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!


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