Each day, we are barraged with hundreds of useless “junk” emails. Many have learned the tricks on how to make it through our spam filters and firewalls. However, amongst all that “noise” each week, one can find a few “pearls”. For me, the pearls are the emails I regularly receive from our Telluride Scholar Alumni.
Michael Slade, a second year medical student and Telluride Patient Safety Summer Camp alumni, recently emailed me to share the following reflection on how his Telluride educational experience has translated into further patient safety education at his home institution. It’s this passion and enthusiasm for both patient safety and innovations in medical education that Telluride aims to inspire, in hopes that both will go viral in healthcare environments across the country.
One of the biggest things I took away from Telluride was the power of knowledge. Because of the Telluride conference and the speakers who presented, those of us who attended were able to go back to our home institutions with a transforming set of ideas. The problem is that, quite simply, we aren’t going to be able to make healthcare safer or more effective by empowering a hundred or two hundred providers at a time. We all need to go back to our respective healthcare homes not only as technicians, but also as educators.When I left DC, that was my goal. The medical school here allows first year students to take several elective courses. With the help of a patient safety champion in the faculty, I spent the fall organizing a 10 hour course that included lectures on many of the topics we discussed at Telluride (HREs, human factors, standardized communication, etc) and attendance at hospital PS&Q conferences. We met our goal of enrolling 15 students in the course and completed it a couple of weeks ago. The feedback from the class was almost universally positive; one student (encouragingly) wrote “These are concepts that every med student can (and should!) buy into without extensive medical knowledge. I got a great snapshot of how things work in the hospital (good + bad), w/o being overwhelmed.” A student from the course is also taking over our local IHI branch next year and applying for Telluride this summer. We’re planning on offering the elective for the foreseeable future.
I just wanted to thank you (and by extension, the entire staff) for investing in me and the other attendees of the Telluride experience. The road to safe, reliable healthcare is not going to be an easy one, but I’m proud to be a part of the journey.
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:
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.
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.
For the last twelve months, our health system has undertaken a system-wide initiative to join the ranks of healthcare organizations like Cincinnati Children’s Hospital, Poudre Valley Hospital, and Mainline Health on a journey that seeks high reliability. We have already seen the fruits of this journey, and believe that when the benefits of a High Reliability culture are combined with the expertise provided by our National Center for Human Factors in Healthcare, led by Terry Fairbanks MD, MS, along with the guidance provided by our National Patient and Family Advisory Council for Quality and Safety, exciting opportunities to improve quality and safety while reducing cost can be realized.
An important part of this journey includes creating a learning culture built on transparency that many in healthcare are still uncomfortable with. Overcoming these barriers requires consistent and repetitive role-modeling and messaging around core principles that help instill and reward open and honest communication in an organization. One of the ways we continue to reaffirm these important messages is through our “60 Seconds for Safety” short video series, which highlights different high reliability and safety principles. Each week, a video from the series is attached to our “Monday Good Catch of the Week” email, delivered throughout our system. The video highlights one important safety message all our associates can become more familiar with, and hopefully apply as they go about their daily work that week. Similar to starting every meeting with a safety moment, we want all of our associates to start each new week with an educational message reminding us that safety is our number one priority. The videos are available on MedStar’s YouTube Channel, under the Quality & Safety playlist. Please feel free to use any of these videos in your own Quality & Safety work — and please share ways you are getting the quality & safety message out to your front line associates.
About once a week I receive an email from one of our Telluride Scholar Alums. These young care providers are eager to share new quality improvement projects or risk reduction programs they are leading, or provide an update on work started shortly after finishing their Patient Safety Summer Camp week with us. This week was no exception. Dora Zamora-Flores, MSN, RN, CPNP and Pediatric Nurse Practitioner, who attended Telluride East in Washington DC last summer, emailed to share how the knowledge gained at our Summer Camp is translating to real healthcare care change at the bedside of a small community hospital in South Texas.
Each year, thanks to the generous support of The Doctors Company Foundation, COPIC, CIR and MedStar Health, the number of applicants for a seat at one of four, week-long sessions continues to grow, as does the level of talent. We are always thrilled to see how these creative young healthcare providers take the learning from the heart of the Rocky Mountains (and now Washington DC) straight to the heart of patients. Here is Dora’s story…
I attended Telluride East this summer and want to give you an update on how I have used the knowledge gained. A small community hospital in deep South Texas is opening a brand new Women’s Services department next week. They currently do not deliver babies. I asked the CNO if she would allow me 1 hour to speak to all of the nurses- nursery, L&D and post-partum. I shared Diane Ford’s story, the NICU heparin incidents, findings from “To Err is Human”, a brief intro to Human Factor’s Engineering and the importance of teams, communication and reporting near misses. I ended with the Lewis Blackman video which you were kind enough to send me.
The response and the questions were tremendous. There were some tears in the room. It went much better than I expected. I encouraged them to take advantage of this unique opportunity to set the tone from day 1 of this unit for a culture of safety. A CRNA in the room, Tim Sparks was very interested in my experience in DC and he contributed to my presentation by sharing some of the mishaps he has witnessed during his years as a CRNA. I have given him your contact info. He oversees over 50 CRNAs and is interested in putting together a Safety Training for them. Thank you again for allowing me to be part of Telluride East. I continue to have many rewarding experiences due to the knowledge I gained there. -Dora
With the winter many of us have experienced this year, it is emails like Dora’s, along with the promise of June sunshine over the Sangre de Cristo mountain range in Telluride, that have me looking forward with great anticipation to meeting our 2014 Telluride Scholars when we gather this summer. For information on how to apply to attend one of the 2014 Telluride Patient Safety Summer Camps, you can go to our website at www.telluridesummercamp.com
Larry Smith, Vice President of Risk Management at MedStar Health, is a true pioneer – one of a small number of leaders in healthcare who have developed early communication and resolution programs when harm from medical error occurs. Programs like University of Michigan led by Rick Boothman and Susan Anderson, University of Illinois led by Tim McDonald and Nikki Centomani, and MedStar Health led by Larry Smith and Steve Evans have long moved from a “deny and defend” approach to medical errors to one of open and honest communication. These programs have been able to bring closure and healing to all parties involved while using the court system and the long, difficult battles that result where no really wins except maybe the attorneys as a last resort.
This week, Larry recruited not only his own team of insightful and skilled Risk Managers, but also plaintiff attorney, Paul Bekman, Esq., defense attorney, Michael Flynn, Esq., and the Honorable Howard Chasanow, former Maryland Supreme Court Justice and now a full-time mediator, to participate in MedStar Health’s Quality, Safety & Risk Management retreat. It may sound like an unlikely gathering of peers to many, but for Larry, the only way to move towards the “just culture” required of high reliability organizations is to continue to unite those whom often seem disunited.
As the panel of experts shared what really occurs in court rooms in the aftermath of a medical error, all attendees gained a deeper understanding of the complexities inherent to managing a healthcare system. At a time when patients and caregivers are caught up in the pain, uncertainty and fear related to what is often a life-changing event, the medical-legal piece can either remove, or compound, the emotional, physical and financial costs involved. One thing many of the attendees learned was that when a patient forfeits control, and ultimately a say in the final decision of such an intimate and painful event, to a jury of peers with what can be at times an attorney not well-versed or well-intended when it comes to medical-legal matters, additional problems can be created for all involved. Claims filed often cost health systems millions of dollars, and patients many times do not receive what they truly deserve when cases are handed over to the courts. Judge Chasanow was truly inspirational and shared that true healing for all can be found through skillful mediation led by those knowledgeable in the intricacies of medical harm events–especially when led by those who have the patient and family’s best interest as the top priority. He also shared the amazing healing power that can result from two words –”I’m sorry”. When offered in a sincere and meaningful manner, anger and tension seem to dissipate and true progress towards closure and healing through mediation can begin for all.
Moving forward, we have two options:
Or a second option. A few years ago, Transparent Health put together a short trailer for a longer piece of work that sums up another approach to managing medical errors and the harm that can come from them. When harm is managed openly, honestly and with transparency, healing can begin. Here is that short clip:
Healthcare remains at a crossroad. If we are to truly achieve a Culture of Safety and drive towards Zero Harm, we must embrace open and honest communication, practice just culture principles that balance systems and process breakdowns with reckless personal accountability, and follow the wise words of Carole Hemmelgarn who so eloquently said it should always be “Patient first, last and everything in between”.
The continued learnings that have come from the Asiana crash in San Francisco have reinforced one of the most important safety and quality issues affecting healthcare today–an existing culture that inhibits caregivers and support staff from holding each of us accountable and speaking up when we perceive a problem with patient care.
In a recent ETY post, Lessons Healthcare Can Learn From Asiana Flight 214, I shared the thoughts of Steve Harden as he applied the learnings from the Asiana crash to common weaknesses in patient safety. In a recent follow-up to his original piece, Harden reports on the interviews and investigations that have taken place since the crash last fall. He writes:
Though Captain Lee was an experienced pilot with the Korea-based airline, he was a trainee captain in the 777, with less than 45 hours in the jet. Captain Lee’s co-pilot on that fatal flight was an experienced instructor pilot who was responsible to mentor and monitor Captain Lee’s performance…(Lee) told investigators he had been “very concerned” about attempting a visual approach without the instrument landing aids, which were turned off. A visual approach involves lining the jet up for landing by looking through the windshield and using numerous other visual cues, rather than relying on a radio-based system called a glide-slope that guides aircraft to the runway.
…he did not speak up because other airplanes had been safely landing at San Francisco under the same conditions. As a result, he told investigators, “(he) could not say to his instructor pilot (that) he could not do the visual approach.”
What does this story have to do with healthcare? Harder emphatically shares that:
…after working with over 140 healthcare organizations, reviewing scores of root cause analyses, and conducting hundreds of real time observations in hospitals, clinics, ASCs, and labs – many of my experiences with healthcare staff sound just like Captain Lee’s interview. The culture in many of our healthcare organizations might as well have been created at Asiana.
This past weekend, I was an invited participant on the Culture of Safety Panel at the Patient Safety Summit held in Laguna Niguel, CA. The Summit was founded by Joe Kiani, the CEO of Masimo, and was keynoted by President Bill Clinton. It also included a number of thought leaders from across the country who came together with one common goal…Zero Preventable Hospital Deaths by 2020. During our panel, I posed the question, “If we as caregivers struggle to take collective professional accountability for safety concerns happening around us, who will? When we don’t stand up and share safety concerns about our patients with one another, we lose the most important element of any caregiver-patient relationship, which is trust.”
In his article, Harden asks the question, “How would (your healthcare teams) answer this question?
In 100 out of 100 cases where it is needed, am I absolutely sure that my most junior and inexperienced staff member, when they perceive a problem with patient care, can and will have a stop-the-line conversation with my most senior and experienced physician?
At the Patient Safety Summit this weekend, Dr. Mark Chassin the CEO of the Joint Commission, asked the audience almost the same question Harden posed:
How many in the audience can answer yes to the following question (paraphrasing): If one of your junior staff members saw a potentially unsafe condition, how many of you are confident the staff member would “stop the line” and report that potential unsafe condition?
About 2-3% of the audience raised their hands. Dr Chassin confirmed that when he has asked the same question at other meetings, the responses are consistently between 0-5%, with no raised hands being the most frequent observation.
Harden’s article and the panel discussions on accountability this past weekend at the Patient Safety Summit took me back to the words of Dr. Sidney Dekker, a Professor of Humanities at Griffith University in Brisbane, Australia. Dr. Dekker has a PhD in Cognitive Systems Engineering and is the author of Just Culture: Balancing Safety and Accountability:
Calls for accountability themselves are, in essence, about trust. Accountability is fundamental to human relationships…Being able to offer an account for our actions (or lack of action) is the basis for a decent, open, functioning society.
The vast majority of caregivers want to do the right thing but the long-standing incentives and pressures to “look the other way” are powerful. To achieve a true safety culture, leaders need to be held accountable to removing these barriers and celebrating caregivers who raise their hand when safety concerns arise. Collective accountability can restore honesty and trust in our healthcare work place, and is essential to any healthy patient-caregiver relationship.
The success of our Telluride Roundtables and Summer Camps over the last ten years can be credited, in large part, to the generous time and participation of our faculty made up of patient safety leaders from around the world. The students and residents chosen to participate through the Telluride Scholars Program have been the beneficiaries of the knowledge and experience these great leaders and teachers all are so willing to share each year. Rosemary Gibson, Rick Boothman, Cliff Hughes, Kim Oates, Peter Angood, Kevin Weiss, Bob Galbraith, David Longnecker, Helen Haskell…the list goes on and on.
In the summer of 2011, students had the great fortune of working with Lucian Leape, who joined the faculty of our Telluride Patient Safety Summer Camp. It was an honor to have him with us, and something our alumni–young and old–will always remember. Lucian’s focus that week was managing disruptive behavior and returning joy and meaning to the healthcare profession. The photo included captures him in action doing what he does best–educating the young. As we begin a new calendar year still struggling with many of the issues Lucian called to light in his 1999 seminal work, I believe his teachings on Joy and Meaning in the workplace are more important today than ever before, and that those strategies will play an even greater role in preventing harm to our patients.
Caregivers at the frontlines consistently put considerable energy into achieving the highest quality, safest care possible for their patients in the face of considerable economic pressure and evolving healthcare models. We expect so much from our caregivers, and they far too often extend themselves beyond what is healthy–physically, emotionally and mentally–to meet the growing demands of the new healthcare. Lucian’s work on joy and meaning in the workplace is based on Alcoa leader Paul O’Neill’s premise that every employee should be:
As healthcare leaders, we need to clear a safe path for all frontline associates to be respected, supported and appreciated. At the same time, we also need to eliminate the disruptive behaviors that have plagued healthcare for far too long. This year, a driving focus should be on ensuring those well intended healthcare professional are elevated, their humanness not only accepted but also protected through just culture approaches and human factor partnerships that mitigate and finally eliminate the potential for patient and employee harm while embracing a workplace built upon the high reliability foundations of a true learning culture.
As Lucian continues to remind us, it is our dedicated caregivers working at the bedside that need to feel safe — to know that their effort is appreciated and celebrated, that they have our support, and are respected for the work they do.
Applications are now being accepted for the 2014 Telluride Patient Safety Resident Physician Summer Camps in Telluride, CO and Washington, DC
Resident physician leaders are now invited to apply to attend a week-long, immersive learning experience with leaders and educators in patient safety, along with patient and healthcare advocates at the 10th Annual Telluride Patient Safety Educational Roundtable and Resident Physician Summer Camps. Residency programs will be responsible for covering travel, lodging, and meeting registration fees for their attendees. MedStar Health, COPIC and CIR have been generous supporters of past Telluride Resident Summer Camps, and have sponsored many resident physician alumni, who are now change agents at their home institutions. We are again grateful for their support and participation in our 10th year!
The Telluride, CO and Washington, DC Patient Safety Resident Summer Camps are one-week, educational opportunities offering an in-depth exploration of current patient safety issues and risk reduction strategies for achieving optimal patient care. Two, one-week resident summer camps will be offered in 2014:
- Monday, June 9th – Thursday June 13th, 2014 (to be held in Telluride, Colorado) — Arrive Sunday, June 8th for evening reception
- Thursday, July 31st – Sunday August 3rd, 2014 (to be held in Washington, DC) — Arrive Wednesday, July 30th for evening reception
Over the last nine years, interprofessional leaders in patient safety, communication, informatics, human factors, patient advocacy and education have met in beautiful Telluride, CO to address patient safety issues. Because of the growing interest and number of resident applications, a second patient safety summer camp was added in Washington, DC in 2013.
The Telluride Roundtable Vision is to create an annual retreat where experts in patient safety come together with patients, residents and students in an informal setting to explore, develop and refine a culture of patient safety, transparency and optimal outcomes in patient care. The 2014 Patient Safety Summer Camps will again use an immersive, interactive format to examine ethical, professional, legal and economic issues around patient safety, transparency, disclosure and open and honest communication skills when medical errors and adverse events occur.
Applications and additional information can be found on the Telluride Patient Safety Summer Camp website (www.telluridesummercamp.com). Residency Programs interested in funding a resident to attend one of the patient safety summer camps will need to submit the following resident materials by March 1st, 2014:
- Two-page maximum CV
- Personal statement on your interest in patient safety and how attending the Patient Safety Summer Camp would benefit you
- Support letter from faculty or a mentor about your leadership and engagement in patient safety
- First and second choice for the summer camp weeks (Telluride CO or Washington DC)
Questions regarding the Patient Safety Resident Summer Camps can be directed to David Mayer, MD at: email@example.com