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.
I continue to enjoy following all the quality and patient safety work being led across the country by resident physicians. Many have come into healthcare with a much different perspective regarding quality, safety and outcomes than my generation did years ago. Be it the daily focus by the media on preventable medical errors, required transparency of outcomes, or the newer reimbursement models based on quality and safety, this new generation of physicians is asking the right questions and looking for the right solutions. It is why the premise “Educate the Young” is such a critical component to any enduring culture change.
In this spirit, we want to share another wonderful example of how resident physicians are changing the landscape of quality and safety in healthcare for the better. The AAMC webinar highlighted below, The House Staff Patient Safety Council: Creating a Culture of Safety and Openness, is being led by Nate Margolis and Say Salomon, both Telluride Patient Safety Summer Camp Scholar Alums, who are helping inspire resident physicians on how to lead change in their own academic institutions. What a great example of “pushing it forward”.
Date and Time: Wednesday, October 30, 2013 3:00 pm ET
Duration: 1 Hour
Description: In support of the Best Practices for Better Care Initiative commitment area to teach quality and patient safety to the next generation of doctors, this webinar will spotlight two institutional approaches to creating a culture of safety and openness by leveraging House Staff Patient Safety Councils to improve care processes and outcomes.
House staff patient safety councils create a culture of safety, engage residents in process improvement, and help satisfy ACGME requirements. A successful resident driven project will be described in which the distribution of badge buddies, incident report guidelines, and an incident reporting presentation increased house staff adverse event reporting in a 3-hospital academic program. In addition, the Safety Council activities and outcomes from Woodhull Medical Center will be shared. Some examples of their core projects include: the triaging of critical care value from an ambulatory care clinic, standardization of hand off processes and just culture conferences to improve quality of care delivered to its patients.
–Nate Margolis, M.D., is a chief resident in Radiology and the co-chair of the House Staff Patient Safety Council at NYU, Bellevue & Manhattan VA hospitals
–Say Salomon Jr., M.D., is an Associate Chief Resident in Internal Medicine at Woodhull Medical and Mental Health Center
To register, click here. It should be a great discussion!
I have been very fortunate through my career to have met, learned from, and become friends with many patient advocates from across the country. People like Helen Haskell, Patty Skolnik, Linda Kenney, Sorrel King, and Carole Hemmelgarn to name just a few. Their ability and willingness to turn personal loss into a life-long commitment to make care safer and of higher quality is quite inspiring…they are the true heroes of this mission.
The same holds true for Victoria and Armando Nahum who I was so fortunate to meet about two years ago. Over a period of 10 months in 2006, the Nahums had three family members stricken by hospital acquired infections, at three different hospitals in three different states, culminating in the death of their 27-year-old son, Josh. Like the families I mentioned above, they also turned their own personal loss into a crusade to reduce and hopefully eliminate hospital acquired infections by starting the Safe Care Campaign.
Last week at the Quality Colloquium, I moderated a morning long session on quality and safety at the bedside. Because patient partnership is a critical piece to any quality and safety mission, I asked Victoria and Rosemary Gibson, author and healthcare advocate, to be part of the panel and lead a patient partnership discussion with the audience. Both Victoria and Rosemary (as usual) were outstanding speakers, and had the audience fully engaged. However, during Victoria’s presentation, something truly special happened. Victoria shared the following video that she and her husband Armando created. Lke most in the auditorium, I had not seen the film before. The video delivered its message that morning in a unique and quite remarkable manner. Few times have I seen an audience as captivated at a medical meeting as they were last Thursday while we watched the Nahum’s two-minute film. The audience burst into spontaneous applause at the conclusion of the video, even though Victoria was still in the middle of her talk. It was an inspiring moment. The Nahum’s creativity and message captured us all that morning. Take a look for yourself:
The Nahum’s courage is powerful, and their message so very important if we are to escalate the fight to reduce risk and improve the quality of care providing to our patients. We need a greater sense of urgency around all of these efforts, especially at a time in the evolution of healthcare when competing agendas vie for attention and funding. Like Don Berwick, Carolyn Clancy and other healthcare quality and safety leaders who have inspired us to do better, patient advocates like Victoria, Rosemary, Helen, Patty, LInda and Sorrel are leaders who inspire us with their passion and commitment to help us get it right. It is encouraging to see them with a seat at the hospital conference or board room, as keynote speakers at national conferences, and included in hospital quality and safety improvement committees. How we thought we could do this important work without them still befuddles me.
Over the past few years, I have really come to enjoy reading Paul Levy’s blog, Not Running A Hospital, especially when the focus is on quality and safety. I have found it educational, thought provoking, and timely. Paul’s post last Sunday, Kill this monster, was no exception, as he starts off by saying, “The time has come to drive a stake through the heart of an oft-repeated assertion. How often have you heard something like the following when those of us in healthcare who want to stimulate quality and safety improvements draw analogies to the airline industry?”
“Well, in an airplane, the pilot has an extra incentive to be safe, because he will go down with the ship. In contrast, when a doctor hurts a patient, he gets to go home safe and sound.”
His story took me back in time, as I remembered first hearing that comment many years ago. A pilot remarked similarly to me as we walked off a stage together, having just concluded an “Ask the Experts” patient safety panel at a national medical meeting. To be honest, I was a little offended, feeling as though I had just been insulted for being a physician. He had challenged the essence of why the great majority of us enter the medical field, which is to help others and always put our patients above our own self-interests. Before I could respond and defend my chosen profession, he was off…running to catch his plane. But his comment stuck with me and forced me to think deeper into why it bothered me. While it is true that similar complexities exist in both professions–high stress, high risk, varying conditions forcing both pilots and physicians to adapt–why do we, as healthcare professionals, struggle to grasp simple elements–those repeatedly passed on by human factors engineers–that aviation seems to easily adopt and follow without push-back?
I first thought about my specialty – anesthesiology. Why is it that many surgeons will tell anyone who is willing to listen that anesthesiologists are overpaid. They complain that many of us read newspapers, answer emails on our handhelds, or talk on our cell phones with friends while a case is in progress. Would an airline pilot ever consider reading the newspaper, answering emails or using their personal cell phone while working in the cockpit?
How about the accepted practice of running our anesthesia machines through a set of safety checks before using them each morning for surgery? While the manufacturers have added many self-check features through the years, there are still a few things we as anesthesiologists are asked to do each morning. Unless things have drastically changed in recent years, this “recommended safety practice” is not being followed regularly, the assumption being the machine worked fine yesterday so it should be ok today. Would an airline pilot ever think of not doing a pre-flight, airplane walk-around, checking the plane he or she is about to fly, and instead say, “Lets skip the pre-flight walk-around this afternoon…the plane was flown earlier today and I am sure nothing happened during the previous flight”.
Wrong-sided anesthesia blocks have seen significant increases in the past few years as regional anesthesia has become an important element for pain management supplementation in the post-operative recovery period. With the Joint Commission mandating the use of human factor tools like pre-procedure site markings, time-outs, and the use of checklists designed to help eliminate the “humans will be humans and forget at times” factor, we still see over 90% of these wrong-sided, wrong-site, wrong patient procedures attributed to a lack of following Universal Protocol and the use of a checklist. Would a pilot ever think of saying “Let’s not do the pre-flight checklist today. The extra two minutes it takes to do it just kills my day”?
The same figures hold true for surgeons. Many refuse to use timeouts and checklists. They will be quick to point out they have never had a wrong-sided surgery in their ‘fifteen or twenty years of practice’ and don’t need to use these safety tools. As John Nance says, those are the physicians that scare him the most. They believe they are, and will always be, better than the rest of us who will under the right circumstances make a mistake when the holes of James Reason’s Swiss cheese all line up. Having interviewed a number of surgeons and anesthesiologists who were involved in a wrong-sided procedure, every single one of them said the same two things right after the event: (a) They never thought this could happened to them, and (b) They are always so careful. But after the event, they realize we are all human. So why do some physicians still choose not to adopt the same mindset as pilots, before a patient gets harmed?
If you believe Paul’s premise–that it isn’t because pilots have more personal “skin in the game” than physicians do (see More Skin in the Game…)–maybe it could be one, or a combination of, three of the following reasons why we see differences in safety adoption between pilots and physicians: (1) Physician autonomy, (2) Financial incentives, and (3) A lack of accountability by leadership in the face of less than “reckless” behaviors.
To be continued….