For the third year in a row, MedStar Health celebrated its “HeROs” at a red carpet “Academy Awards” like luncheon in honor of healthcare professionals who went above and beyond the call of duty in 2015 to ensure patients stayed safe while under our care. The HeRO program is part of our continued high reliability journey to create a culture where every associate feels safe speaking up when they see something in the care environment that might contribute to patient harm. Our weekly Good Catch Monday stories and our monthly Good Catch surprise celebrations across our health system have now become embedded within our culture.
Sorrel King, who has served on MedStar’s Patient and Family Advisory Council for Quality & Safety since the Council was launched in November of 2012, has participated in our Annual Good Catch Luncheon the past two years, where she presents the Josie King Foundation’s Josie King HeRO Award to one of our MedStar caregivers. This year, our HeRO’s luncheon fell on an anniversary no parent should have to recognize—fifteen years to the date since Sorrel’s daughter Josie died due to preventable medical harm. Sorrel acknowledged the date during her remarks and said she could think of no other place she would rather be than celebrating our MedStar HeROs and the work they are doing to ensure no family experiences a similar loss.
Patients and family members like Sorrel have always been my greatest mentors and personal heroes. The work they do to prevent harm after a loss of that magnitude never ceases to inspire and amaze me…something I am not sure I could do faced with similar personal tragedy. This year, in honor of Sorrel and all she does every day to make care safer, MedStar Health created a new Community HeRO Award. I had the honor of presenting this award to Sorrel…the very first of its kind. The words thank you will never express the depth of gratitude we have for Sorrel and so many other patient and family advocates who volunteer their time and work alongside healthcare professionals to help make care safer for everyone.
If you are looking for something to do over the holiday weekend, why not submit an abstract to the American Journal of Medical Quality? The following opportunity was shared by Telluride Alumni (2013), Martin Wegman, and offers another outlet for the excellent work we know Telluride Alum are leading across the country!
Quality Training to Improve Performance (QTIP)
American Journal of Medical Quality
Call for Abstracts
The American Journal of Medical Quality (AJMQ) recognizes that opportunities to learn about the perspectives of professionals in training are limited. To expand learning opportunities for its readership, AJMQ launched a column dedicated to publishing student work on the topic of performance improvement in 2013. Through collaboration with the American College of Medical Quality, articles will be solicited for the column, “Quality Training to Improve Performance (Q-TIP),” which will be published in the 2016 issues of AJMQ.
Abstracts of no more than 150 words, written by health professions students, describing improvement work and interdisciplinary collaborations should be sent to the faculty advisor, James Pelegano, MD, MS (email@example.com) by September 15, 2015. Eight abstracts will be selected by the faculty advisor and an Editorial Advisory Board for full article submissions and up to six articles will be published in AJMQ during each publication cycle (one article per issue). Questions regarding “Quality Training to Improve Performance (Q-TIP)” or submissions may be directed to Dr. Pelegano at firstname.lastname@example.org.
The American Journal of Medical Quality (AJMQ) is a peer-reviewed bi-monthly journal for those practicing, conducting research, and teaching in the field of clinical quality improvement. AJMQ publishes research studies, evaluations of the delivery and management of health care, and reports on changes in the field of medical quality, utilization, and risk management. Each issue provides information on the latest innovations in quality, editorial commentary on issues of importance in the field, and pragmatic suggestions to improve practice.
Please visit the AJMQ website, http://ajm.sagepub.com/, for more information about the journal, or to view an issue free of charge.
Breakout sessions at last week’s Lucian Leape Forum included Dr. Lucian Leape himself, Paul O’Neill, Former Chairman and CEO, Alcoa, 72nd Secretary of the US Treasury and more. I had the long-awaited pleasure of hearing Paul O’Neill speak in person, during his breakout session entitled, Operationalizing, Disseminating and Implementing Joy & Meaning In Work and Workforce Safety, along with Julie Morath, RN, MS, President & CEO, Hospital Quality Institute of California. O’Neill’s unwavering standards and expectations in business, and for healthcare, have been an inspiration for many. Therefore, it came as no surprise that he seemed irritated with our progress to date, pulling no punches when asking the group how many of us in the room knew the real-time facts about injury to the people who do the work in our hospitals, and, did a system currently exist to provide that information with a 24-hour lapse? No one in the room raised a hand, and he shared that only 6/100 in a recent audience responded affirmatively to the same questions.
“We’re too far away from this type of excellence,” he said, following with a story that while at Alcoa, the company’s screen saver included real-time safety data. When a particularly concerning near miss appeared on his screen one day, O’Neill picked up the phone and called the team in Russia where it had occurred, asking for more information about what had happened. The personal attention to this near miss resonated throughout the organization, furthering the culture and behaviors that make organizations stronger. It’s this type of response and awareness to healthcare professional harm, as well as patient harm, that will move us to where we need to be.
“Why can’t we do this (in healthcare)?” was O’Neill’s resounding and animated challenge, many in the room knowing full well why we have not. Healthcare culture, leadership that says one thing but fails to support the necessary changes at pivotal moments, inertia–all of these however, are choices made by leadership. Either you’re in or you’re out.
Much of O’Neill’s breakout session was based on the LLI white paper, Through the Eyes of the Workforce, a must read for anyone serious about improving the quality and safety of care. Key takeaways from this breakout, as well as the summary session that followed, include:
- It will be very challenging to protect patients if we first can’t protect our own.
- The physical and psychological safety of our healthcare workforce is pivotal to ever improving the quality and safety of care.
- Real leadership is enabling not controlling.
- A leader’s first responsibility is to his/her people.
- Safety is not negotiable – it’s not a trade-off. You figure out how to pay for it. A pre-condition is that people who work ‘here’ will not get hurt.
- Habitually excellent organizations don’t “report” – they share information and act in a timely way when things go wrong.
- The response is key when people do share information. You can shut down a reporting culture in a heartbeat if you criticize someone for what/how/where they shared information.
- How would your healthcare workforce answer O’Neill’s 3 Questions: 1) Am I treated with dignity and respect by everyone each day? 2) Do I have what I need so I can make a contribution that gives meaning to my life? 3) Am I recognized and thanked for what I do?
We were reminded that it is hard to make a business case for healthcare professional safety, but data also shows that unhappy, un-empathetic, uninspired or unrecognized healthcare professionals directly impact the safety of patients, which directly impacts the “business case” in immeasurable ways. Too often, many in healthcare have observed our colleagues defend or excuse sub-optimal results, or continue to look the other way when observing behaviors that clearly are not in the best interest of colleagues or patients. O’Neill’s unwillingness to compromise standards or expectations is not only inspiring, those values created a company in Alcoa with a safety record that set the bar for his industry, as well as other high-risk industries. O’Neill left the group with many pearls, but following is one that particularly resonated along with advice from the world of storytelling:
“Organizations are either habitually excellent or they’re not – there’s no in between,” said O’Neill.
“Do or not do, there is no try,” fictional sage Yoda advises via the story world of Star Wars.
It is time for healthcare to do differently.
For the last 18 months or so, we have been sending out our Monday morning “Good Catch” of the Week. Our initial email list included about 30 associate leaders, and it was a weekly email highlighting a story we had heard about through our Quality & Safety Directors across our health system. Our initial intent was to recognize caregivers at the front lines for all the great work they do every day. Through their mindfulness (sensing something wasn’t quite right) – and their actions (stopping the line), our patients were safer in our environment…and with the knowledge gained, we now had the ability to seek solutions to possible clinical care gaps. Both associate empowerment and recognition, along with greater knowledge about the health of our system, all are instrumental as we continue to seek high reliability at MedStar Health. An additional plus around our Good Catch celebrations is the Joy and Meaning we hope to inspire within our front line caregivers…something that is so badly needed in healthcare today.
And it’s working! Our Good Catch stories have become infectious. Over the course of the last 18 months, our email list has grown to almost 2,000 of our associates–a result of receiving many requests to, “please add me to the list”. Our Good Catch program has taken on a life of its own, and we no longer have to seek out stories from the front lines of care – they are sent proudly by many. Many of our entities also have a Good Catch program of their own in place, which adds a nice “local flavor” to the celebrations. It is truly inspiring to see.
But what has been even more amazing, is that people are now reaching out to us for more good catch stories. Stories that they can use as Safety Moments to start every one of our meetings! As a result, our last Good Catch Monday, put out by Seth Krevat, AVP of Safety, provided some tips on how to find and take note of all the safety moments around us. Seth’s recent email inspired Richard Corder, a fellow Telluride faculty and good friend/mentor, to pen the following after an unfortunate event in his kitchen. Richard’s story highlights the importance of the term “unconsciously competent” – doing certain tasks so often that we take the related risk involved for granted, and begin without thinking while multi-tasking, or with numerous distractions occurring around us. Pilots follow what is called “sterile cockpit” – no personal conversations or distractions during take-off and landing when the plane is below 10,000 feet so they stay focused on the task at hand even though they have done it thousands of times. In healthcare, there are many rote tasks related to the delivery of care and taking even the simplest of those for granted can result in harm to a patient or provider. Richard’s story (Re-learning the lessons of distractions and over-confidence) is well worth the read, and shows how even the simplest of kitchen tasks can present a risk when not staying mindful and in the moment.
One-Day Conference to Help Physicians Improve Patient Care and Publish the Results
Join a group of young healthcare innovators at the New York Academy of Medicine
November 23, 2013
CME Credit and Exposure to National Patient Safety Innovators
“QI: Plan. Execute. Publish” is the tagline for the November 23, 2013 conference, jointly sponsored by Albert Einstein College of Medicine (@EinsteinMed) and the CIR Policy and Education Initiative (@CIRSEIU), where resident and faculty physicians in New York-area hospitals will take a leap forward by meeting to empower physicians to conduct scholarly quality improvement (QI) projects. Many of the resident physicians and organizers are Telluride alumni, and we are always excited to watch them carry quality and safety initiatives to the next level.
Saturday’s meeting agenda includes the following faculty:
- Robert Sidlow, MD, MBA, Associate Professor of Clinical Medicine Albert Einstein College of Medicine Interim Chairman of Medicine Jacobi Medical Center and North Central Bronx Hospital, Bronx, NY
- Karyn Baum, MD, MSEd, Associate Chairman for Clinical Improvement
University of Minnesota Medical School Minneapolis, MN
- Gregory S. Ogrinc, MD, MS, Associate Professor of Medicine and Community and Family Medicine, Director, Office of Research and Innovation in Medical Education, Dartmouth Medical School Associate Fellowship Director, White River Junction Veterans Hospital, White River Junction, VT
- Amit S. Tibb, MD, FCCP, Assistant Professor, Department of Medicine, Albert Einstein College of Medicine Director, Medical Intensive Care Unit, Jacobi Medical Center
- Sepideh Sedgh, DO, Pulmonary Critical Care Fellow, Maimonides Medical Center, Brooklyn, NY
National President, Committee of Interns and Residents
- Farbod Raiszadeh, MD, PhD, Committee of Interns and Residents Policy and Education Initiative
- David Eshak, MD, Internal Medicine Resident Jacobi Medical Center, Bronx, NY
New York Regional Vice President, Committee of Interns and Residents
“It is tremendously gratifying to witness the cultural transformation which has taken place in the world of graduate medical education: it is now axiomatic that physicians must be given the skill set to “round on” and “cure” sick systems in addition to sick patients,” said Dr. Robert Sidlow, Associate Professor of Clinical Medicine at Albert Einstein College of Medicine and Interim Chairman of Medicine at Jacobi Medical Center. “Since frontline housestaff are now expected to learn and apply principles of Quality Improvement to their everyday work, it is only natural that we, as educators, teach trainees how to convert their efforts into generalizable, publishable scholarship and communal learning. This conference intends to accomplish just that.”
“As physicians on the frontline, we know our patients and we want the best for them. That’s why we’re leading quality improvement and patient safety endeavors in our hospitals,” said Dr. David Eshak, Telluride alum and an internal medicine resident at Jacobi Medical Center in the Bronx and a regional vice president of the Committee of Interns and Residents. “For us to be effective in QI, we need to work hand-in-hand with all stakeholders and we need to publish our work.”
The program features nationally recognized patient safety and quality improvement innovators Dr. Greg Ogrinc from Dartmouth Medical School and Dr. Karyn Baum from the University of Minnesota. Their hands-on, case-study approach focuses on closing the gap in training in evidence-based methods of process improvement and patient safety.
More information on the one-day program CLICK HERE
So many of the healthcare stories shared in the mainstream are those that focus on patient harm, or egregious behavior by providers. It can make us forget that while these occurrences are still far too frequent, they are not the norm. For every patient harmed, there are roughly three success stories rarely shared. Stories of care teams, often operating in systems yet to be designed for optimal success, who manage to use the wonderful technology, knowledge and compassion at their disposal to send a patient home safely. While every patient story is of great value, so are the stories of those care providers whose voices are less frequently heard. When patients and providers work together throughout the course of a healthcare encounter real magic occurs. Human connection has power to heal, and will always complement any prescription or treatment. And it costs absolutely nothing…
Here is one of those success stories, recently shared by a colleague. Melissa, a patient in the Vidant Health system, was found to have an aortic dissection immediately after giving birth to her son. She shares with viewers a triumphant and tear-jerking healthcare experience, as well as what made her time with Vidant so positive and successful despite the odds. Following are a few of those highlights for those who don’t have time to view the entire video:
- Melissa felt she was listened to by the care team
- She needed someone to be human and care, and that is exactly what her healthcare team did
- Someone cared enough to push harder within the system when her survival depended on it
Here is Melissa’s story, in her own words. There is a wonderful tribute to the healthcare team that was part of her “family” during this challenging time in her life. If you have time, Melissa’s story is well worth a few moments of yours. It is also a story worth sharing–one that healthcare colleagues and consumers will equally appreciate.