Hemmelgarn, who generously shares a reminder to all on why patient safety work is so important, and why National Patient Safety Week will continue to matter even after we get it right. Carole continues to give her time as a patient advocate, coaching healthcare organizations across the country on the power of words, as well as a better understanding on what it means to truly communicate with patients.

March 8th starts National Patient Safety week and it is with great irony that I write this blog because it is the anniversary of the day my daughter, Alyssa, died from medical errors. I am grateful for the focus being made in the field of patient safety. We need to become High Reliability organizations, enhance our communication skills, offer communication and resolution programs, implement bundles and the host of other programs that impact safe patient care.

Carole_Alyssa_ETY030815However, I want to bring the focus back to the human side of patient safety and that is the patient and family after harm has occurred. There is this aftermath, which is rarely spoken of, and it is what happens to those survivors living without their child, spouse, parent or sibling years down the road.

I’ve come to realize grief is my twin. It will never go away and we have learned to coexist. Please understand grief is not always bad. I find solace in my grief because we speak the same language. We laugh and cry together and there is no judgment. At other times, my twin is like an anchor weighing me down causing me emotional pain and draining my often limited resources. So you may ponder why the dichotomy? Well, because life moves on, but it is different for us now. I’m a different person. My beliefs, values and what I held to be true have turned upside down.

What most people don’t realize is loss of a loved one, and in particular, a child, changes so many things.

  1. Marriage changes. I’m no longer the person my husband married and trying to figure out who we are in this new space is exhausting. Parents grieve differently and the one thing they don’t want to do is hurt their spouse because they know they are already in pain. This just opens up the door for communication problems.
  2. Your children are affected, but rarely do we talk about the impact it has on them. My husband and I often ask the question “Is this who our son is, or is this who he became after his sister’s death”? It is difficult to watch your son cringe when asked if he has any brothers or sisters and he says “no” because he can’t go there and talk about his sister.
  3. Your relationship with family members change. Sometimes they become stronger with certain members of your family, and others, a riff occurs because they expect you to move on or be the person you were before, and that individual no longer exists. Partaking in family events that once use to be enjoyable can be extremely emotional. You are there, but only as the great pretender, when underneath you are screaming to be set free. Why? Because you are watching their children progress through life, and do the very things, your child will never get to do.
  4. Friendships change…..

The most difficult are the milestones your child will not experience: moving through elementary, middle, and high school, not graduating from college, getting a job, married or having children. These events go on for years and this is the aftermath not seen.

I share this with you because I want you to see the importance of the work you do in the area of patient safety. So as you participate in the 2015 National Patient Safety Week, your goal is to make sure we minimize and mitigate the aftermath of harm I discuss above, and my goal is to help others avoid having grief as their twin.


Sharing Patient Safety Messages

Trying to get and keep the attention of busy healthcare professionals with content related to new initiatives can be a challenge to those leading culture change in healthcare. So many healthcare organizations are choosing the path of high reliability, greater patient engagement and shared decision-making, and a 5-star patient experience–all areas which will help us achieve zero preventable harm for patients. With the adoption of a new agenda comes the acquisition of new knowledge for all involved in executing and delivering on the programs.  SolidLine Media has been a partner in developing award-winning healthcare content just south of ten years, and continues to hit the mark most recently with their Minute for Medicine series which includes (52), one-minute episodes containing quick, entertaining hits on several different domains key to providing the safest, highest quality care to patients. Knowing all too well the value a simple, turnkey solution can provide to so many looking to share information without having to start from scratch or develop it themselves is the driving force behind sharing this tool. And in the interest of full disclosure, I am a partner in the series.

Check out the following, or go to Minute for Medicine for more information on how to take part yourself! Share feedback on the series, and/or please share additional tools your teams have found effective in sharing and creating meaningful content within your healthcare organization!  We don’t have time to recreate the wheel — it’s time to pick up the pace for patient safety!

 


Putting A New Spin on Healthcare Culture

A friend sent the following link to the post, 7 Cultural Concepts We Don’t Have in the US, over the holidays this year and it was a nice break from my regular reading. The author, Starre Varten, highlights seven cultural concepts originating in other locales around the world, such as “Kaizen” from Japan, which many in healthcare have already adopted with resounding results. I especially liked the Danes practice of “hygge”, or the idea of togetherness, coziness as a mental state versus physical one. She describes “hygge” as being akin to family and friends, gathered around the warm crackle of a fireplace enjoying good food and drink together as the first winter snow falls outside. Denmark is repeatedly rated as one of the happiest countries despite the long, cold winters they endure. Given the extent and brutality of our last two US winters, I would be more than willing to adopt hygge as a core part of my own culture!

Varten also reminds readers:

Culture is ours to do with as we choose, and that means that we can add, subtract, or edit celebrations or holidays as we see fit — because you and me and everyone reading this makes up our culture, and it is defined by us, for us, after all. 

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Culture change is admittedly not an easy or quick event, especially within healthcare. It takes time and commitment, and sometimes a game-altering nudge to the status quo! Changing the narrative and creating a new picture of an ideal healthcare environment is one place to begin–and while it may seem foreign at first, the benefits can very often outweigh any risk. There is a growing group of healthcare change agents embracing the uncertainty of change–certain that by taking the leap to innovate healthcare–patient and provider alike will be the beneficiary. This group is behind USA Change Day (@USAChangeDay), which is built off the pioneering work of the National Health Service (NHS). The NHS launched Change Day in 2013, and Helen Bevan (@helenbevan) has been a lead healthcare change agent in the UK, putting a refreshing and inspiring spin on something that began as a grassroots campaign, started by a small team and which has now taken flight. From the USA Change Day website:

…Its mission was simple—to challenge everybody within the organization to pledge just one thing that they would commit to doing in the next year to improve healthcare. This small initiative turned into a huge success, and now we’ve brought the movement to the United States of America.

You can follow their efforts @USAChangeDay, or better yet, join the cause!

What will you commit to doing in the next year to improve healthcare?


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