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
On 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 Safety…The Sydney Australia Experience!
Today marks the first time our Academy for Emerging Leaders in Patient Safety (#AELPS16) goes global with our “Telluride Experience” Patient Safety Summer Camp curriculum 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.
The 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.
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.
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 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
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.
The cab driver that took me to the Cincinnati airport as I left the HPI Safety Summit last week was from Ethiopia. He had made a point to say “east Africa” when I asked where he was from, as the Ebola virus had greater than average attention in the Queen City due to one of the two nurses who contracted the virus having recently passed through northern Ohio. Even though she never came any closer to Cincinnati than almost 250 miles away, almost every cab driver encountered during our stay mentioned Ebola. This gentleman, in broken but completely intelligible English, shared that he had been in Cincinnati for nine years, and was lamenting the fact that his accent remained far too apparent while his young children now spoke perfect English. Our conversation continued on the beauty of different cultures and their languages, and he told me 80 different languages are spoken in his small country of origin. A quick Google search confirmed this, as well as that anywhere from 1,500 to 3,000 different languages are spoken across the African continent. It dawned on me that the magnitude of such disparate means of communication might not only contribute to a lack of understanding, but with it, the slow-moving development experienced across Africa on the whole. He agreed, which led to an impassioned explanation on how the inability to communicate in a common language leads to a lack of trust among clans, violence and often the need to hire a translator just to travel from the north to the south of Ethiopia. I told him he had inspired an ETY post, as it is becoming increasingly clear that data and fact lose almost every time to fear, ignorance, poor communication and a good old-fashioned wives’ tale spun by a convincing storyteller.
Communication was one of the overriding themes at the Safety Summit as well. HPI is endeavoring to make the language of patient safety universal across healthcare by providing consistent, process-driven training that gives healthcare professionals a vocabulary in high reliability, resilience and a systems approach to care. The number of partnerships HPI has formed with healthcare organizations across the US seeking to join the high reliability journey is growing, and with it, so follows the number of patient lives positively impacted by those employing their teachings at the frontlines of care. Their teaching excels in parallel with a clients’ ability to communicate the learning, and the session my colleague Erin Agelakopolous and I presented on the topic was standing room only. With newer clients in attendance at this year’s Safety Summit, there were many who wanted to understand how we were communicating the HPI learning across a health system of 30,000. We shared the tool kit designed by MedStar’s Communications team, our 60 Seconds for Safety videos, patient and provider stories, and a Good Catch program recognizing the excellent work at our frontlines while reinforcing the learning culture HROs need to thrive. And we shared that this has indeed been a journey—with our internal communications efforts growing in tandem with a collective comfort level in the new just culture tenets being increasingly embraced.
There were many excellent sessions at HPI’s Safety Summit. Of particular note was the keynote given by nationally recognized patient advocate, DePaul University Professor, Mom, MBA and former McKinsey consultant, Beth Daley Ullem. Beth emphasized the need for healthcare consumers to have access to data and information about the healthcare procedures they are purchasing. “We spend more time evaluating the purchase of mutual funds,” she said, “than heart surgeries.” Having lost a child to preventable medical harm directly related to the culture of medicine, Beth and her approach to this work, provided yet another inspirational reminder that we need a greater sense of urgency around the change we were all in Cincinnati to support.
The Children’s Hospital of Philadelphia shared their Good Catch program in a session. Cancer Treatment Center’s of America shared their HRO internal communication campaign and Safety Superheroes. Piedmont Healthcare shared how they are trying to communicate taking transparency to the next level. All expressed how important it is to find ways to communicate HPIs high reliability teachings and culture change across the health system. Being at the Summit was spending time with those already drinking the Kool-Aid of culture change. With all the social media and content development tools available to us, we now need to figure out how to take this excellent work along with the messages of just culture, transparency and open, honest communication in healthcare viral–
For more information on HPI and the Safety Summit, go to: www.hpiresults.com
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.
Historically in healthcare, when an error occurred we focused on individual fault. It was the simplest and easiest way out for us to make sense of any breakdown in care – find the person or persons responsible for the error and punish them mostly through things like shame, suspension or remediation. Re-train, re-educate and re-policy were the standard outcomes that came out of any attempt at a root cause analysis. Taking that route was easy because it didn’t require a lot of time, resources, skills or competencies to arrive at that conclusion especially for an industry that lacked an understanding, or appreciation of systems engineering and human factors. High reliability organizations outside of healthcare think differently, and have taken a much different approach through the years because they appreciate that it is only by looking at the entire system, versus looking to place blame on the lone individual, that they can understand where weaknesses lie and true problems can be fixed. James Reason astutely said “We cannot change the human condition but we can change the conditions under which humans work”.
The following short video is about Annie, a nurse who courageously shares her own story…a story that highlights when we didn’t do it right, but subsequently learned how to do it better by embracing a systems approach that is built on a fair and just culture when errors occur. A special thanks to Annie and to Terry Fairbanks MD MS, Director, National Center for Human Factors in Healthcare who helps us make sure our health system affords the time, resources, skills and competencies necessary to do it correctly.
For the last twelve months, our health system has undertaken a system-wide initiative to join the ranks of healthcare organizations like Cincinnati Children’s Hospital, Poudre Valley Hospital, and Mainline Health on a journey that seeks high reliability. We have already seen the fruits of this journey, and believe that when the benefits of a High Reliability culture are combined with the expertise provided by our National Center for Human Factors in Healthcare, led by Terry Fairbanks MD, MS, along with the guidance provided by our National Patient and Family Advisory Council for Quality and Safety, exciting opportunities to improve quality and safety while reducing cost can be realized.
An important part of this journey includes creating a learning culture built on transparency that many in healthcare are still uncomfortable with. Overcoming these barriers requires consistent and repetitive role-modeling and messaging around core principles that help instill and reward open and honest communication in an organization. One of the ways we continue to reaffirm these important messages is through our “60 Seconds for Safety” short video series, which highlights different high reliability and safety principles. Each week, a video from the series is attached to our “Monday Good Catch of the Week” email, delivered throughout our system. The video highlights one important safety message all our associates can become more familiar with, and hopefully apply as they go about their daily work that week. Similar to starting every meeting with a safety moment, we want all of our associates to start each new week with an educational message reminding us that safety is our number one priority. The videos are available on MedStar’s YouTube Channel, under the Quality & Safety playlist. Please feel free to use any of these videos in your own Quality & Safety work — and please share ways you are getting the quality & safety message out to your front line associates.