Resilience in Healthcare

The following post is by Guest author, Natalie Lin, University of Michigan MHSA Candidate & MedStar Health Quality & Safety Intern, Summer 2013. Natalie recently attended “Ideas to Innovation: Stimulating Collaborations in the Application of Resilience Engineering to Healthcare”, and she shares her reflections from the meeting.

Resilience ConferenceOne of the main concepts that has been drilled into my head in school, at MedStar Health, and at the recent Resilience Engineering conference co-hosted by the University-Industry Demonstration Partnership and MedStar, is that we don’t have a safety problem in health care, we have a systems problem. Systems fail, and disaster happens. Traditionally in health care, this is where the finger-pointing begins, because we think doctors are supposed to be perfect, and because we need someone to blame for the mistakes–mistakes that have hurt people. Slowly but surely, we have realized that pointing fingers isn’t going to help.

During this conference, we discussed the idea of resilience–what it is, and where we can find it in health care.  In health care, we’ve only just begun documenting and studying the accidents and mistakes that happen. We then implement checklists, guidelines, and barriers to avoid making the same mistake again. I thought this was a huge step forward. Apparently, this is the idea of “Safety I”, where the assumption is that the system is well designed and well understood. Given that health care is very complex and that the system is neither well designed nor well understood, I learned that perhaps Safety I is not the exact model we should be following.

Safety II, an alternate view, assumes that we have an unsafe system. What if, instead of constraining associates with checklists and guidelines, people could learn to adapt to conditions to prevent accidents? Safety II describes safety as an activity, and studying normal work to manage, not eliminate, the unexpected, because the absence of events does not equal the presence of safety. Of course, in order to do so, we have to be transparent and be able to understand the flaws in our system so that we are able to respond, monitor, learn, and anticipate  the risks before failure and harm can occur. The current literature suggests that we move from a Safety I approach to a Safety II approach, but what I struggle with is–are the two really mutually exclusive?

The concept of resilience in health care is still blurry for me. In the brief exposure that I’ve had to Lean, one of the things that I’ve learned was that we create “workarounds” to problems that arise. Lean teaches us to identify, address, and correct the root cause of the problem in order to eliminate workarounds, thereby making processes more efficient and safe. For example, if we place drugs with similar names right next to each other on the same shelf, how can we expect the pharmacists to be able to pick out the right drug and the right dosage, every single time, when this set up is just a disaster waiting to happen? With Lean thinking, we might come up with a solution to label the drugs more clearly or color code the bins. However, resilience engineering prompts us to study “how they do that”, how the pharmacist is able to pick out the right drug, almost all of the time. It’s a miracle that mistakes aren’t being made every single time! And that is resilience. I cannot say that I am completely sold on this idea yet, but I am trying to process it and re-work my thinking. In the meantime, where else can we find resilience in health care?

After all this talk on resilience and brittleness, Sorrel King’s point is what hit home for me. She said, it all boils down to inspiring the caregivers. Caregivers, who are the ones in daily contact with patients and families, need to be inspired and motivated. They are the ones who “do the work”. Along with being inspired and motivated, we need to provide a supportive culture, where they can feel comfortable and truly work as a team, and will want to work that much harder, knowing that their efforts will save the little girl down the hall. Health care might be extremely complex, but we can’t lose sight of the simplicity of it all–the patient.

More #meded Reflections from Telluride Patient Safety Roundtable #TPSER9

DSC_0905Reflections from students across all areas of the health sciences continue to come in after two pivotal weeks of education in Telluride, CO. The following reflection is by Quyen Nguyen, a University of Illinois-Chicago Pharmacy student. Additional reflections can be found here.


One of the most important lessons I have learned from the past three days is the urgency in which we need to act to bring ethics back to the forefront of healthcare systems. Too often the best interests of the patients and their families are put behind financial, legal, and personal factors. It may never be possible to prevent every error, but we have a professional duty to take responsibility and put patients’ and their families’ needs first in the aftermath of a medical error. I wish to express a sincere thank-you to Carole for your courage in sharing your personal story so that future healthcare professionals can learn from it. I hope that each of us will continue this conversation of patient safety to make a difference in patient care when we return to our institutions.

Today I also learned about the concept of anchoring. Anchoring is a practice in which a person’s perspective is biased by the first information given. The tendency of anchoring increases significantly when one becomes tired, fatigued or distracted by any other human factors. The heartbreaking tragedy we have seen in Carole’s and Helen’s stories stems from anchoring bias. As a caregiver, we have to be mindful and avoid bias when dealing with patients. However, after several talks with several medical students and nursing students, I learned that many residents may have to work up to 80 hours/week on average and many times they have to work more than 8 hours in a shift (please correct me if I am wrong). I wonder whether it is possible for one to maintain a clear mind with an objective perspective under these working conditions. Should there be a change to reduce such long working hours in residency programs?

Yesterday, I went shopping and talked to a cashier in a souvenir shop in downtown Telluride. After I asked her whether she offered any discount for Telluride scientists, we started having an interesting conversation. On being asked what I was there for, I shared with her that I was in a 4-day summer school with medical students, nursing students, and pharmacy students to learn more about patient safety and how to improve healthcare quality. She then told me that since we were learning about patient safety, we should make sure that nursing school teaches nurses how to take blood sample of a patient without pricking her patient five or six times. She suggested that doctors should invent some kind of X-ray imaging on a patient’s arm so that they can test the blood without pricking a patient. We both laughed and I said, “Yeah, why not?” Such an invention may be possible in the future and it would increase the ability to deliver high quality patient care. I thought this is an interesting anecdote of those outside the medical profession on how they perceive those inside.

Needed: A Greater Sense of Urgency Around Patient Safety & Culture Change in Healthcare

TSPRE9_Resident_Wk_2013_Grp_PhotoAfter spending a week with some amazing resident physicians at the Telluride Patient Safety Educational Roundtable & Student/Resident Summer Camp, I feel an even stronger need to create a greater sense of urgency around patient safety–as well as building patient centered care environments with a just culture as the foundation. The stories this passionate group carried with them to Telluride and shared with the group were the muse for this post.

For example, one physician, fighting back emotion, courageously told the group how she recently had to push a senior level care provider to finally acknowledge her concerns about an infant who later died. The physician sitting next to her, with emotional intelligence off the charts, not only acknowledged her pain, but that he also knew she had done everything she could in the best interest of her young patient. In a reflective blog piece, another Telluride alum expressed concerns about just how dangerous the academic medical environment is for patients. And more than one physician shared how coming together in Telluride, having an opportunity to compare similar experiences in an environment where open, honest communication was revered, was a reminder of why they went into medicine in the first place. But I wonder, how long can the Telluride influence last if the culture of our care environments these amazing, but human, care providers return to, does not change to embrace rather than ostracize those who truly put patient centered care before all other agendas?

Paul Levy, (Not Running A Hospital, and more), Telluride faculty for a second year, was equally as awed by the residents who attended. In a parting post on his blog, Not Like Too Many Hospitals, he also expressed the understanding that while this patient safety journey takes time, that time includes costs. Those costs are the lives and well-being of patients across the country. Here is an excerpt from his post:

As I have said before: Sometimes, I remind myself to be patient.  It is hard to change the medical system quickly.  But, more often,  I find myself agreeing with the words of Captain Sullenberger: “I wish we were less patient. We are choosing every day we go to work how many lives should be lost in this country. We have islands of excellence in a sea of systemic failures. We need to teach all practitioners the science of safety.”

I hope and trust that our attendees these last few days in Telluride will have the commitment and courage to make a difference during their careers.

I came across an old post on the Transparent Health blog, Stand Up-Stand Out, as I was reading resident and student reflections from this year and last. In this post, I had referenced Dr. Don Berwick’s essay in JAMA, To Isiah. Following is an excerpt I shared with Telluride 2012 alumni to carry with them as they returned to those who have yet to learn what they have, or worse, those who create barriers to progress. It remains true — even more so today.

…There is a way to get our bearings. When you’re in a fog, get a compass. I have one—and you do too. We got our compass the day we decided to be healers. Our compass is a question, and it will point us true north: How will it help the patient?

TPSER9_Residents_Jump_for_JoyThe faces of this year’s Telluride 2013 Class are reflective of all the good that the healing profession has to offer. Anyone reading this post who is in a position to Stand Up and Stand Out–to clear the way and allow their passion to expand and elevate, not only patients, but the spirit of colleagues as well, please help. Today —

Meanwhile, the Telluride alumni network continues to grow, building a critical mass of voices who believe patient centered care comes first, above all else. We are here for you–reach out, continue to share your stories — they can move mountains!

AMA Awards $11M to Medical Schools Poised to Transform #meded

The American Medical Association (AMA, @AmerMedicalAssn) has announced the final 11 medical schools that will receive funding as part of its Accelerating Change in Medical Education initiative. The goal of the initiative is to transform the way future physicians are trained. Following is a short video clip which provides insight into the program.

Here are short summaries of proposals submitted by the winners for innovation in medical education:

Indiana University School of Medicine

The proposal seeks to create a virtual health care system (vHS) and a teaching electronic medical record (tEMR) to teach clinical decision-making and ensure competencies in system, team and population-based health care skills. The tEMR will be a clone of an actual clinical care EMR, populated with panels of patients for students to manage with information gleaned from de-identified actual patient data…(for more information click here)

Mayo Medical School

This proposal will create an innovative educational model based on the science of health care delivery to prepare students to practice within patient-centered, community-oriented, science-driven collaborative care teams that deliver high-value care. The “science of health care delivery” curriculum’s experiential learning program will focus on how interprofessional teams, patients, communities, public health resources and health care delivery systems can impact patient care, health outcomes and cost…(for more information click here)

Oregon Health & Science University School of Medicine

The proposal will develop and implement a learner-centered, competency-based curriculum that enables medical students to advance through individualized learning plans as they meet pre-determined milestones. A portfolio-based system will track milestone achievement and clinical experiences. Faculty will develop innovative methods for teaching and assessing critically important skills related to informatics, quality science and interprofessional teamwork…(for more information click here)

The Brody School of Medicine at East Carolina University

The proposal will implement a new comprehensive core curriculum in patient safety for all medical students. The proposal will feature integration with other health-related disciplines to foster interprofessional skills and prepare students to successfully lead health care teams for systems-based health care transformation. One component of the proposal will be a “Teachers of Quality Academy” to help faculty develop the skills necessary to practice and teach this new curriculum(for more information click here)

The following schools are the remaining 7 winners:

  • NYU School of Medicine
  • Penn State College of Medicine
  • The Warren Alpert Medical School of Brown University
  • University of California, Davis School of Medicine
  • University of California, San Francisco School of Medicine
  • University of Michigan Medical School
  • Vanderbilt University School of Medicine

From the AMA’s recent press release, it is encouraging to note that of the 141 eligible medical schools, more than 80 percent (119) submitted letters of intent outlining proposals. From their PR department: In March, 28 individual schools and three collaborative groups of schools were selected to submit full proposals before a national advisory panel worked with the AMA to select the final 11 schools. For more information about the initiative, visit

If interested, additional comment and coverage can be found at MedCityNews, What Does the Future of Medical Education Look Like?

Let the Record Reflect I No Longer Practice

By Guest Author, Sarah Easterling, Telluride Patient Safety Roundtable Health Science Attendee, 2013

-Previously posted on Transparent Health

As it was, I didn’t feel great about my time as a defense attorney.  I enjoyed being a lawyer in the most utopian sense of the word:  I enjoyed being an advocate and an adviser to healthcare professionals.  I didn’t enjoy hanging a plaintiff’s dirty laundry out to dry.  I didn’t enjoy burying someone in motions to buy time or meet my billables.  I didn’t enjoy working at a law firm.

I got out of litigating because my work didn’t mean anything.  By the time I was involved, something had already gone grievously wrong, and someone was angry (and injured) enough to bring suit.  I worked the case to a resolution, but that didn’t mean anything either.  I billed the bejesus out of it, distributed the insurance money accordingly, and went about my day.  I always wanted to go back to the hospital or the provider and say, “Let’s make sure this never happens again!”  But, it wasn’t my place.  Three years ago, I was fortunate to be in touch with Dr. McDonald who advised that if I wanted to make a difference in a risk management/patient safety capacity, I should go to nursing school.

And now, here I am. One week away from my NCLEX, and two weeks from working in the risk management department I’ve admired for years.   After my first day, I was excited to be here, despite feeling winded after three flights of stairs.  After yesterday, I couldn’t be more ready to start working next month.  I still maintain that at some level, I helped healthcare providers at a time of personal crisis.  But now I also see what I might have unintentionally done to families, and I wholeheartedly apologize for that.

The Telluride Patient Safety Educational Roundtable (#TPSER9) is giving me a new perspective.  Patients and physicians are no longer plaintiffs and defendants.  I work as an advocate and adviser to both:  By working directly within healthcare (and not as outside counsel), I will educate providers on why transparency is crucial, support providers when they are hesitant about disclosing, and maintain open lines of communication with patients.

Ia Ora Te Natura E Mea Arofa Teie Ao Nei

Latitudes_Harbor_St_Thomas“And there’s that one particular harbor
Sheltered from the wind
Where the children play on the shore each day
And all are safe within.

I know I don’t get there often enough
But God knows I surely try
It’s a magic kind of medicine
That no doctor could prescribe”

For those who have followed our Educate the Young blog through the past year, you know I am a big Parrot Head…yes, a long-time Jimmy Buffett fan. Fellow Parrot Heads will quickly recognize that the title of this post and the lyrics above are from the Buffett song titled “One Particular Harbor”.

The song always comes to mind when I arrive in Telluride each year for our annual Patient Safety Roundtable and Summer Camps. Telluride is my personal “One Particular Harbor”…”I don’t get here often enough but it is a magic kind of medicine that no doctor could prescribe.” All who join us each summer leave inspired and invigorated – they discover this “magic kind of medicine”.

The one hundred resident physicians and health science students who won scholarships to attend one of our Patient Safety Summer Camps this summer are the children. They bring a passion and energy that is contagious to others. The residents and students come to learn, to test, to validate, to network, and to play. They work side-by-side with patient advocates, those who have lost loved ones due to medical error but have passionately dedicated their lives to making care safer for others. Like the lyrics of the song, the residents and students discover they “all are safe within”…sharing their own personal stories in a safe haven – a haven that is not always safe back at their home institutions. If you have been reading their reflections this past week posted on this blog, it is easy to recognize that they discover they are not alone and quickly connect with others who have similar passions – safe, high quality patient care. You can feel their passion and commitment to things like outcomes, best practice, standard work, open and honest communication, and most importantly patient-partnership. They are asking important safety and quality questions…questions many from my generation including myself never asked.

Be it the great quality and safety educational work being led by the AAMC, the ACGME and many other academic organizations and institutions across the country, change is happening. It is happening with our new caregivers. Many resident physicians across the country (including numerous past Telluride Scholar alums) are now leading safety and quality projects at their hospitals. Each year, the residents that come to Telluride seem to start the week where last year’s group left off.  You can feel the change…it is palpable and it must continue. Kim Oates, an international leader in patient safety education from New South Wales, travels from Australia each summer to join us to Telluride. He flies over 8200 miles in the hope he can make a difference in a young caregiver’s career. Kim is one of a handful of physicians who can say Don Berwick was his resident when both were at Boston Children’s many years ago. Despite significant jet lag that stayed with him for most of the week, he shared that if the residents and students who attend Telluride each year are a true reflection of the next generation of healthcare leaders, we are in good shape (See TH post-I have looked into the future and it looks good). I fully agree – while we are not at the tipping point quite yet, the future is bright. We can’t lose sight of “Educating the Young”.

Amazing first week of work in this “One Particular Harbor” called Telluride.

*By the way, Ia Ora Te Natura E Mea Arofa Teie Ao Nei means: Nature lives, Have pity for the Earth, (Love the Earth).

Resident Reflections from Telluride 2013 #TPSER9

IMG_7727Having just returned from Telluride, I can share that the future of medicine looks extremely bright. Twenty-eight residents, all extremely passionate about patient safety, patient-centered care, shared decision-making and righting the wrongs they see in healthcare, have all promised to tell 10 colleagues about the empowering cultural messages shared in Telluride. They will then ask those 10 colleagues to share the lessons learned with 10 more, and so on…

As Telluride organizers Dave Mayer and Tim McDonald say, they will pay it forward.

Following are just a few of those messages in excerpts from resident reflections on the Transparent Health blog. All post can be found here.

From Dr. Kerrie Bossard — The opportunity that I see after completing this exercise is that although we can all make small incremental changes in our respective practices, how can we reshape the practice of medicine to make our small individual changes part of a bigger and more permanent cultural change? If all 28 of the scholars would communicate with 10 colleagues about the importance of shared decision-making and informed consent we could make a small change. But if we made our goals for next week bigger and decided to change the entire process for all residents for generations to come, we may succeed in making lasting change and forever changing the practice of medicine related to these issues…(continued here)

From Dr. Shabnam Hafiz — What an incredible week! I have been so fortunate to be surrounded by such a brilliant group of people leading change all over the country. You have all inspired me and energized me to go back and promote the mission that we have all set out for ourselves- create a system that is patient first… (continued here)

From Dr. Michelle Espinoza —today’s experience was life changing…To be here in Telluride is truly a blessing, and to be surrounded by such knowledge, talent, wisdom and passion is AMAZING…Today I learned that I am not alone in thinking our hospitals are one of the most dangerous places for patients. That my internal conflict regarding my concerns for residency training is not isolated to my hospital, and that there are people who not only believe this is wrong, but have dedicated their lives to making a change…(continued here)

From Dr. Lauren Sontag — Shabs recent post, How Can We Teach, regarding her QI project standardizing an appropriate informed consent discussion. She says several times that we need to put “patients first.” It warms me from within to hear this; I was already going to put up a little post about that very idea. I had the great fortune to go to medical school at the Mayo Clinic in Minnesota, and the most important thing I learned there was this philosophy: the needs of the patient come first. When we believe this and act upon it, we have the courage to address problem behaviors among our peers (and even our attendings and consultants!). We find the moment to sit down instead of hovering near the exam room door and we don’t accept the status quo. Consider it as a mantra for yourself and something you teach others!

From Dr. Stephanie Wappel — …It is so easy to become jaded in medicine, especially as a resident, and this is exactly what I needed at this point in my life to reinforce why I went into medicine in the first place: for the patient.  I’m making a personal commitment to myself and to everyone here at TSRC that I am taking this home and will implement more patient safety measures and quality improvement at my home program…I am going to start with resident education because I feel like this is the greatest need at present. We can each make a difference as long as we keep our eye on the common goal which is the health and safety of the patient…(continued here)

Changing Behavior Through Patient Stories in Telluride

Each new session of the Telluride Patient Safety Summer Camps, Dave Mayer and Tim McDonald share the Tears to Transparency educational documentary films — stories of harm that befell Michael Skolnik and Lewis Blackman–both promising young men–and the impact that harm had on their two families.  As a result, Patty Skolnik and Helen Haskell (Lewis’ Mom) have dedicated their lives to changing healthcare for the better, and have become nationally recognized patient advocates. Through their new careers, both Moms have recognized the need to both “educate (and empower) the young”. The medical and nursing students and resident physicians who attend Telluride often have the opportunity to talk with both parents after each film in an open Q & A. Many students express this being a first exposure to the dysfunctional side of medicine. On the flip side, many also express having witnessed similar poor behavior by those entrusted with leadership positions in an academic medical environment.

Through the generosity of both Michael and Lewis’ families with the sharing of their stories, Telluride attendees are able to practice the difficult discussions focused on in the films in a place where open and honest communication is not only encouraged, but also modeled and set as the baseline. This also re-emphasizes the power of story to change behavior, and as a result, culture. Hopefully this sets a “new normal” for all Telluride alumni – a mindset they can take back to workplaces and educational systems where bullying or a lack of respect prevails and infuse new ideas. Or simply to carry these stories home in their heart, along with the power of the resulting discussions to further embolden environments where a just culture is the norm.

A trailer to the film, The Story of Michael Skolnik, played yesterday morning for our resident scholars is included above. We have been told more than once that the value of the conversations that follow these films each year are unmatched by anything yet to be experienced in the educational experience of health science students. The resident reflections on the Telluride blog today (found here) share some of the takeaways both The Lewis Blackman Story and Michael’s story have inspired this year. The theme from Michael’s story is “Can a conversation change an outcome? Can a conversation save a life?” Based on the enthusiasm for a new normal in Telluride this week, I am happy to report back that the answer to both questions is a resounding YES! When healthcare professionals and patients authentically share their stories and experiences it becomes contagious, inviting others to do the same. I’ve watched this yet again take hold in Telluride. Let’s take this idea viral along with the courage to do the right thing for patients, no matter how difficult, every time.

Follow Telluride 2013 Resident Summer Camp Reflections at Transparent Health Blog

IMG_0188Please join us in Telluride this week!

We are well into day two with our resident scholars in Telluride, where the topic for 2013 is Change Agents: Teaching Caregivers Effective Communication Skills to Overcome Patient Safety Barriers in Healthcare.

This amazing group is engaging in some truly moving conversations around patient centered care, shared decision-making, personal experiences with near misses and the dangers that exist within medical education. Their bravery, knowledge and commitment to their patient is so very evident — it is inspiring, and gives hope of a very bright future for healthcare.

We will be posting summaries of the days events for the next two weeks here on ETY, but please also join us this week at our Transparent Health blog, (found here). Today’s post on the TH blog shares a number of resident reflections and can be linked to here.

Paul Levy, Not Running A Hospital, has joined us in Telluride to teach negotiation skills to our resident physicians and is also blogging about the experience. You can find his reflections here.

What Doctors Feel

Screen Shot 2013-06-07 at 9.49.58 AMI came across a post last week on Slate, The Darkest Year of Medical School, revisiting the idea that medical students lose not only empathy during their medical education, but according to author and NYU physician, Danielle Ofri, “altruism…generosity of spirit, love of learning, high ethical standards—are eroded by the end of medical training.” On June 4th, Ofri also published What Doctors Feel: How Emotions Affect the Practice of Medicine, having performed numerous interviews to draw her conclusions. I read some of the comments on her blog post above–many sharing “medical school was great”. Yet research–past and present– shows many students are not having that experience.

Ofri’s post and newest publication caught my eye as we embark upon the 9th year of the Telluride Patient Safety Educational Roundtable and Resident/Student Summer Camps. This will be my third year in Telluride. The first year I attended, I had the privilege to share a breakout discussion with Lucian Leape and a group of students in the shadows of the San Juan mountains. Throughout that week, Lucian emphasized the need to get a handle on the bullying that occurs in medicine, and instead, instill a greater respect for all in the medical workplace. He shared that unless we are able to do this — treat one another with respect — patients would pay the price, as well as healthcare providers and students.

Having not yet read Ofri’s book, I wonder if medical students who report enjoying medical school overall, were safely ensconced within a workplace with the culture of respect that Dr. Leape refers to as being so very important to patient well-being. It is safe to assume just how empowering a culture of respect would be for students, making them feel competent, part of a team and confident in their newly acquired skills. It’s also safe to assume how students who were bullied might feel (see Bullying in Medicine: Just Say No).

For more information on a culture of respect, and how to create one, see Lucian’s papers:

Perspective: A Culture of Respect, Part 1: The Nature and Causes of Disrespectful Behavior by Physicians
Perspective: A Culture of Respect, Part 2: Creating a Culture of Respect