12 Years and 1400 Patient Safety Leaders Later…

Sunlight_over_mtnsTwelve years…that is how long it has been since we first traveled to Telluride, CO to kick-off our inaugural Patient Safety Educational Roundtable and Summer Camp. As we headed west again this weekend to meet with the 36 graduate resident physicians and future health care leaders who were selected from a large group of applicants, it is hard not to think back about all that has happened in those twelve years and the many who have contributed to make it happen.

Twelve years ago, those who came to Telluride believing in our Educate the Young mission consisted of patient safety leaders Tim McDonald, Anne Gunderson, Kelly Smith, Deb Klamen, Julie Johnson, Paul Barash, Gwen Sherwood, Bob Galbraith, Ingrid Philibert, and Shelly Dierking to name just a few. However, the smartest thing we ever did was invite patient advocates to the Patient Safety Educational Roundtable. People like Helen Haskell, Carole Hemmelgarn, Patty and David Skolnik, and Rosemary Gibson were active partners in our work from that first year and made our discussions more productive and our outcomes better.

Over the years, many new faculty joined us in our Educate the Young journey. Some of these additional patient safety faculty included Lucian Leape, Richard Corder, John Nance, Paul Levy, David Classen, Kathy Pischke-Winn, Joan Lowery, Roger Leonard, and Tracy Granzyk. We were also fortunate to have international safety leaders join our faculty, including Kim Oates and Cliff Hughes from Australia, who became regular attendees and popular “mentors” to the future healthcare leaders even though they had to travel almost 10,000 miles to join us each year.

Through all these years, two things remained constant – our commitment to Educating the Young and our partnership with patients. Helen, Carole, Patty, David, and Rosemary continue to be active participants each year but additional patient advocates have joined us including national advocacy leaders Dan Ford and Lisa Freeman.

Through the vision and support of Carolyn Clancy and the AHRQ, what began as a small educational immersion for twenty health science students has now exploded. We continue to grow because of the generous support of The Doctor’s Company Foundation (who provides full scholarships to close to 100 medical and nursing students each year), the Committee of Interns and Residents, COPIC and MedStar Health. This year, over 700 residents, medical students and nursing students will go though one of the Telluride Experience Patient Safety Summer Camps. Out Telluride Scholars Alumni network continues to grow – our future health care leaders staying connected through the years, sharing quality and safety project successes and learning from each other.  And, for the first time, the Telluride Experience went International this past spring as we ran patient safety camps in Doha, Qatar and Sydney, Australia.

Thanks go out to the many passionate and committed faculty and others who have given so much to make our Educate the Young journey so very special. It has been an amazing twelve-year run…


Student Reflections from the Telluride Experience: Sydney

TESydney_GroupShotTaking the Telluride Experience global continues to equally educate our faculty on what both the delivery and culture of healthcare around the world is really like. While many cultural differences exist, it is the similarities in our human experience throughout that connects us all. The local challenges may create the obstacles, but returning to the patient, no matter the locale, grounds every care provider in “how to proceed”. Reflections from yet another impressive group of Academy for Emerging Leaders in Patient Safety alumni follow:

I work in emergency medicine. A buffer for the undifferentiated, where time-poor workers battle a “controlled” chaos. It’s also where patients come. Patients who have a stubbed toe, sprained ankle, a cough or a heart attack. By practicing the virtues of patient-centred care we can appreciate that these aren’t patients who have presented to be an inconvenience, but have come because there was nowhere else to go. Ask why. Why did they present. There are many reasons why they present including health literacy and healthcare infrastructure. The truth distills down to the fact that, in their mind, we are their only hope.

Viet Tran, Emergency Medicine, Registrar

It was very important today to see face to face the huge impact that medical errors can have in a person/family’s life; it has certainly touched me and I wish that every health professional I work with got to experience and see the testimonies I have been able to experience today. Seeing a mother with two children who suffer from chronic illness and how their lives have been shaped by this, and how a mother who lost a child in a way that could have been prevented has the courage and strength to re-live this painful experience in order to teach and change in some way how we practice and how we deliver care. This for me was the highlight of the day. Anyone can make mistakes, it can happen to any of us, but we never think that in reality we are going to be in that position. I have been touched by Susan’s and Carol’s talks, they have been just life changing.

Lina Belalcazar, Medical Student

We talk and even joke about aha moments but the past is marked by many such moments that go on to spark movements and eventually change the face of history. In years to come we will look back on the negligent attitudes towards patient safety the same way we look back on segregation and gender inequality, in disbelief. Doctors of the future simply wont believe that patient safety was not always highly valued, well taught and at the forefront of everybody’s mind during each patient encounter.

I am so pleased to have met the leaders in this field and feel privileged to be one of the first followers. Now let’s not stop till everyone is dancing with us.

Anna Elias, Medical Student

I will continue to strive for excellence in patient safety and I will utilise whatever means on hand to achieve our primary goal. A safe and highly satisfactory patient journey. We cannot perform without our patients and they should be central to what we do. This I feel we as a cohort of professions fail to achieve. I am a professional. I am an expert. These excuses create barriers which have become ingrained in our culture. I hope that as evidenced by this conference with the Australians bucking the trend we can continue to do so and continue to strive towards excellence and truly take place as advocates and global leaders in healthcare.

Ben Gross, Nursing

Today another lived experience was shared. It was that of a widowed husband, this time from the UK, who shared the experience of his wife, undergoing what was a routine surgery but ended up not making it to surgery and having a fatal consequence as a net result of an adverse event and subsequent accrual of system failures, particularly those of a human factor nature. This brings to the light the many human factors that we continually witness in practice, which may be harmful especially when aligned in particular contexts, notably in situations that are unfamiliar or deviate from the norm. One of the things I particularly reflected on is how we as humans are fallible to task focus and makes us become situationally unaware. It is something we need to keep in mind when retrospectively analysing incidents. Even I have to admit that I have been unaware on occasion. It is important to be conscious that we can become like that. This emphasises the importance of teamwork, communication and dynamics, which are able to overcome authority gradients and their pertinence to allow goals to be met.

Kym Huynh, Pharmacy


#AELPS16: The Sydney Experience Kicks Off April 20th in Australia

Academy Emerging Leaders Logo color

Kim_Oates

Kim Oates

After a very successful Academy for Emerging Leaders in Patient Safety: The Doha Experience (#AELPS16) workshop in Qatar last month, our faculty will now head to Sydney, Australia mid-April to continue sharing our Telluride Patient Safety Summer Camp curriculum with future healthcare leaders from around the world. Through the years, many Australian patient safety leaders, such as Cliff Hughes, Peter Kennedy and Kim Oates, have been regular attendees and teachers at our patient safety workshops in Telluride CO, Washington DC and Napa CA. The Clinical Excellence Commission (CEC) in New South Wales has also supported a number of young Australian physicians to attend our US patient safety immersive workshops. These young physicians have then gone on to assume quality and safety leadership roles at their institutions upon returning home.

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Carrie Mar

Kim Oates, emeritus professor and Director, Undergraduate Quality and Safety Education at the University of Sydney and Carrie Marr, Chief Executive, at the CEC are the visionary leaders bringing the Academy for Emerging Leaders in Patient Safety: The Sydney Experience program to Australia. The Sydney Experience team includes fellow CEC and Australian healthcare leaders such as Telluride Alum Sarah Dalton MD, and first time attendees, May Wong and Teresa Mastroserio. Thanks to the generous support of the Avant Mutual Group, the major medical defense group in Australia, the Division of Midwifery and Nursing, New South Wales Health, and the CEC, over thirty young medical and nursing leaders will be able to attend #AELPS16: The Sydney Experience, an immersive, four-day patient safety education program. The program has also received significant support from Minister Jillian Skinner, New South Wales Minister for Health, who will attend the last day of The Sydney Experience, and will address both learners and faculty.

We are both honored and energized by the opportunity to distribute our patient safety education curriculum to those at home and around the world who have similar passion of finding new and better ways to deliver the highest quality, safest care to patients. In just two months time, we will welcome Qatari and Australian healthcare professionals into our now global Telluride Experience Alumni network. In 2016 alone, over 700 future healthcare leaders will attend one of many Telluride Experience Patient Safety Summer Camps around the world and become part of this growing network of dedicated and caring patient safety leaders.


Systems Approach and Just Culture Resonate at Doha Telluride Experience

TE_DOHA_SethOn day three of our Academy for Emerging Leaders in Patient Safety…the Doha Experience, Dr. Seth Krevat, AVP for Patient Safety at MedStar Health, led discussions on the importance of in-depth Event Reviews, Care for the Caregiver, and Fair and Just Culture approaches to preventable harm events. Seth shared the event review process used at MedStar Health which was designed by experts in patient safety, human factors engineering and non-healthcare industry resilience leaders. This event review process has been adopted by AHRQ and AHA/HRET, and has been incorporated into the upcoming CandOR Toolkit being released shortly to US hospitals.

The young learners engaged in deep discussions around Fair and Just Culture – the balance between safety science and personal accountability. This topic followed interactive learning the previous day on human factors and system/process breakdowns. Similar to challenges we have in the US, the culture in the Middle East blames the individual first without a thorough understanding of all the causal factors leading up to an unanticipated event. After Seth showed the video, Annie’s Story: How A Systems Approach Can Change Safety Culture, and shared other case examples demonstrating how a good event review can disclose system breakdowns versus individual culpability, the young leaders gained a new appreciation of effective error reduction strategies. In the short clip that follows one of our young leaders, so empowered by the short three days with us, explains how she used what she learned to try to change her parents point of view on patient harm:

The passion and commitment of these future leaders to patient safety was inspiring for our US faculty, as well as for the leaders from the numerous Qatar healthcare institutions that participated in our sessions. I have no doubt this next generation of caregivers will be the change agents needed to achieve zero preventable harm across the world. We have seen many examples of their work already.

It was exciting to be in Qatar working collaboratively with others who are committed to “Educating the Young” as a powerful vehicle for change. Next stop for the Academy for Emerging Leaders in Patient SafetyThe Sydney Australia Experience!


Telluride Alum Rebal Turjoman Brings #AELPS16 to Doha, Qatar for Peers

Eggbert_DayOne_StudentsAfter a very engaging faculty development program for healthcare leaders from Qatar, we kicked off our Academy for Emerging Leaders in Patient Safety “Doha Experience” patient safety camp for future interprofessional healthcare leaders today. The collaboration is being sponsored by WISH – the World Innovation Healthcare Summit and the Qatar Foundation for Education, Science and Community Development.
Egbert Schillings, CEO of WISH, remarked: “WISH has a long-standing commitment to patient safety across a number of our programs. This training academy for students and faculty from all the health science colleges of Qatar takes our efforts to a whole new level. Her Highness Sheikha Moza bint Nasser founded WISH to help improve health through global collaboration. There is no better example of this vision in action than by bringing together the best expertise the world has to offer, for the benefit of young leaders and the patients they will take care of right here in Qatar.”

Rebal_DayOne_StudentsRebal Turjoman, a third-year Qatar medical student and former Telluride Patient Safety Summer Camp participant, worked closely with organizers from the US and Qatar to bring the Academy for Emerging Leaders in Patient Safety curriculum to the Middle East. On the last day of our four-day sessions, every Telluride Patient Safety Summer Camp participant is required to make a public commitment to become a change agent for safety, and to identify and lead a specific program that will impact patient safety back at their home institutions. Rebal felt so empowered after his week-long immersion in patient safety, he decided to make his commitment a challenging one. “I was quite eager to help bring the Academy to Qatar, as the curriculum is unprecedented for students here,” he said. He shared his vision, knocked down obstacles, built coalitions and made it happen. Because of Rebal, over 70 young healthcare leaders from Qatar are experiencing the same curriculum that empowered Rebal to become a true leader and change agent.

After just one day of shared learnings with faculty and students from the region, it became very clear to all of us that our Academy for Emerging Leaders in Patient Safety curriculum resonates deeply and brings great value to others facing similar challenges across the world. We are excited to be in Qatar and working with fellow healthcare leaders who are also committed to “Educating the Young” as a powerful vehicle for change.

For more information, the Qatar Tribune covered the event: WISH to hold global academy for emerging leaders in patient safety  

 


Telluride Experience Goes International: Next Stop Doha, Qatar

Today marks the first time our Academy for Emerging Leaders in Patient Safety (#AELPS16) goes global with our “Telluride Experience” Patient Safety Summer Camp TE_Qatar_Faculty_2016curriculum kicking off in Doha, Qatar from March 23rd – 26th. A number of our faculty traveled from Washington, DC, Chicago and Denver to Doha yesterday to collaborate with health science leaders from Qatar in bringing our four-day Telluride Experience curriculum to many of the country’s current and future healthcare leaders.
In addition to our four-day safety camp, we will also be leading a faculty development program so healthcare leaders from Qatar can continue offering their own “Doha Experience” patient safety curriculum to future healthcare leaders on an annual basis. The collaboration is being sponsored by WISH – the World Innovation Healthcare Summit and the Qatar Foundation for Education, Science and Community Development.

TE_Qatar_BrochureThe Telluride Experience team is very excited about being in Qatar, and are looking forward to the growing number of international collaborations ahead of us, with those who also believe ensuring the highest quality, lowest risk healthcare to the communities we serve requires Educating the Young – our future healthcare leaders.


The Telluride Experience Goes International in 2016

AELPS_Logo_SmallerOver the past twelve years, our Telluride Patient Safety Summer Camps (now known as The Academy for Emerging Leaders in Patient Safety) have continued to grow and prosper through the annual support of The Doctors Company Foundation (TDCF), MedStar Health, the Committee of Interns and Residents (CIR) and COPIC. That continued support also includes our outstanding faculty who generously volunteer their own time each summer because they believe in our “Educate the Young” mission.
The value of our Resident Physician and Health Science Student Patient Safety Summer Camps continues to spread–not only nationally but also across the globe. It is in this international spirit that we are excited to announce two international Telluride Experience Patient Safety Summer Camps for young learners this coming year. The first will be held in Doha, Qatar on March 23rd – 26th and the second will be held in Sydney, Australia on April 23rd – 26th.

Screen Shot 2016-02-28 at 8.28.03 PMOur Doha, Qatar Telluride Experience will be generously sponsored by WISH – the World Innovation Healthcare Summit and the Qatar Foundation for Education, Science and Community Development and Weill Cornell Medical College – Qatar. WISH is a global healthcare community dedicated to capturing and disseminating the best evidence-based ideas and practices. Their vision is “A healthier world through global collaboration”. Some of our Telluride Experience faculty will be traveling to Doha later this month to lead both young learner as well as faculty development sessions with the goal of having educators in Qatar continue and expand the Telluride Patient Safety Summer Camp curriculum within the Middle East.

All of us at AELPS are grateful for the growing number of international partners and the collaborations that result from those partnerships. The Telluride Experience model is now being adopted around the world by healthcare leaders who also believe ensuring the highest quality lowest risk health care requires “Educating the Young” – those who will be our future healthcare leaders.


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