An Addendum to Annie’s Story

Following is additional information from our team who helped share Annie’s Story, led by RJ (Terry) Fairbanks (@TerryFairbanks), MD MS, Director, National Center for Human Factors in Healthcare, MedStar Health, Tracy Granzyk (@tgranz), MS, Director, Patient Safety & Quality Innovation, MedStar Health, and Seth Krevat, MD, Assistant Vice President for Safety, MedStar Health.

We appreciate the tremendous interest in Annie’s story and wanted to respond to the numerous excellent comments that have come in over YouTube, blogs and email. The short five minute video sharing Annie’s story was intended to share just one piece of a much larger story–that is, the significant impact we can have on our caregivers and our safety culture when the traditional ‘shame and blame’ approach is used in the aftermath of an unintended patient harm event. At MedStar Health, we are undergoing a transformation in safety that embraces an all-encompassing systems science approach to all safety events. Our senior leaders across the system are all on board. But more importantly, we have nearly 30,000 associates we need to convince. Too often in the past, our Root Cause Analyses led to superficial conclusions that encouraged re-education, re-training, re-policy and remediation…efforts that have been shown to lack sustainability and will decay very shortly after implementation. We took the easy way out and our safety culture suffered for it.

Healthcare leaders like to believe we follow a systems approach, but in most cases we historically have not. We often fail to find the true contributing factors in adverse events and in hazards, but even when we do, we frequently employ solutions which, if viewed through a lens of safety science, are both ineffective or non-sustainable. Very often, events that are facilitated by numerous system hazards are classified as “nursing error” or “human error,” and closed with “counseling” or a staff inservice. By missing the opportunity to focus on the design of system and device factors, we may harm individuals personally and professionally, damage our safety cultures, and fail to find solutions that will prevent future harm. It was the wrongful damage to the individual healthcare provider that this video was intended to highlight.

In telling Annie’s story, we chose to focus on one main theme–the unnecessary and wrongful punishment of good caregivers when we fail to cultivate a systems inquiry approach to all unfortunate harm events. This is the true definition of a just culture…the balance between systems safety science and personal accountability of those that knowingly or recklessly violate safe policies or procedures for their own benefit. Blaming good caregivers without putting the competencies, time and resources into truly understanding all the issues in play that contributed to the outcome is taking the easy way out. We wanted our caregivers to know we are no longer taking the easy way out…

You will be happy to know that the patient fully recovered, that Annie is an amazing nurse and leader in our system, the hospital leaders apologized to her, and all glucometers within our system were changed to reflect clear messaging of blood glucose results. We believe we have eliminated the hazard that would have continued to exist if we had only focused on educating, counseling and discipline that centered around “be more careful” or “pay better attention”. We also communicated the issue directly to the manufacturer, and presented the full case in several venues, in an effort to ensure that this same event does not occur somewhere else.

This event, which occurred over three years ago, gave us the opportunity to improve care across all ten of our hospitals. It also highlighted the willingness of our healthcare providers to ask for help because they sensed something was not right and wanted to truly understand all the issues–they also wanted to find a true and sustaining solution to the problem using a different approach than what had been done in the past. Thanks to everyone for sharing your thoughts and for asking us to tell the rest of the story. We have updated the YouTube description as well.

And, thanks to Paul Levy for opening up this discussion on his blog, Not Running A Hospital, and to those of you who continue to share Annie’s story.

For those who have yet to see the video, here it is:

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Taking the Easy Way Out When Errors Occur

Historically in healthcare, when an error occurred we focused on individual fault. It was the simplest and easiest way out for us to make sense of any breakdown in care – find the person or persons responsible for the error and punish them mostly through things like shame, suspension or remediation. Re-train, re-educate and re-policy were the standard outcomes that came out of any attempt at a root cause analysis.  Taking that route was easy because it didn’t require a lot of time, resources, skills or competencies to arrive at that conclusion especially for an industry that lacked an understanding, or appreciation of systems engineering and human factors.  High reliability organizations outside of healthcare think differently, and have taken a much different approach through the years because they appreciate that it is only by looking at the entire system, versus looking to place blame on the lone individual, that they can understand where weaknesses lie and true problems can be fixed. James Reason astutely said “We cannot change the human condition but we can change the conditions under which humans work”.

The following short video is about Annie, a nurse who courageously shares her own story…a story that highlights when we didn’t do it right, but subsequently learned how to do it better by embracing a systems approach that is built on a fair and just culture when errors occur.  A special thanks to Annie and to Terry Fairbanks MD MS, Director, National Center for Human Factors in Healthcare who helps us make sure our health system affords the time, resources, skills and competencies necessary to do it correctly.


Top 10 Takeaways From #SXSW2014: Part One

As I did in 2013 for SXSW, here are five of my Top 10 Takeaways from #SXSW2014 that can be applied to healthcare! Stay tuned for the remaining five later this week…

1) Storytelling for Change-From Storytelling for Change: A Decade of Impact put on by Participant Media (Waiting for Superman, The Help, Food, Inc.) to The Secrets Behind Addictive Storytelling to A Conversation with Jon Favreau (@jonfavereau) on the release of his new movie Chef (trailer below), brand builders and filmmakers shared tips and success stories throughout the week on projects that have gone viral, and others that have entertained audiences around the globe. As a writer and believer that good stories move mountains, I gravitated to those who told their own authentic stories versus those using story to move products. While many have been using story to sell and manipulate, good storytellers, filmmakers and change organizers know that the real movement occurs when we write from the heart to the heart.

2) The Doctor’s Office is Changing-In the session, Doctors Offices on Their Deathbeds, Dennis Schmuland MD from Microsoft and Gautam Gulati MD (@drgautamgulati) among others led a panel looking at what can be accomplished when providers and patients collaborate to stay well versus treat illness. The idea of flipping the clinic in light of data acquisition and transfer via wearable technology (think FitBit) and better designed health IT systems will put pertinent information about patients in the hands of providers  before they enter the clinic. This will allow clinic time to be spent developing a better understanding by both of how to stay well, treat chronic illness and stay out of the healthcare system. In the future, that provider may be a virtual physician or an avatar according to the panel in the session, The Avatar Will See You Now.

3) Wearable Tech-Fitbit, Nike and Jawbone all had a presence at SXSW and everywhere you turned, a different developer was trying to slap a new device on your wrist, touting the benefits of “owning your own data” and “the quantified self”. While I’m the first to admit I love my Fitbit–a constant reminder that I’m sitting at the keyboard too long each day–wearable technology is here to stay and entrepreneurial physicians, health tech start-ups, the government and computer scientists all see the opportunity these devices hold. Whether health IT infrastructure develops the flexibility to communicate with the rest of the world or not, a multitude of data points are already being collected by the innovative organizations openly embracing what consumers/patients want. Look for this movement to gain traction, driven both by consumers/patients and those involved in the redesign of healthcare.

4) Patient Engagement/Ownership-Following on the wearable tech movement, all health panels I attended mentioned the need for patient engagement and ownership of their health and wellness. Those with a FitBit or FuelBand are already on the band wagon, and most likely aren’t the ones taxing the current healthcare system. But as the over-arching healthcare model shifts to one where providers are paid to keep patients out of the clinic, where will that leave those with literacy challenges, or a chronic illness that affects motivation and cognitive capacity? These are two sides to this same coin, and as we move forward by placing increased responsibility on patients, how will we ensure we don’t leave the less engaged for whatever reason behind?

Screen Shot 2014-03-16 at 9.22.08 AM5) Develop A Content Strategy-In Go Home Marketing, Your Drunk, Kristina Halvorson (@halvorson) led a hilarious session, educating and entertaining a ballroom spilling over with fans and followers. Wanting to move to the next great thing in content development is great, but do you have a strategy? In her experience, many clients come to her looking to run before they can walk. Fix your sh@#! was the takeaway here. Know what you have, develop a plan and then embrace all the innovations in content design and development. For those who couldn’t attend, her book, Content Strategy for the Web, could be a good substitute. If nothing else, I highly recommend downloading a copy of her slides from slideshare here.


Telling Stories at the Heart of #SXSW2014

Screen Shot 2014-03-15 at 12.08.15 PMOur ETY storytelling series often includes tips and examples of good storytelling for healthcare leaders who wish to embrace the power of story to change healthcare for the better. At #SXSW this past week, I attended more than one session focused on the power of story in both brand building and filmmaking–all of which provided takeaways easily incorporated into the work of telling our healthcare stories. One such session was put on by the NYTimes Op-Doc producers. Op-Docs is a series of short films submitted by both established and up-and-coming filmmakers, covering health, the arts, science, world news, tech, sports, opinion and more.

One of the Op-Docs short films covers an interview with writer/director/lead actor Jon Favereau (@JonFavreau) for the movie Chef, which premiered at #SXSW. The film, which includes an all-star cast, inspires the audience to do what they love–one of my Top 10 Takeaways from #SXSW2014 to come in a post next week. In a #SXSW session dedicated to a conversation with the filmmaker, Favereau told the audience he used to work on Wall Street and was sadly uninspired, giving to the job only what he absolutely had to in order to get through another day. It was when he committed to a career in filmmaking that he found his passion, along with the desire to put all of himself into his work. As evidence of that commitment, he shared that he wrote the script for Chef in only 2 weeks, explaining how the story took hold of him and he couldn’t stop writing until it was finished. To hear more of his thoughts on the film and his own filmmaking process, view the NYTimes Op-Docs interview with Favereau at NYTimes Op-Docs Chef. And go see the film if you get the chance — it’s truly one of those “feel good” movies!

Check out NYTimes Op-Docs for storytelling ideas here, but beware…the content will pull you in, and keep you on the site far longer than intended.


#SXSW2014 Kicks-Off with Full Healthcare Innovation Agenda

Drs_Office_DeathbedLast Friday marked the start of SXSW 2014 in Austin, TX — a meeting that pulls creatives and innovators from healthcare, media, film, tech and more, together to learn, exchange ideas and provide a jolt to the collective creative energy that stimulates change. Before the first session had even begun last Friday morning–and before I’d even had a real cup of coffee–I already had had thought-provoking discussions with a content developer from St. Jude Medical, a User Interface designer from Blue Cross/Blue Shield, and even bumped into Guy Kawasaki at the SXSW Bookstore. Those attending the meeting know it’s best to wear running shoes and pack power bars, as trying to absorb and get to as much content as possible requires almost marathon-like training.

Here are some highlights from the health tech sessions I have attended so far with more to follow:

  1. A hot topic during the session, Doctors Offices on Their Deathbed (shown above), was the idea of flipping the clinic–similar to flipping the classroom in education. According to Dr Gautam Gulati (@drgautamgulati), Chief Medical Officer & Head of Product Innovation at Physicians Interactive, who Skyped into the meeting, our ability to capture increasing amounts of data about patients outside the office will allow clinic time to be used by patients and providers to collaborate on care plans together–care plans that address the needs, values, preferences and goals of the patient.
  2. In the session, You Got Them to Do What…, wearables were the focus! Your Fitbits, Fuel Bands and more are gaining critical mass. While this has truly been a consumer-driven health movement, entrepreneurial physicians, manufacturers and developers, as well as consumers in-the-know, realize what power the data being collected on a daily basis holds for health prevention, treatment adherence and future prescriptions.
  3. And in Hacking Medical Training Through Innovation, the need to embrace the innovative/start-up minded student, provider and healthcare administrator was emphasized. According to the panel, medicine is losing these folks in droves as opportunities are slow to expand in the space, and are exploding in tech, biotech and health tech organizations. Many leading healthcare organizations are rising to this call, developing Accelerator programs and new positions, such as the Chief Medical Innovation Officer, to reward and recognize their entrepreneurial spirits.

Alyssa’s Story

Hero – a remarkably brave person; somebody who commits an act of remarkable bravery or who has shown an admirable quality such as great courage or strength of character especially under difficult circumstances; somebody admired.

Carole Hemmelgarn is a hero.

In the video that follows, Carole poignantly shares her daughter Alyssa’s story, and why their family’s loss has been the driving force behind the change Carole is fighting for – the delivery of safer care for all patients and families. Every person lost to preventable medical harm is a tremendous loss. Carole, and other courageous heroes like her, including Patty & David Skolnik, Helen Haskell, Victoria & Armando Nahum and Sorrel King give their time, their heart and their stories so we never forget these unfortunate events are not just statistics.

They are my heroes.