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: firstname.lastname@example.org
Medical and Nursing Student scholarship applications are now being taken for the 2014 Patient Safety Summer Camps
Through the generous support of The Doctor’s Company Foundation and MedStar Health, scholarships are now available for 40 medical and 20 nursing student leaders to engage in an immersive experience with leaders, educators, and advocates in patient safety at the 10th Annual Telluride, CO and Washington, DC Patient Safety Educational Roundtable and Health Science Student Summer Camps. The student scholarships cover travel, lodging, meeting registration fees and many meals during the week.
Each of the Patient Safety Student Summer Camps are one-week, and offer an in-depth exploration of current patient safety issues and risk reduction strategies to achieve optimal patient care. Two, week-long student summer camps will be offered in 2014. Dates are:
- Sunday June 15th – Wednesday June 18th, 2014 (to be held in Telluride, Colorado)
- Tuesday July 29th – Friday August 1st, 2014 (to be held in Washington, DC)
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 student 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). Students interested in applying will need to submit the following materials by February 14th, 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 Summer Camps can be directed to:
- Medical Students: David Mayer, MD at: email@example.com
- Nursing Students: Gwen Sherwood, PhD, RN, FAAN at: firstname.lastname@example.org
I have always been amazed by the apparent marketing brilliance of bottled water companies. If someone would have told me years ago I, and many others, would spend three dollars for a bottle of water – something we can all get free from our water faucets – I would have laughed and said they were crazy. Shows you what I know…
That same marketing brilliance came to mind last week while reading an article on the Harvard Business Review (HBR) Blog Network, Fix the Handful of US Hospitals Responsible for Out-of-Control Costs, regarding CMS payments to hospitals for in-patient procedures. Using Medicare Provider Analysis and Review (MEDPAR) data published last spring by CMS, the authors applied a six sigma approach to identify hospitals that were three standard deviations from the average fee paid to hospitals for the most frequently performed 100 in-patient procedures. Their findings forced me to stop and make sure I was reading their conclusions correctly. Their findings:
- Payments to hospitals whose accepted charges were above the national average for those 100 procedures added $5.3 billion dollars in excess cost to CMS.
- Two of the top 100 procedures accounted for more than 10% of the total costs – major joint replacement (6.1%) and septicemia (4.6%). Major joint replacement payments varied between $9,000 – $39,000 per procedure and septicemia payments varied between $7,500 – $44,000 per treatment between hospitals.
- Less than 1% of the over 3,200 hospitals included in the data (32 hospitals) accounted for about 25% of that excess cost – over $1.25 billion dollars. By Six Sigma definition, what they were being paid was three standard deviations from the norm.
How are they doing it, and perhaps a better question is, how are they justifying the difference? I understand and appreciate the issue always raised when data like these become public…”Our patients are sicker than everyone else’s patients” but 5-7 times sicker?
After reading the HBR post, I couldn’t help but stop and think that these 32 hospitals appear to make the bottled water marketing teams look like amateurs.
The Doctors Company (TDC) and their Foundation (TDCF) have been committed to medical education for many years. They have been the major supporter of our annual Telluride Patient Safety Summer Camps for medical and nursing students the past four years, providing full scholarships to sixty medical and nursing students last year so they could attend this week-long immersion in safety, quality and transparency.
I have been honored the past two years to be invited to attend TDC Annual Advisory Board Retreat. The retreats have become a favorite meeting of mine, as well as one of the best educational meetings I have attended. One of the presentations I enjoy hearing most is given by Dr. Richard Anderson, the CEO of TDC, who opens the meeting with an update and discussion on the current medical malpractice environment. Dr. Anderson shares claims data along with insightful narrative so that a “novice” to the medical malpractice industry like I am can understand and appreciate the challenges healthcare really faces today.
A couple of numbers he shared this year really hit me:
- The average cost of a claim at TDC is $97,000
- 82% of all claims filed do not result in any payment to the patient and/or family
A couple of things came to mind as I reflected on those two facts. First, where is all that money going? If the $97,000 isn’t going to patients or families, who was it going to? Who was getting all that money? The second thing was the pioneering work done by Rick Boothman, Susan Anderson, Skip Campbell and others at the University of Michigan highlighted in the article entitled Liability Claims and Costs Before and After Implementation of a Medical Error Disclosure Program. After full implementation of a disclosure-with-offer program at the University of Michigan, Boothman and colleagues observed:
- Decreases in the monthly rate of new claims from 7.03 per 100 000 patient encounters to 4.52
- Declines from 232 lawsuits (38.7 per year) to 106 (17.0 per year)
- Declines in median time to claim resolution from 1.36 years to 0.95 year
They also appreciated decreases in monthly costs associated with total liability, patient compensation, and non–compensation-related legal costs. Through an open, honest, timely and effective communication approach to unanticipated outcomes, they were able to successfully start addressing the excessive costs Dr. Anderson referred to associated with liability claims.
Maybe there is a better approach to the “deny and defend” model we have seen used through the years.
One additional figure Dr. Anderson shared also hit me hard this year. The number of claims filed asking for compensation above $10,000,000 has tripled over the last year, with the total claim pool going from $400,000,000 to $1,200,000,000 in total costs in just twelve months. Even gas prices haven’t risen that fast. Has the severity of patient harm suddenly tripled over the past year or are there other factors contributing to this sudden escalation?
If interested, The Doctor’s Company website contains numerous healthcare, patient safety and risk reduction resources. Click here for more information.