Its 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.
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.
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.
“If transparency were a medication, it would be a blockbuster, with billions of dollars in sales and accolades the world over. While it is crucial to be mindful of the obstacles to transparency and the tensions—and the fact that many stakeholders benefit from our current largely nontransparent system—our review convinces us that a health care system that embraces transparency across the four domains will be one that produces safer care, better outcomes, and more trust among all of the involved parties. Notwithstanding the potential rewards, making this happen will depend on powerful, courageous leadership and an underlying culture of safety.”
The previous paragraph comes from the fifth and final National Patient Safety Foundation’s Lucian Leape Institute (LLI) White Paper entitled, “Shining a Light: Safer Health Care through Transparency”. Each of the five white papers address key issues that healthcare stakeholders will need to successfully manage if healthcare is to achieve zero preventable harm. I was honored to be part of the panel that helped create this paper and the 39 recommendations for greater transparency throughout healthcare.
Defining transparency as “the free, uninhibited flow of information that is open to the scrutiny of others”, the paper provides recommendations in four different domains of transparency:
- Transparency between clinicians and patients (illustrated by disclosure after medical errors)
- Transparency among clinicians themselves (illustrated by peer review and other mechanisms to share information within health care delivery organizations)
- Transparency of health care organizations with one another (illustrated by regional or national collaboratives)
- Transparency of both clinicians and organizations with the public (illustrated by public reporting of quality and safety data)
I encourage everyone to visit the LLI website and download the White Paper (click here for a copy). Increased transparency is critical to any Patient Safety mission. Greater transparency throughout the system is not only ethically correct, but will lead to improved outcomes, fewer errors, more satisfied patients, and lower costs.
Those where the words shared by former President Bill Clinton as he helped kick-off the 2015 Patient Safety, Science and Technology Summit this past weekend (http://patientsafetymovement.org/). The former president has been a keynote speaker at all three annual Summits and sees the Patient Safety Movement’s mission similar to the Clinton Foundation Global Initiatives Program (GIP).
Working with former President Clinton, Joe Kiani adopted a similar “commitment” model used by Clinton’s collaborative GIP in selecting preventable medical harm and setting a goal of Zero Preventable Deaths by 2020 (0X2020). There has been a lot of great work by many patient safety advocates since the release of the IOM report on preventable medical harm fifteen years ago. The Patient Safety Movement is another example of people wanting to make a difference and help reduce risk in healthcare. We hear “it takes a village” and Joe Kiani continues to bring more people wanting to make a difference into the “safety village”.
This year, Joe worked his magic and was also able to bring Vice President Joe Biden into the safety village. The Vice President was wonderful – he spoke passionately and eloquently about the safety crisis. He admitted that two years ago when he agreed to meet with Joe, he knew little about the preventable medical error crisis but quickly changed his 30 minute meeting with Joe into a two-hour tutorial on the issue. Like many others, he has become an engaged partner and re-arranged his very busy schedule so he could attend, address the crowd and hear about the great work going on by many.
In a short time, the Patient Safety Movement has brought high-ranking “partners” into the safety village, added tremendous value to the mission, and brought significant attention to the great work done by many others over the past fifteen years.
As former President Clinton said, we need to embrace more “people who are dying to be asked to make a difference”. It does take a village…and we need to continue to grow our safety village.
Leadership is not so much about technique and methods as it is about opening the heart…about inspiration–of oneself and of others. Great leadership is about human experiences, not processes…it is not a formula or a program, it is a human activity that comes from the heart and considers the hearts of others. It is an attitude, not a routine.
Secretan’s teachings are based on the core principle of connecting the soul with what we consider as “work”– the two becoming intertwined in a way that redefines our “work-life” balance, making both truly fulfilling. It combines our inner passion to make a difference in someone’s life with our reason to get up each morning and go to “work”.
Each day in healthcare we are given the opportunity to make the world a better place—for our patients, our colleagues and our communities. As healthcare providers, we entered into our profession to care for others–to keep our patients safe at all costs while under our care. Think of the healing power that could occur not only in our healthcare workforce, but also in our patients, if leaders created care environments that were truly places that nurtured the soul.
Rosemary Gibson said it best when she paraphrased Gandhi, reminding us: “A patient is the most important visitor on our premises. They are not dependent on us – we are dependent on them. They are not an interruption in our work – they are the purpose of it. We are not doing our patients a favor by serving them, they are doing us a favor by allowing us to serve them.”
Can healthcare leaders create a work environment that reflects and honors the creative spaces of the soul and brings passion back into our daily work? Can healthcare leaders inspire caregivers to connect with their own inner values in helping health systems achieve the highest quality, safest care possible for both patients and caregivers?
As we move into the New Year, I am hopeful we can all “lead from the heart” in ways that inspire ourselves and others to achieve the highest quality, safest care possible for our patients and our caregivers.
Wishing everyone a healthy and happy new year.
“Calling all resident physicians in the Washington DC/Baltimore area!”
The MedStar Health and University of Maryland Resident Physician Quality Improvement & Patient Safety Council, or QIPS Council, is hosting its second “Evening of Wine & Wisdom” educational speaker series and networking event. The event will take place on January 14th, from 5:30-8:30pm at Westminster Hall on the University of Maryland campus. You can register for this free event at www.QIPScouncil.org, and take part in engaging discussion after listening to presentations on “Inspiring and Empowering Change thru the Face of Medical Harm,” given by leading national patient and healthcare advocates.
Building on the great success of our first QIPS “Wine and Wisdom” event held in DC that featured Paul Levy, author and leadership coach, our second event will include talks by speakers Helen Haskell and Rosemary Gibson. Helen is President of Mothers Against Medical Error, and Rosemary is an author, Senior Advisor at the Hastings Center and an ACGME Board Member. Both healthcare leaders have been working to educate the young (and old) on what it means to deliver care that is safe and patient-centered for the better part of their careers.
We hope you will join us for a great evening of Wine and Wisdom.
Not sure how late summer and fall flew by so fast, but it is already November, and we are now taking applications for our 2015 Telluride Summer Camp sessions!
Step up and become one of our Telluride Patient Safety Champion Alumni–over 500 strong– by applying to spend one of FIVE weeks immersed in learning and discussions on how to become a patient safety leader. This coming summer, there will be three locations for medical students and advanced practice nurses, and two locations for resident physicians.
Because of the tremendous success we have seen through the years, and as a result of our continued growth both nationally and internationally, the Telluride Patient Safety Summer Camps will take on a new look and name beginning in 2015, but the spirit in which the patient safety intensive workshops will operate will not change. The newly anointed (chosen by our Telluride Alumni Scholars) “Academy for Emerging Leaders in Patient Safety: The Telluride Experience,” will continue to gather patient safety leaders from around the world, along with patient advocates and industry leaders to discuss issues related to the open, honest communication and patient-centered healthcare, both critically needed to produce the highest quality. safest care possible.
Once again, we will be taking applications online (click here) and the deadline for 2015 sessions is January 15, 2015. On the website you will also soon find familiar faces, starring in a new, mini-documentary on the Telluride Experience.
Telluride Alumni continue to create change at their home institutions, and inspire their colleagues. The following reflection was shared by a Telluride Scholar at the end of her first day at one of last year’s sessions. It is messages like this that reinforce how important the work being done in Telluride has been, and will continue to be through the Academy. And it is most definitely a two-way exchange of inspiration. Many of us have similar days and weeks of frustration and despair, feeling the changes so badly needed aren’t happening fast enough. Our faculty also leave “recharged” after seeing and feeling the passion and commitment these future healthcare leaders have for achieving safe, high quality patient care. Please consider joining us in 2015!
From a Telluride Scholar, 2014:
“As of late, I have felt uninspired and more bewildered by the apathy and active discouragement by my superiors almost reprimanding me for doing the right thing for my patients. After meeting the Telluride faculty at this meeting, I am beginning to feel empowered again to be a conduit of change.”
“So often at work I am so disheartened by what I see and do when it comes to patient safety and quality of care, and I am usually too tired and pessimistic to do anything but complain. I now have renewed energy and commitment to making things better. I also now have some tools and support and I’m again excited for the next two years of residency.”
“Thank you so much for this amazing week. After the hardest year of my residency as well as my personal life, this conference has re-inspired me at a time when I was starting to feel exhausted by work and alone in the system. Just a few days before I arrived in Telluride, a faculty member told me to ‘stop pushing and coming up with ideas because you don’t understand how things work here’. This was greatly upsetting and discouraging as I actually consider this person a mentor and a progressive thinker. Although this really upset me, I am so fortunate that I got to attend this conference…I learned that I certainly am not alone and will not stop pushing.”