How To Engender A Reporting Culture

In my last post, I mentioned the intervention we designed at the University of Illinois Medical Center to increase incident reporting by resident anesthesiology physicians. In the two-year retrospective analyses we used as our baseline measure, we found that residents reported 0 adverse events (AE) per quarter. At the end of the intervention period (7 quarters after study completion), we found that number had increased to 30 reports per quarter.

Resident Physician Incident Reporting

What changed in the residents, other than the fact that we required they submit an AE into the incident reporting system? And equally, what changed in us and our system through this study? To begin with, the students were exposed to an educational program that:

  1. Defined AEs, medical error, serious error, minor error and near miss.
  2. Discussed ACGME core competencies in relation to reporting of harm events.
  3. Discussed and clearly communicated the mechanics of filing a report.
  4. Provided 24 hour access to a consult service.
  5. Discussed how their report would be followed-up, and consistently adhered to this committment.
  6. Provided an educational manual/reference tool.
  7. Included regular conferences every 3-4 weeks for: a) Review of educational material; b) An opportunity for discussion around the AEs that were reported in an aggregated, de-identified manner; and c) Process improvements that came from their reports and feedback.
  8. Included support of the Department of Safety & Risk Management which provided “near-immediate feedback to residents upon receipt of their reports”. When possible, the residents were included in the root cause analysis of the event, or the quality improvement the team put together to address the near miss or unsafe condition.

The increase in resident reporting was very encouraging. But what truly tested our just culture was that the reports in one of the three-month periods shed light upon the fact that more than 50% of procedure related incidents reported that quarter were associated with lack of attending physician supervision. No one knew who the reporting residents were in these cases (except our safety department team) and no one knew who the attending physicians were that the residents felt had not supervised them adequately enough.  This was because the data was always shared in an aggregated, de-identified manner. The purpose was to learn and improve, not finger-point or blame. Instead of arguing the data, our department rallied around it, and improved our own system of being there at the times residents reported feeling we had not been. Not only were the residents exposed to the educational messaging of the intervention, but maybe just as important, they also experienced firsthand the just culture that engenders a reporting culture after the study is complete and the researchers are no longer measuring.

Without a culture in place to reward, support and model incident reporting that effectively addresses the incidents and devises solutions to problems in real-time, results like those found in this study will not last. It would be interesting to give the survey now, to the same group of residents–some who have moved on to other institutions–and see what their attitudes and beliefs around reporting are today.

These same messages are shared with our students in Telluride, during the Student Summer Camps, and they have embraced the idea that the reporting of unsafe conditions, near misses and harm is a good thing. See numerous posts on the Transparent Health blog that give evidence to a fresh culture emerging:

Why Not Put Adverse Events Right In Patient Charts?

Reflections From the Roundtable

It is up to us, as role models and educators, to ensure this is the culture that takes hold in medicine moving forward.


Web 2.0 and Medical Education

In May of 2008, James McGee MD wrote an article for AAMC’s website, Web 2.0 and Medical Education: It’s Here. Are You Ready?.Web 2.0, in a nutshell, is the ability to interact with, change and shape information out on the world-wide web, while Web 1.0 traditionally sent information outward without the average user having the ability to influence the content or message. Here is a visual of the Web 2.0 vs Web 1.0 comparison provided in McGee’s AAMC article:

McGee wrote this piece four years ago, and since then Web 2.0 has matured considerably. In 2008, Facebook had 145 million users–in December 2011 they had 845 million users. The 2012 Summer Olympics were Tweeted about 150 million times and the 2012 Presidential election is being called ‘the Twitter election’ according to the Twitter blog with “more  Tweets sent every two days today than had ever been sent prior to Election Day 2008 — and Election Day 2008’s Tweet volume represents only about six minutes of Tweets today. Has this much changed in medical education since 2008?

McGee points out, the Millennials (aka Gen Yers and those born between early 80s and early 00s) are now in medical school. This group has grown up with technology and social media playing an increasingly larger role in their day-to-day experience. What we GenXers and Boomers wondered about in our formative years, Millenials simply “Google-it”, and have an answer within seconds. Or at least the start at an answer. Their ability to vet what is being shared in a lecture hall, find a second opinion or way of looking at an issue, or watch an engaging video, can happen in seconds, before the educator has even moved on to the next Power Point slide.

In an excellent post on her blog, Future Docs, Rising Above the Sea of MacBooks: “Edu-tainment” and Other Tips, Vineet Arora MD (@FutureDocs) knows she is competing with the world through the MacBooks sitting in front of her medical students, and she is facing that challenge by designing her lectures to meet the needs of the changing classroom environment. (Please forgive the lengthy quote–the information was too good not to share). She advises:

1.  Engage in “edu-tainment” – As Scott Litin at Mayo refers to it, “edu-tainment” is the goal – entertainment via education.  How does one incorporate entertainment into lecture style?  Well, the easiest way is through humor.  This is difficult since not everyone is funny by nature so it may be that you have to inject humor in odd ways.

2. Play games – Games are inherently fun and interactive can stimulate a lot of learning and discussion.  While you may be thinking about computer games, easy games can often stimulate learning.  One of our research ethics faculty played 20 questions with the group of students to teach about landmark research ethics cases.

3. Turn into a talk show – There is nothing more boring than watching the same person for an hour give a talk.  It is much more interesting to watch a panel of people tell a story about themselves – whether it be a patient, another physician, or another student.  I still remember medical school lectures with invited guests that had this talk show appeal due to the lack of power point and focus on the story.  While I’m not suggesting a Jerry Springer approach, who doesn’t love Oprah – at least Chicago has several role models to choose from.

4. Showcase video – Video is one of my favorite teaching tricks.  One well made video can communicate a thousand research articles.  In our week of Scholarship and Discovery, our faculty used videos from Xtranormal (no it was not the famous orthopedics vs anesthesia) but a similar one.  One faculty who could not attend taped a welcome introduction, and another used a clip from “Off the Map” which is now off the air but is still an effective reminder of how NOT to perceive global health.

5. Use audience response – Use of Turning Point clickers can result in instant feedback and engagement with students as they see the results of their poll immediately…Here Steve Jobs can help again – Turning Point has audience response systems for iPhones and iPads that can be used and automatically identify people but it would require that everyone have a smartphone and purchase a license to the software.

6. Refer to the internet– Given that students are on the computer, you can take advantage of it and ask them to visit internet resources in class by showing them urls or web pages that are of use.  Sometimes you may actually refer to your own course website like we do.

7. Provide fancy color handouts – …there is nothing like a fancy color brochure or handout to create a “buzz”.  It’s almost like a souvenir of their hard journey to class that day.  If you ever want to provide someone with a ‘leave behind’ that looks important, lamination is key.  A color laminated leave-behind is even better.  Pocket cards are some of my favorites.

Arora is aware of the need to meet her students where they are–my nephew’s 4th grade teacher unfortunately is not. Vince started school this week, and sadly had to leave his iPad at home. They don’t allow them in the school he attends. He informed his mom and dad he no longer likes school. This is the kid who, in 3rd grade, ran from the bus to the kitchen table at the end of the day to get his homework done without prompting. This is also the kid who sat all day in his room on Saturday making movies with an app he found on the internet, using iPad photos he took of the Lego superhero scenes he built, creating his own storyline without a lesson plan. I fear his teachers don’t allow iPads in class because they don’t want to be shown up by a nine-year-old. I also hope that his will not be the lost generation–the kids who sit in school waiting to get home so the real learning can begin. I hope Gen Yers will not be the lost generation of medical school–sitting in lectures that stop at the four walls of the classroom.

Please share examples of technology being used to its fullest in classrooms around the world–medical or otherwise. I know it’s out there in pockets, and can be,–but we need to expand its reach!


Reporting on Near Misses and Patient Harm: More Than Just Facts

Source: Evans SM, Berry JG, Smith BJ, et al. Attitudes and barriers to incident reporting: a collaborative hospital study. Qual Saf Health Care. 2006;15:39-43. [go to PubMed] Image reprinted with permission from AHRQ WebM&M. Available at: http://webmm.ahrq.gov/dykarchivecase.aspx?dykID=22.

One of the foundational aspects of high reliability organizations is the transparent reporting of events that cause harm, and equally as important, near misses and unsafe conditions. The reporting of these events allows for open and honest reflection, feedback and mindful awareness of areas in need of improvement. The reporting I am referring to is more than just data points–because without a plan in place to act upon the data received, to help uncover the root cause, and to reward and provide feedback for the mindfulness of those reporting the near miss or unsafe conditions, the report remains simply data. These reports can provide rich information about the health of a system, and need to be acted on immediately once shared. In high risk industries, the reporting of near misses and unsafe conditions is fundamental to their improvement culture. According to Weick & Sutcliffe:

…candid reporting of errors takes trust and trustworthiness. Both are hard to develop, easy to destroy, and hard to institutionalize. (James) Reason argues that it takes four subcultures to ensure an informed culture. Assumptions, values, and artifacts must line up consistently around:

  1. Reporting culture–what gets reported when people make errors or experience near misses.
  2. Just culture–how people apportion blame when something goes wrong.
  3. Flexible culture–how readily people can adapt to sudden and radical increments in pressure, pacing, and intensity.
  4. Learning culture–how adequately people can convert the lessons that they have learned into reconfiguration of assumptions, frameworks, and action.

A culture that embraces, rather than punishes, reporting is the just culture that James Reason talks about. We have not yet reached that same mindset or cultural transformation in healthcare, but many health systems are making great advances in this area.

The reporting of near misses and unsafe conditions is not only essential for patient safety, but also in the training of current and future healthcare workers.  In Jericho et al, results of an educational intervention for resident physician attitudes, knowledge and skills around adverse event reporting performed at my old institution, the University of Illinois Medical Center (UIMC) are discussed. I will share results in a later post, as the existing attitudes and culture around reporting first need to be recognized. Jericho et al share:

More than 10 years ago, the authors of the Institute of Medicine report “To Err is Human” asked health care organizations to create voluntary reporting systems to improve the understanding of factors that contribute to medical errors.1  The Joint Commission requires the establishment of a reporting system by accredited organizations for adverse events.2 Despite these mandates and perceived benefits of reporting,1,2 a survey of physicians in teaching hospitals revealed that only 54.8% of physicians surveyed knew how to report medical errors and only 39.5% knew what to report.3

At UIMC, fewer than 1% (<30 total reports) of event reports came from the more than 500 resident physicians who rotated with us before the intervention was implemented. Why is it that caregivers do not take the time to report these events? Research has shown that two main factors contribute to this reluctance: (1) fear of retribution or being seen as a whistle-blower, and (2) no feedback or follow-up after the report was submitted – the feeling that nothing gets acted on so why take the time to report the event. It is important for healthcare organizations to overcome both those barriers so that reporting of near misses and unsafe conditions becomes a norm and not an exception. In particular, how do we move our graduate residents from asking “why do we report patient safety events?” to “where do we report patient safety events?” Examples on how to overcome these barriers in subsequent posts…

  1. Kohn LT, Corrigan JM, Donaldson MS (Eds). To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.
  2. Joint Commission on the Accreditation of Healthcare Organizations. 2009 Patient Safety, http://www.jointcommission.org/PatientSafety, Accessed April 18, 2010.
  1. Kaldjian LC, Jones EW, Wu BJ, Forman-Hoffman VL, Levi BH, Rosenthal GE.  Reporting medical errors to improve patient safety: a survey of physicians in teaching hospitals.  Arch Intern Med. 2008;168(1):40-46.

The Need For Better Communication in Medicine

“If they haven’t learned it, you haven’t taught it.”

I love this John Wooden quote–and John Wooden for that matter. Both Dave Mayer and I have blogged about Wooden’s leadership on and off the basketball court, and how medicine could benefit from his example of leadership. I was again reminded of this Woodism, last week after following a Tweet to Dr. Tyeese Gaines’ post, “Doctors and moms: Speaking Different Languages”  in Health on TODAY. In her post, Dr. Gaines speaks to the need for better communication skills among care providers. This same need was voiced by the American Hospital Association’s Physician Leadership Forum, and highlighted in a July 2012 white paper on: “the core competencies needed to deliver coordinated, team-based, value-driven care and recommendations for how hospitals and physician-associated organizations can develop these skills in the next generation of physicians.” In the white paper, core competency #6 was defined as Interpersonal & communication skills where physicians should be able to:

  1. Demonstrate skills that result in effective information exchange
  2. Work effectively with other members of the health care team

The gap in the need for good communication skills among medical professionals and the existing skill set around the same was named as a strategic imperative by the Physician Leadership Forum moving forward–a positive step toward thwarting the miscommunication among care providers thought to play a major role in medical error.

Returning to Dr. Gaines’ post, I can’t help but once again think of John Wooden. Physicians and patients, including Moms–unless they’re involved in medicine, often do speak different languages. When you add a sick child to the equation, you amp up the stakes and the ability to comprehend the information shared by a care provider decreases significantly. Education level, anxiety level, previous experiences with healthcare providers, frame of reference–all factor into that complex social interaction. And I can’t help but return to a health psychology class, many years ago, where the one statistic that has stayed with me over time is that patients comprehend 30% of what is said in any given conversation with a healthcare provider. If “they haven’t learned it”, maybe the information has yet to be taught in a way that bridges that expansive 70% gap? Wooden had practice time with his players daily, and it still took time for them to acquire a new skill. A 20 minute appointment on a new health topic under stress without “practice” time is a challenging learning environment for both teacher and student.

Even when the news communicated was positive, Dr. Gaines shared her frustration with the story of a Mom who refused to believe her child was healthy and ready to leave the ER. Rory Staunton, the young boy whose death was attributed to sepsis missed in an ER, and cases like this, may contribute to communication challenges even around positive results. With social media and the intensified scrutiny on all aspects of healthcare, every miss of magnitude is brought to the public for evaluation. “It’s just a rash” or “it’s just a virus” uttered by care providers no longer commands the same level of trust it once did, and as such, those conveying the positive findings may still have to battle against medical errors of their peers to gain the trust of patients once given without question. How can care providers most effectively convey this complex, sometimes charged, information in a way that makes sense and sticks with patient and family? Please share your thoughts!

Medicine has indeed become a team sport, and everyone on the care team has to be on board–fully aware of their contribution to a successful outcome.


Bullying In Medicine: Just Say No

The internationally award-winning documentary film, Bully, tells the story of four kids who were victims of bullying in their respective schools. Tyler Long, who committed suicide because of the unrelenting physical and mental abuse he endured each day in school, was one of the kids whose stories was shared in the making of the film.  A short trailer for the film follows.

While filmmaker Lee Hirsch focused on school age children, physician and author Pauline Chen MD recently wrote about the bullying that goes on in medical schools in the NYTimes Well blog (see The Bullying Culture of Medical School.) Bullies, and the pain they inflict upon others, does not stop in middle school, and according to Chen:

…For 30 years, medical educators have known that becoming a doctor requires more than an endless array of standardized exams, long hours on the wards and years spent in training. For many medical students, verbal and physical harassment and intimidation are part of the exhausting process, too…early studies found that abuse of medical students was most pronounced in the third year of medical school, when students began working one on one or in small teams with senior physicians and residents in the hospital. The first surveys found that as many as 85 percent of students felt they had been abused during their third year…

Lucian Leape MD published two papers this past July in Academic Medicine on the disrespectful behavior that continues to occur in medicine, further confirming Chen’s assertions. A Culture of Respect, Part 1: The Nature and Causes of Disrespectful Behavior by Physicians, and A Culture of Respect, Part 2: Creating a Culture of Respect both address this problem, and share that patients, as well as medical professionals, suffer when bullies are allowed to reign. Lucian says:

Students and residents suffer from disrespectful treatment. “Education by humiliation” had long been a tradition in medical education and still persists. Patients suffer when physicians do not listen, show disdain for their questions, or fail to explain alternative approaches and fully involve them in the decision-making process…

We have talked often in this blog about creating high reliability organizations (HROs) in healthcare. Other high risk industries do not tolerate bullying like healthcare does. Why is that? Does healthcare lack the strong leadership needed to eliminate it? Bullying does not belong in healthcare period, or anywhere else in learning cultures for that matter. While it is allowed to persist in any given health system, it will be almost impossible to achieve high reliability.


The Power of Storytelling In Medicine

In the Co.Create section of Fast Company magazine recently, Jonathan Gottschall, author of The Storytelling Animal, writes about the science supporting story as the most powerful means of communicating in his article, Why Storytelling Is the Ultimate Weapon. He writes:

…Until recently we’ve only been able to speculate about story’s persuasive effects. But over the last several decades psychology has begun a serious study of how story affects the human mind. Results repeatedly show that our attitudes, fears, hopes, and values are strongly influenced by story. In fact, fiction seems to be more effective at changing beliefs than writing that is specifically designed to persuade through argument and evidence…

The more absorbed the reader is in the story being told, the more likely he or she is to be changed by it, according to his research. We know that stories shape entire societal belief systems–and Gottschall uses the example of how we once believed the world was flat. Until Columbus discovered America, people lived in fear of falling off the end of the earth. How powerful is story?

It’s true the business sector has known for some time that stories sell–entire marketing departments are built upon this belief. But now, science and medicine are slowly catching on to the power of story to create the change that has stymied healthcare leadership, organizational and behavioral psychologists. We know the proposed steps of behavior change, and have for a while, yet the instance of obesity in the US continues to hit record highs. Maybe getting patients to make that critical move from pre-contemplative to contemplative stage is where story can be most effective.

After all, how do you help someone recognize they need to change? Tell them a story they can relate to–at least researchers and the media increasingly seem to think so. Patients are sharing their own stories on the NYTimes Well Blog, connecting with others around the US struggling with similar health challenges. Researchers like Amy McQueen and colleagues from Washington University in St. Louis looked to better understand the effects of breast cancer survivors’ stories on African American women in their 2011 Health Psychology study, Understanding Narrative Effects: The Impact of Breast Cancer Survivor Stories on Message Processing, Attitudes, and Beliefs Among African American Women. And McQueen is far from the only researcher beginning to measure the effects of story in medical populations, as the body of research in this area continues to grow.

Anecdotally, we have had similar results with our Tears to Transparency film series.

By sharing Lewis Blackman’s and Michael Skolnik’s stories of patient harm with other care providers, medical students and residents in order to prevent similar harm from occurring, we have watched in awe the transformation that occurs in the room when the credits roll and the lights go back on. These stories stimulate conversation around medical error that creates change in the moment. We need to study this, and evaluate how lasting an effect these stories have, and whether or not a booster shot of story is needed, and how often.

Story indeed appears to hold promise for medicine, and healthcare in general. Why don’t people exercise as they should? Or eat things that are good for them? It’s not about the data–we’ve known exercise is good and Twinkies are bad for us, yet behavior change remains a tricky business. It keeps heart surgeons and Hostess in business. But hit someone between the eyes with a story that touches their heart–about a grandfather who adores his grandchildren but now sits on the sidelines in a wheelchair watching them laugh and play, unable to walk for more than a few blocks because of complications from a heart surgery that might have been avoided altogether had he just lost those thirty extra pounds–well that tells a little more compelling story than obesity statistics.


Travel Buddies: Leaders Share Insights Along the High Reliability Journey

During our time in Telluride over the last eight years, preparing medical students and residents to handle the challenges that lie ahead–interpersonally, professionally and through patient care–we would make an annual hike up to the waterfall at Bear Creek mountain. The hike itself was an excellent environment to apply creative thinking to the material presented throughout the week. It also served as a physical metaphor for the professional challenges that the students will face once they graduate. A long hike like this that starts at 9000′ and rises to over 11,000′ is always safest with a buddy–and navigating the healthcare profession is no different–especially today.

Our hike is also a journey, not a race, taking almost four hours to complete. On the hike we talk about the similar “journey” healthcare is taking towards High Reliability. That’s why those like myself, leading change within healthcare systems, like my own MedStar Health, have focused our direction toward high reliability. We look to others who have already started down the road to high reliability for insight. Steve Muething MD and VP of Patient Safety at Cincinnati Children’s Hospital (CCH) has provided great insight through his online presentations, along with others who openly share their stories of transformation, such as Gary Kaplan at Virginia Mason Medical Center.

In 2010, Steve gave a talk on situational awareness at the 2010 Risky Business meeting. Risky Business is a non-profit collaborative between CCH, the Great Ormond Street Hospital for Children NHS Trust and others, and their goals are:

  • To think outside our “box” and share new ideas about managing risk and human factors from other high risk industries.
  • To understand why humans make mistakes, and how to mitigate and recover from them.
  • To learn how to manage and add value from critical incidents.
  • To learn from defining moments in other high risk industries.
  • To share ideas about leadership and teamwork from the highest achievers in sport, business, politics, the arts, exploration, space and medicine.
  • To hear about the experiences of well know whistleblowers when all else failed.
  • To learn more about the importance of appropriate regulation, when, by who and by how much.
  • To understand the role of the law and the media when things have gone wrong.
  • To share pragmatic examples of excellence in improvement and transformation at individual and organizational level.

Steve’s talk at this meeting focused on how his organization was reducing Serious Safety Events by raising situational awareness with the use of a tool that could predict and catch children likely to deteriorate at a time care providers could intervene and have a chance at changing the outcome. He describes three levels of situational awareness and where they occur:

  1. At the bedside level: Where less experienced healthcare providers are caring for patients.
  2. At the microsystem level: Where more experienced providers are in charge and understand the need to act on data received.
  3. At the organizational level: Where hot spots in the hospital are known, and the ability to provide additional resources to be successful is available.

And he shared the five risk factors CCH identified, at least one of which they found to be present every time a child deteriorated:

  1. Elevated PEWS (Pediatric Early Warning Score)
  2. High risk drug or therapy
  3. Family expressed concern
  4. Communication breakdown
  5. Patient is a “watcher”–the gut says “something is happening”

To catch a child before they coded or needed to transfer to the PICU, each level of patient care was required to report up a level on each of these five risk factors every four hours, even if the answer was to report no concerns. They took the “let me know if there is a problem” mentality out of the equation, and simply made it policy to anticipate and catch a problem by being aware around the clock. He also shared insight from his visit to an aircraft carrier, and the resulting knowledge that taught him just how similar his hospital was to that environment. I encourage you to watch the video and share your thoughts.

For those embarking on their own high reliability journey, I welcome the trial and error discussion here–a place where those of us traveling the same road can share what is working, what presents challenges and who has found some answers we can all apply. We can both teach and learn together, as we each do our part to improve the system in which we have dedicated our lives to serve our patients.