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  

 


Sorrel King Recognized at MedStar Health HeRO Luncheon

Screen Shot 2016-02-28 at 1.40.30 PMFor 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.

Screen Shot 2016-02-28 at 1.38.52 PMSorrel 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.

Screen Shot 2016-02-28 at 1.39.31 PMPatients 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.


Patients and Families Can Help Prevent Diagnostic Error

Communication has been shown to be a significant key in preventing medical error, and the picture is becoming ever more clear: Patients and families have to play an active role in their care. From the front lines of healthcare delivery:

  1. Ask questions of your healthcare providers without fear
  2. Engage in the care you receive
  3. If a healthcare professional rebukes the input you provide into the care you are about to receive, take that as a sign you need to seek care elsewhere. Immediately!

It could save your life, or the life of a loved one. More to come on this, but the following video was put out by the Institute of Medicine…


A Young Nurse and Telluride Alumni Shares Inspiring Words on Keeping Patients Safe

Today’s post is from guest author Brennan Killeen, RN, BSN, Clinical Nurse at MedStar Georgetown University Hospital (MGUH) and Telluride Scholar June 2015. Brennan was asked to give a speech to this year’s MGUH Nurse Residency graduating class. Her focus was patient safety and her experience at the Telluride Patient Safety Summer Camps. We are so happy to see the premise “Educate the Young” continues to build momentum in a new generation of healthcare leaders.

Hello everyone and congratulations on your graduation. I’m Brennan Killeen. I graduated from the Nurse Residency Program here at Georgetown this past March. I work on C4-1, the Cardiovascular and Thoracic Intermediate Care Unit and I’m coming up on my 2-year mark as a nurse in February. I was a second-degree nursing student here at Georgetown before starting my career as a nurse on C4-1. I remember feeling all of the same emotions you all felt after graduation: the anxiety of finding a job, picking a city, finding the right hospital, the right manager, deciding whether or not being part of a residency program was the right fit… I want you to take a moment and reflect on all of your accomplishments thus far. Graduating from nursing school, passing your boards, landing a job at such a well-respected place like Georgetown and completing your first year as a nurse are big deals!

2015-06-08 15.16.19I’ve actually been to this ceremony 3 times now. The first time was when I was still a baby nurse and had barely gotten on the floor yet. I remember sitting here and feeling slightly panicked that I’d never be able to complete an NRP poster or that I’d make a make a med error, I wouldn’t know how to hang blood, or I’d never get over being intimidated by doctors and senior nurses – there were so many emotions that flooded my mind that first ceremony. I did feel very overwhelmed but I never felt alone. I felt calm knowing that if I didn’t feel confident about my poster presentation I had Kristine and Kim, or if I was scared about making a med error or performing a procedure incorrectly I had my coworkers and policies to turn to, or if I felt intimidated I had my manager, Elly, or educator, Alisa to ask for guidance. This is the beauty in a place like Georgetown. The support that is provided to you as a new nurse is incredible. There are systems in place so that it’s hard for us as new nurses to fail and there are people around you who truly care about your success. There’s a palpable sense of pride at Georgetown. We honor our spirit values, we support one another and we always put the patient first by practicing as safely as possible.

The second ceremony this past March was my graduation. It was a day when everything really came full circle. I felt proud of myself and my NRP partner for completing a project that we felt passionate about. I felt so excited my classmates and I had survived our first year as nurses. I remember walking around and observing the posters and feeling giddy. It was such a big moment for all of us. We’d become comfortable in our practice and it was hard to believe that we were no longer the new nurses. By this time, I’d become involved in Georgetown’s falls task force because of my interest in patient safety and I knew that my second year of nursing would give me the opportunity to take on more responsibility.

Today is my third ceremony and I felt so much confidence in Georgetown when I walked around the room earlier and looked at your presentations. You all should be so proud of yourselves! You’ve survived your first year. But with that comes a new set of challenges and goals. It’s time to push yourself to really dive into this wonderful community. You’re veterans now and it’s you who’s going to be guiding the new nurses. The opportunities that Georgetown provides for us are countless. During my second year as a nurse I felt a strong sense of obligation to get involved. Georgetown invests so much time and energy in creating a safe environment for us as new nurses and in turn a safe environment for the patient. I can’t tell you how many times I felt thankful over the last year and a half for all of the safety measures that were in place for me at Georgetown: policies, MC75s, double checks, bed alarms, daily rounding and the list goes. All of these measures promoted safe practice for me and influenced my passion for patient safety.

Students_Reception_Mtn_BackgroundThis summer I had the amazing opportunity to attend a safety camp in Telluride, Colorado sponsored by The Doctors Company Foundation and MedStar Health. It was the first year that Georgetown nurses were included in the camp in large part due to Eileen’s Ferrell’s efforts. Med students, nursing students, doctors and nurses from around the country were able to gather together in Telluride to expand our knowledge on patient safety. We spent the week discussing patient safety improvement, techniques, philosophy and approaches for reducing patient injury and adverse outcomes. Family members of victims devastated by medical errors also attended the camp to collaborate with us on ways to make system changes to avoid such errors. It was an eye-opening week for me and I learned so much. The sense of empowerment I felt after the conference was incredible. Knowing that we’re at a place like Georgetown where we can make a change after just a year and a half of being a nurse is an amazing feeling. One of the risk reduction strategies we discussed during the week was education. In our residency program Georgetown specifically carves out time during our classes to educate us on such strategies. This community encourages us to call for help and demands that this is a sign of excellence and not a sign of weakness. We belong to an organization with a just culture that applauds transparency and shared-decision making. As nurses we are encouraged to promote a culture of compassion, empathy and trust and in doing so we stand by our mission to provide safe, high quality care, excellent service and education to improve the health of our community.

Telluride truly has been the highlight of my nursing career thus far and I have Georgetown to thank for that. I didn’t think that back in March I’d be standing up here speaking to you all about my Telluride safety experience but Georgetown challenged me to be better, to do more and to get involved.

I want to leave you with a story from Telluride that really resonated with me and inspired me to prioritize patient safety during my nursing career. Lewis Blackman was a 15-year-old boy who died from a medical error following elective routine surgery in November of 2000. He suffered due to deficiencies in the system. He’d been prescribed Toradol post operatively. He was on an inadequate amount of IV fluids and it was a 2-day struggle to get the IV fluids increased but by then it seemed like the damage had been done. After 30 hours of alarming clinical decline, 24 hours of no urine output and 4 hours of an undetectable BP, Lewis died on post op day 4 from an NSAID induced duodenal ulcer. During the morning of Lewis’s death, doctors and nurses scoured the hospital to find a cuff or a machine that worked so that they could detect Lewis’s undetectable BP. They took his BP 12 times using 7 different machines and cuffs, dismissing the undetectable BP as an equipment error. Lewis eventually went into cardiac arrest. Could his death been averted by an assertive nurse? Could open and honest communication have prevented this error? If the doctors and nurses had practiced mindfulness and considered the family as part of the healthcare team would Lewis still be alive today?

This story speaks directly to safety. It’s an example of why nurse empowerment in reference to patient safety is so critical and why you all are so valuable to the lives of our patients. We belong to an institution that empowers us to speak up, to be accountable, to communicate and above all to practice as safely as possible. I ask you all to remember this every day and to teach our new nurses that it’s okay to speak up, it’s okay to say you’re unsure of something, it’s okay to ask questions. By doing so, you could save a Lewis Blackman or a family from tragedy like this.

Now that you are official graduates of your residency program, I challenge you to lead by example and continue to foster a safe environment here at Georgetown. You are now leaders and it’s your job to take our new nurses under your wing and show them the way. Dave Mayer, our VP for Quality and Safety here at MedStar told our Telluride group this: “leadership is like tennis, it’s a skill that you always have to work on.” I’m proud to have you all as leaders and I have confidence in each and every one of you that we will be a safer institution because of you. Congratulations!


John Nance Reflects on The Telluride Experience and Need for Patient Safety Immersive Learning

Today’s post is by Guest Author, John Nance, Telluride Experience Faculty, Author and ABC Aviation Consultant

JNance_Napa

Having had the delightful experience of attending and working with all of the sessions of the Telluride Experience this summer,  I’ve spent some time since returning from Napa thinking through the scope and the effectiveness of what we all came together to advance: The goal of never again losing a patient to a medical mistake or nosocomial infection.

It may well sound hackneyed, but in fact I think all of us as faculty mean it to the depth of our beings when we say that the medical students and residents and nurses – all of those who joined us – are truly the best hope of changing the course of a noble but tattered non-system that slaughters people at the rate of 50 per hour.  That does not mean that existing healthcare professionals cannot or will not embrace the dramatic changes that are required to keep patients safe, because, indeed, thousands are passionately involved in just such efforts.   It does mean, however that the opportunity for leadership from the newer members of this profession will be critical, from the small and subtle gestures, to the grand and sweeping reforms.

And the potential for meaningful  leadership, of course, is why those who joined us were selected in the first place, and what we expect of them from here on:  Courageous leadership steeled against the oppressive influence of the status quo.

Having participated in this battle for patient safety for nearly a quarter of a century, I can say with some degree of authority that no matter how many presentations, discussions, articles, consulting hours, or other efforts are thrown at the problem nationally, creating a major cultural change is perhaps an order of magnitude more difficult when you’re surrounded by the very environment you’re needing to alter.  Coming together at a distance – especially in a resort atmosphere, or in the incredible beauty of Telluride itself – is an important element in achieving transference of ideas, concepts, goals, and determination as free of dogmatic and traditional thinking as possible.  And, of course, catching people at the beginning of their careers before the insidious influence of cultural rigidity has been allowed to take root and oppose change,  is an equally important key.  I know of no better forum than this, and I’m truly honored to be a part of it.

John Nance BooksAnd so we came together and told you horrifying stories that made us all cry, exposed young learners to the realities and predictability of professional human failure,  and rubbed all our noses in the reality that a profession whose routine operations count as the third leading cause of death in America does not possess the ethical choice to resist meaningful change.

But at the end of the day – and our time together – it all comes down to taking those small sparks of understanding and recognition and fanning them into flames back home,  never forgetting that every hospital room,  scheduled surgery, ambulance arrival,  admission, or diagnostic test involves a fellow human who is as entitled to the highest standard of care and caring as your own family.

From a very personal POV, I thoroughly enjoyed meeting each of our participants this season and pushing the quest forward, and I look forward not just to next year, but to hearing how the seeds we all helped sow will sprout and change the landscape of American healthcare.


The Doctors Company Foundation Opens Applications for 2016 Young Physician Leader Essay Contest

Vinyard_With_ViewAs our final week of the 2015 Telluride Experience comes to a close, our Telluride blog has been nourished by a new year of talented healthcare trainee reflections. Many of these young physicians and physicians-in-training, along with their nursing colleagues, have submitted reflections that we will share more on moving forward, but they can be viewed here today.

Because our scholars and Alumni often return to the ETY blog as a reference tool, we wanted to share another opportunity for all to showcase their passion and commitment for keeping patients safe through writing. The Doctors Company Foundation, an organization that also sponsors a number of medical student attendees to participate in our Academy for Emerging Leaders in Patient Safety each year, is once again partnering with the Lucian Leape Institute at the National Patient Safety Foundation (NPSF) to offer The Doctors Company Foundation Young Physicians Patient Safety Award. The award will recognize young physicians for “their personal insight into the importance of applying the principles of patient safety to reduce the incidence of medical error.” Applicants are invited to submit essays of 500-1,000 words about a patient safety event they personally experienced during clinical rotations that resulted in a personal transformation.

More information can be found on The Doctors Company Foundation website. A short summary follows:

Applicants are invited to submit essays that will be judged by a panel identified by NPSF. Six winners of this prestigious award will be selected and receive a $5,000 award, which will be presented at the Association of American Medical College’s (AAMC) Integrating Quality meeting in Chicago, June 2016. Nominations must be submitted by 5:00pm ET, Monday Jan 25, 2016.

Eligibility:

  • As of July 1st, 2015, applicants must be either a 3rd or 4th year medical student at an American medical school
  • Award is for the best essay explaining your most instructional patient safety event experienced during a clinical rotation and that resulted in a personal transformation
  • Award will be presented by The Doctors Company Foundation at AAMC’s Annual Integrating Quality meeting in Chicago
  • Registration, hotel and travel will be covered to the AAMC meeting for Award recipients

Examples of winning essays from 2014 can be viewed via a past ETY posts (click here), and a review of the 2015 Essay Winners will soon follow. For additional questions, visit The Doctors Company Foundation website, here. We know there are many Telluride Alumni deserving of an award like this so please enter, and share the patient-centered care you are working so hard to make standard of care. Good luck!