I want to begin by saying THANK YOU for sending me to Telluride to learn from some of the nation’s pioneer leaders in patient safety and quality improvement. I have been so moved that I want this to be my “niche” in medicine as I continue on to become a pediatric hospitalist. I am hoping at some point to sit down with all of you to discuss the processes CMH has in place to reduce error and at the same time acknowledge human factors. I have not yet made it to error prevention training due to scheduling conflicts, but I am excited CMH is taking this step towards becoming a high reliability organization. Nick Clark (a previous Telluride Patient Safety Summer Camp alum) has done a great job of incorporating patient safety moments into many of the meetings he has led, and I hope to carry this forward in some way.
We watched a variety of videos and heard multiple stories of near-misses and unfortunately, preventable patient morbidity and death. Carol, one of the representatives from the patient perspective, shared the powerful story of the loss of her daughter who had been diagnosed with leukemia 9 days before she died from a hospital acquired (and too late recognized) C. diff. infection. A C. diff. infection! This year has been particularly hard for Carol and her family as her daughter would have gone to senior prom this previous April and then graduated from high school in May.
In order not to make this email too long, I want to just make 2 more points and then, hopefully, I can discuss my thoughts with all of you in person at some point.
1) John Nance, writer of “Why Hospitals Should Fly,” said during his talk: “You have been trained to be the center of your own universe.” I do feel as if I was trained in medical school to practice “independently.” On rounds as students and many times as residents, we are expected to diagnose a patient (even if we are completely wrong), come up with a firm plan…and then present it confidently. Our goal is for everyone around us to nod their heads in agreement with the plan we have made. We hope no additional input is needed. However, this erases the team-based approach to medicine we MUST have in place in order to create the most safe environment for our patients. Our plans may be acceptable plans, but others’ ideas should be elicited EVERY time and considered EVERY time, so that we can ensure we have considered all options.
2) I want to begin my own QI project, but I’ll need a mentor. I just don’t know yet what I want to focus on. Sometimes it’s better when I write or talk about my interests or concerns, and then a person outside of my head points out the obvious to me. I appreciate all thoughts any of you have to offer.
Joy Solano, MD PGY-1
For the last six years, health science students and resident physicians have inspired our Academy for Emerging Leaders in Patient Safety faculty as much as they report we have inspired them to become patient safety leaders within their medical centers. Each year, our faculty receive numerous emails sharing the safety projects they have been leading to make care safer for their patients. We hear about how the Telluride Experience has re-focused their purpose within medicine, sometimes even keeping them engaged at a pivotal point in their own careers when the burden of the current culture of medicine seems too much to bear. Bringing close to two hundred passionate and committed learners and future healthcare leaders to Colorado, Maryland and California each summer to work with our faculty from around the world is what keeps me excited and wanting to come back each year.
This post was inspired by the following reflection, Email I sent to my program leaders, posted on our Telluride Blog by Joy Solano, MD-PGY1. Thank you Joy! And thanks to all our Telluride Patient Safety Summer Camp Alumni (close to 500 strong now) for working to make healthcare safer for our patients, families and our caregivers.
Email I sent to my program leaders. Published June 19, 2015 |
As we reflect on our continued commitment to eliminating preventable medical harm, it is important to never forget the lost loved ones that help keep us focused on our important mission. On this Father’s Day, as a proud parent and even prouder grandparent, I can’t help but reflect back this morning to last year’s Telluride Patient Safety Summer Camp and the personal story Caitlin Farrell shared with all of us on Father’s Day last year. Her story is also featured this weekend on http://runningahospital.blogspot.com/ It is one story I will never forget…
Published June 16, 2014 | By CFarrell
Yesterday was Father’s Day, 2014. I woke up before everyone else in my room. Rolling out of bed, I padded down the stairs and brewed a cup of much-needed coffee. Pouring my face over the steaming cup, I looked out my window to the inspiring landscape of endless white-capped mountains. This year marks the ninth Father’s Day that I have spent without my dad, but the mountains and my purpose this week made me feel as though he were standing there with me, sharing our cup of morning coffee, just as we used to.
After taking the gondola ride into Telluride, the students and faculty plunged into our work of expanding our knowledge in the field of patient safety. We watched a documentary outlining the tragic case of Lewis Blackman, a 15-year-old boy who died due to medication error, miscommunication, and assumptions made by his medical team. The film explored the errors in Lewis’s care that have become far too common in our medical system: the lack of communication between providers and families, the establishment of “tribes” within medicine who do not collaborate or communicate with one another, the lack of mindfulness of the providers, and the culture in which all of these errors were permitted to happen.
But what resonated with me the most were the feelings described by Lewis’s mother. She defined her experience as one of isolation and desperation. “We were like an island”, she said. There was no one there to listen to her concerns. Ironically, Lewis died as a result of being in the hospital, the one place where he could not get the medical care that he so desperately needed.
A pain hit my stomach as she said these words. My family also shared the feelings of isolation, uncertainty, and loss throughout my father’s stay in the hospital. After Lewis’s death, his mother was not contacted. Instead, she was sent materials about grieving and loss in the mail. After an egregious error occurred during my father’s medical care, a physician did not give us an apology, but a white rose by a nurse.
An interesting discussion arose after the film. Our faculty emphasized the need for physicians to partner with the families of the patients. This will create not only a team during the course of treatment, but will cultivate compassion, empathy, and trust in the case of a terrible event. I know that despite the growing number of “apology laws” that protect, and even mandate, physicians to apologize to families after catastrophic events, few physicians actually do apologize. This results in families feeling like the events were there fault. I can say from experience that this is a burden that you can carry with you for years to come.
As I got back to my room and put down my books, this conversation mulled in my mind. The death of my father has given me the fuel to pursue medicine and patient safety as my career. It has instilled in me passion, energy, and determination. Yet the one thing that I have not found in the nine years since my father’s death is forgiveness. Although I do not hold any one doctor or nurse responsible for the detrimental outcome in my father’s care, I have not been able to forgive the team for what happened. I have not been able to go back to that hospital. And as I sat on my beautiful bed in the mountains, I realized that I also harbored another feeling: fear. Fear of becoming a physician who does not practice mindfulness, who does not partner with my patients, who does not apologize for my mistakes. I am afraid that despite my best intentions, I will only continue the vicious cycle. A fear that I will allow my patients to feel as though they are “on an island”.
I put away my computer and got into bed. Lying awake, I took in the gravity of the day. I am so grateful to be here at Telluride among students and faculty who share my passion in patient safety. I could not have imagined a more perfect way to spend Father’s Day.
This coming weekend, many wonderful and highly committed patient safety advocates and safety leaders will once again convene in Telluride, CO to continue our mission of Educating the Young. For those not from CO, summertime in Telluride may be one of the best kept secrets in the United States. Be it the old west feel of the town, or the hypoxic magic that happens at an elevation of 9,600 feet, Telluride has always been a learning mecca for everyone that joins us during these memorable weeks of high altitude education at the Academy for Emerging Leaders in Patient Safety: The Telluride Experience.
Over the course of eleven years, 450 students and resident physician scholars have attended one of our Telluride Experience Sessions, formerly known as the Telluride Patient Safety Summer Camps. Many of our alumni have gone on to lead work that has inspired real change at their home institutions–change that is helping make care safer and more transparent. We look forward to meeting yet another class of emerging patient safety leaders that will continue to stand up for patients and a culture of safety we all can feel safe working, or receiving care, within.
Through the generous support of The Doctors Company Foundation (TDCF), Committee of Interns and Residents (CIR), COPIC and MedStar Health, about 180 health science students and resident physician leaders will be attending one of five, week-long Patient Safety Summer Camps this summer. The first two patient summer camps will be starting next week in Telluride, two more patient safety summer camps will be held in the Washington DC/Baltimore, MD region (aka Telluride East) in July, and a final week will be held in Napa CA – our new home for Telluride West–thanks yet again to the continued support of The Doctors Company Foundation.
The smaller, roundtable format utilized at the Telluride Sessions, takes advantage of small group breakouts and learner-centered activities designed to foster creative thought and consensus building through lively conversations in a relaxed and informal setting. This non-traditional learning environment also attracts patient safety leaders from around the world to Telluride each summer, to break bread and share ideas on current issues and challenges while helping train the next generation of Patient Safety leaders. Because of this unique venue and format, much of our discovery and learning happens on the walking paths, hiking on the mountain trails, in a coffee shop, or over a glass of wine.
Next week, we kick off this year’s Patient Safety Summer Camps by welcoming 36 health science students and thirty resident physicians to Colorado. These young scholars and future healthcare leaders were selected from medical schools, nursing schools and residency programs from across the country, and will be immersed in learning about transparency, patient safety, and patient/caregiver partnership. It truly is an amazing experience that always leaves faculty energized for months to follow.
We hope you will follow our activities and learnings through our student, resident and faculty blogs, found here on ETY, at The Telluride Blog, found here or fellow faculty member, Paul Levy’s blog Not Running A Hospital. Please comment and join our conversation on the blogs or on Twitter (@TPSSC and #AELPS11).
As healthcare providers, we are given a privilege to care for others, and must always remember that we treat complex individuals, making choices that affect their lives, families and personal well-being. At the same time, our patients must recognize that care providers are people too– always trying to do the best they can while juggling numerous responsibilities on a daily basis and working in a system that still has too many flaws. The clinician-patient relationship is most effective when both sides meet in the middle–a “safe space” where each is able to truly see one another and achieve the mutual understanding needed to succeed as a care team.
High Reliability science is one area we are looking to for answers to systems failures in healthcare. High reliability organizations stress the importance of “Stopping the Line” when a worker senses something doesn’t feel right. The concept has been shown to help reduce harm in many high risk environments. What if something similar existed for communication concerns in the healthcare environment?
The following short video, entitled Please See Me, created by patients and caregivers for patients and caregivers, offers a possible solution. Can “Please See Me” become that safe space, where patients and family members can stop the line and share those words if they feel their needs are not being heard or addressed? At the same time, can caregivers use the same phrase when they feel they are not being understood by patients and family members?
Many of us believe the phrase “Please See Me” can be the start of something special, creating that safe space and providing a phrase that helps improve communication and understanding in every healthcare environment leading to better outcomes.
Patients and Care Teams
Working as Partners
In the Spirit of Healing and Compassion
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.