“If transparency were a medication, it would be a blockbuster, with billions of dollars in sales and accolades the world over. While it is crucial to be mindful of the obstacles to transparency and the tensions—and the fact that many stakeholders benefit from our current largely nontransparent system—our review convinces us that a health care system that embraces transparency across the four domains will be one that produces safer care, better outcomes, and more trust among all of the involved parties. Notwithstanding the potential rewards, making this happen will depend on powerful, courageous leadership and an underlying culture of safety.”
The previous paragraph comes from the fifth and final National Patient Safety Foundation’s Lucian Leape Institute (LLI) White Paper entitled, “Shining a Light: Safer Health Care through Transparency”. Each of the five white papers address key issues that healthcare stakeholders will need to successfully manage if healthcare is to achieve zero preventable harm. I was honored to be part of the panel that helped create this paper and the 39 recommendations for greater transparency throughout healthcare.
Defining transparency as “the free, uninhibited flow of information that is open to the scrutiny of others”, the paper provides recommendations in four different domains of transparency:
- Transparency between clinicians and patients (illustrated by disclosure after medical errors)
- Transparency among clinicians themselves (illustrated by peer review and other mechanisms to share information within health care delivery organizations)
- Transparency of health care organizations with one another (illustrated by regional or national collaboratives)
- Transparency of both clinicians and organizations with the public (illustrated by public reporting of quality and safety data)
I encourage everyone to visit the LLI website and download the White Paper (click here for a copy). Increased transparency is critical to any Patient Safety mission. Greater transparency throughout the system is not only ethically correct, but will lead to improved outcomes, fewer errors, more satisfied patients, and lower costs.
Those where the words shared by former President Bill Clinton as he helped kick-off the 2015 Patient Safety, Science and Technology Summit this past weekend (http://patientsafetymovement.org/). The former president has been a keynote speaker at all three annual Summits and sees the Patient Safety Movement’s mission similar to the Clinton Foundation Global Initiatives Program (GIP).
Working with former President Clinton, Joe Kiani adopted a similar “commitment” model used by Clinton’s collaborative GIP in selecting preventable medical harm and setting a goal of Zero Preventable Deaths by 2020 (0X2020). There has been a lot of great work by many patient safety advocates since the release of the IOM report on preventable medical harm fifteen years ago. The Patient Safety Movement is another example of people wanting to make a difference and help reduce risk in healthcare. We hear “it takes a village” and Joe Kiani continues to bring more people wanting to make a difference into the “safety village”.
This year, Joe worked his magic and was also able to bring Vice President Joe Biden into the safety village. The Vice President was wonderful – he spoke passionately and eloquently about the safety crisis. He admitted that two years ago when he agreed to meet with Joe, he knew little about the preventable medical error crisis but quickly changed his 30 minute meeting with Joe into a two-hour tutorial on the issue. Like many others, he has become an engaged partner and re-arranged his very busy schedule so he could attend, address the crowd and hear about the great work going on by many.
In a short time, the Patient Safety Movement has brought high-ranking “partners” into the safety village, added tremendous value to the mission, and brought significant attention to the great work done by many others over the past fifteen years.
As former President Clinton said, we need to embrace more “people who are dying to be asked to make a difference”. It does take a village…and we need to continue to grow our safety village.
Leadership is not so much about technique and methods as it is about opening the heart…about inspiration–of oneself and of others. Great leadership is about human experiences, not processes…it is not a formula or a program, it is a human activity that comes from the heart and considers the hearts of others. It is an attitude, not a routine.
Secretan’s teachings are based on the core principle of connecting the soul with what we consider as “work”– the two becoming intertwined in a way that redefines our “work-life” balance, making both truly fulfilling. It combines our inner passion to make a difference in someone’s life with our reason to get up each morning and go to “work”.
Each day in healthcare we are given the opportunity to make the world a better place—for our patients, our colleagues and our communities. As healthcare providers, we entered into our profession to care for others–to keep our patients safe at all costs while under our care. Think of the healing power that could occur not only in our healthcare workforce, but also in our patients, if leaders created care environments that were truly places that nurtured the soul.
Rosemary Gibson said it best when she paraphrased Gandhi, reminding us: “A patient is the most important visitor on our premises. They are not dependent on us – we are dependent on them. They are not an interruption in our work – they are the purpose of it. We are not doing our patients a favor by serving them, they are doing us a favor by allowing us to serve them.”
Can healthcare leaders create a work environment that reflects and honors the creative spaces of the soul and brings passion back into our daily work? Can healthcare leaders inspire caregivers to connect with their own inner values in helping health systems achieve the highest quality, safest care possible for both patients and caregivers?
As we move into the New Year, I am hopeful we can all “lead from the heart” in ways that inspire ourselves and others to achieve the highest quality, safest care possible for our patients and our caregivers.
Wishing everyone a healthy and happy new year.
“Calling all resident physicians in the Washington DC/Baltimore area!”
The MedStar Health and University of Maryland Resident Physician Quality Improvement & Patient Safety Council, or QIPS Council, is hosting its second “Evening of Wine & Wisdom” educational speaker series and networking event. The event will take place on January 14th, from 5:30-8:30pm at Westminster Hall on the University of Maryland campus. You can register for this free event at www.QIPScouncil.org, and take part in engaging discussion after listening to presentations on “Inspiring and Empowering Change thru the Face of Medical Harm,” given by leading national patient and healthcare advocates.
Building on the great success of our first QIPS “Wine and Wisdom” event held in DC that featured Paul Levy, author and leadership coach, our second event will include talks by speakers Helen Haskell and Rosemary Gibson. Helen is President of Mothers Against Medical Error, and Rosemary is an author, Senior Advisor at the Hastings Center and an ACGME Board Member. Both healthcare leaders have been working to educate the young (and old) on what it means to deliver care that is safe and patient-centered for the better part of their careers.
We hope you will join us for a great evening of Wine and Wisdom.
Not sure how late summer and fall flew by so fast, but it is already November, and we are now taking applications for our 2015 Telluride Summer Camp sessions!
Step up and become one of our Telluride Patient Safety Champion Alumni–over 500 strong– by applying to spend one of FIVE weeks immersed in learning and discussions on how to become a patient safety leader. This coming summer, there will be three locations for medical students and advanced practice nurses, and two locations for resident physicians.
Because of the tremendous success we have seen through the years, and as a result of our continued growth both nationally and internationally, the Telluride Patient Safety Summer Camps will take on a new look and name beginning in 2015, but the spirit in which the patient safety intensive workshops will operate will not change. The newly anointed (chosen by our Telluride Alumni Scholars) “Academy for Emerging Leaders in Patient Safety: The Telluride Experience,” will continue to gather patient safety leaders from around the world, along with patient advocates and industry leaders to discuss issues related to the open, honest communication and patient-centered healthcare, both critically needed to produce the highest quality. safest care possible.
Once again, we will be taking applications online (click here) and the deadline for 2015 sessions is January 15, 2015. On the website you will also soon find familiar faces, starring in a new, mini-documentary on the Telluride Experience.
Telluride Alumni continue to create change at their home institutions, and inspire their colleagues. The following reflection was shared by a Telluride Scholar at the end of her first day at one of last year’s sessions. It is messages like this that reinforce how important the work being done in Telluride has been, and will continue to be through the Academy. And it is most definitely a two-way exchange of inspiration. Many of us have similar days and weeks of frustration and despair, feeling the changes so badly needed aren’t happening fast enough. Our faculty also leave “recharged” after seeing and feeling the passion and commitment these future healthcare leaders have for achieving safe, high quality patient care. Please consider joining us in 2015!
From a Telluride Scholar, 2014:
“As of late, I have felt uninspired and more bewildered by the apathy and active discouragement by my superiors almost reprimanding me for doing the right thing for my patients. After meeting the Telluride faculty at this meeting, I am beginning to feel empowered again to be a conduit of change.”
“So often at work I am so disheartened by what I see and do when it comes to patient safety and quality of care, and I am usually too tired and pessimistic to do anything but complain. I now have renewed energy and commitment to making things better. I also now have some tools and support and I’m again excited for the next two years of residency.”
“Thank you so much for this amazing week. After the hardest year of my residency as well as my personal life, this conference has re-inspired me at a time when I was starting to feel exhausted by work and alone in the system. Just a few days before I arrived in Telluride, a faculty member told me to ‘stop pushing and coming up with ideas because you don’t understand how things work here’. This was greatly upsetting and discouraging as I actually consider this person a mentor and a progressive thinker. Although this really upset me, I am so fortunate that I got to attend this conference…I learned that I certainly am not alone and will not stop pushing.”
As the Telluride Patient Safety Summer Camps prepare to expand in 2015, adding a third session for health science students to be held in Napa, CA (and fifth summer camp week overall when we include the two weeks for resident physicians) , our alumni continue to leave a lasting mark on healthcare. Most recently, Jennifer Loeb MD, former Telluride alum and now an internal medicine resident at the University of Illinois Hospital, published her thoughts in Hospital Impact, on how the need to provide patient-centric care drives her work at the bedside. She writes:
For me, safe patient care is more than adherence to checklists and standard operating protocols. It is a consequence of an approach to treating patients that’s characterized by applying medical evidence in a patient-centric way, by ensuring that compassion enters into care decisions and by listening with purpose to a patient’s articulated needs and, often helping them identify what those needs may be. I look forward to becoming a caregiver who can bring those attributes to my patient interactions…To say that I have evolved over many years to this point may be true, but it took a personal family challenge for me to truly appreciate all that it takes to achieve safe care. It’s not easy, it’s not one thing, it’s not just being careful or diligent — rather, it’s the way we deliver care, it’s how we see our role as part of a healing process, it’s how we put “care” into the word”caregiver.”…click here to read entire article
Resident physicians from MedStar Health and medical students from Georgetown University SOM each held gatherings of their own local Quality and Patient Safety Councils inspired by leaders who spent time in Telluride as well. The MedStar Resident QIPS Council, co-founded by alumni Shabnam Hafiz, MD, and Stephanie Wappel, MD, has grown to over 40 members and is focused on inspiring the change needed to make care safer and of the highest quality. The QIPS Council sponsored its first educational event in September at The French Embassy in Washington DC, led by QIPS Council member (and also a Telluride alumni) Lauren Lobaugh, MD, QIPS Education Committee Chair. The event, entitled “Wine and Wisdom,” was standing room only, and the guest speaker was nationally recognized safety expert (and Telluride faculty–there’s a theme here…), Paul Levy, who spoke about “the art of persuasion”. Guests from all over the region (Univ. of Maryland, MedStar Georgetown University Hospital, MedStar Washington Hospital Center, Johns Hopkins, INOVA, Walter Reed, and more) were invited to join the Council for a cocktail hour, lecture, and small group discussions about where we are today, and where we see our healthcare communities going in the future. The event also piqued the interest of local news outlets, and a story ran in the Washington Business Journal in September. Lobaugh was quoted in the article as below, and the rest of the story can be found here:
Making a mistake that harms a patient can be shattering for a doctor, said organizer Dr. Lauren Lobaugh, a fourth-year resident in MedStar Georgetown Hospital’s anesthesiology department. Over the summer, she headed to a patient safety boot camp held in Telluride, Colorado, and said she was impacted by the idea of “caring for the caregiver” instead of “shaming and blaming” them when an error is made.
And finally, Engagingpatients.org recently asked us to comment on their blog about how our patient advocates contribute to the Telluride Experience. Our patient advocates, and their stories, are such an integral piece of the Telluride Experience, it is hard to imagine the workshops without the depth of their contributions. From the post:
The Power of Storytelling
The power of stories is called upon regularly during the Telluride Experience. Patient and healthcare advocates continue to return as Telluride faculty to share their stories—stories that leave a lasting imprint on the hearts and minds of the alumni and faculty audience…The films are a foundational piece of the TPSSC curriculum, and in each session, they stimulate emotional conversations around what was missed, how to avoid future similar harm, and the hidden curriculum of medicine…
The Human Side of Medicine
When Helen or the Skolniks lead the group conversation after the film, an additional element is added to the learning. Young medical students who have yet to even see this side of medicine are exposed in vivo to the impact their future decisions will have on the kind, loving people before them. The patient becomes more than a procedure, and the audience realizes first-hand just how human both patients and healthcare professionals are. Time and time again, we have seen how these stories change people in the moment…For more, go to EngagingPatients.org
Applications for the 2015 Telluride Patient Safety Summer Camps will soon be announced open. Thanks once again to the generous and continued support of our sponsors–The Doctors Company Foundation, COPIC, and CIR–our patient safety army continues to gain reinforcements in hospitals and in medical/nursing schools across the country with now over 400 alumni scholars making patient safety contagious. For more information, go to www.telluridesummercamp.com.
Over the course of history, many young entrepreneurs have changed the world. Be it in the technology arena like Bill Gates, the social media world like Mark Zuckerberg or the newest Nobel Peace Prize co-winner, Malala Yousafzai–real change has been created by young leaders who envisioned a better way. These creative thinking young entrepreneurs are also leading change in healthcare. While their vision and action as patient safety advocates and role models may not send financial ripples across Wall Street, or redefine how we communicate with one another just yet, their efforts will save patient lives.
Over the last two years, ETY followers have read many stories about quality and safety projects being led by resident physician and health science student entrepreneurs, many Telluride Patient Safety Scholars and alumni. The attached video highlights another example of these young leaders in action, role-modeling the use of resilience tools that will make care safer for our patients. Daliha Aqbal, Telluride alumna and a medical student at the Georgetown School of Medicine, role models two resilience tools to over 300 faculty caregivers–the use of Safety Moments, and an example of “Stopping the Line” to validate and verify information when something doesn’t feel right. While many of these young leaders may not win a Nobel Peace Prize, they are truly helping change our safety culture as they lead by example.