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  

 


Why National Patient Safety Week Matters

Today’s post is by guest author, Carole Hemmelgarn, who generously shares a reminder to all on why patient safety work is so important, and why National Patient Safety Week will continue to matter even after we get it right. Carole continues to give her time as a patient advocate, coaching healthcare organizations across the country on the power of words, as well as a better understanding on what it means to truly communicate with patients.

March 8th starts National Patient Safety week and it is with great irony that I write this blog because it is the anniversary of the day my daughter, Alyssa, died from medical errors. I am grateful for the focus being made in the field of patient safety. We need to become High Reliability organizations, enhance our communication skills, offer communication and resolution programs, implement bundles and the host of other programs that impact safe patient care.

Carole_Alyssa_ETY030815However, I want to bring the focus back to the human side of patient safety and that is the patient and family after harm has occurred. There is this aftermath, which is rarely spoken of, and it is what happens to those survivors living without their child, spouse, parent or sibling years down the road.

I’ve come to realize grief is my twin. It will never go away and we have learned to coexist. Please understand grief is not always bad. I find solace in my grief because we speak the same language. We laugh and cry together and there is no judgment. At other times, my twin is like an anchor weighing me down causing me emotional pain and draining my often limited resources. So you may ponder why the dichotomy? Well, because life moves on, but it is different for us now. I’m a different person. My beliefs, values and what I held to be true have turned upside down.

What most people don’t realize is loss of a loved one, and in particular, a child, changes so many things.

  1. Marriage changes. I’m no longer the person my husband married and trying to figure out who we are in this new space is exhausting. Parents grieve differently and the one thing they don’t want to do is hurt their spouse because they know they are already in pain. This just opens up the door for communication problems.
  2. Your children are affected, but rarely do we talk about the impact it has on them. My husband and I often ask the question “Is this who our son is, or is this who he became after his sister’s death”? It is difficult to watch your son cringe when asked if he has any brothers or sisters and he says “no” because he can’t go there and talk about his sister.
  3. Your relationship with family members change. Sometimes they become stronger with certain members of your family, and others, a riff occurs because they expect you to move on or be the person you were before, and that individual no longer exists. Partaking in family events that once use to be enjoyable can be extremely emotional. You are there, but only as the great pretender, when underneath you are screaming to be set free. Why? Because you are watching their children progress through life, and do the very things, your child will never get to do.
  4. Friendships change…..

The most difficult are the milestones your child will not experience: moving through elementary, middle, and high school, not graduating from college, getting a job, married or having children. These events go on for years and this is the aftermath not seen.

I share this with you because I want you to see the importance of the work you do in the area of patient safety. So as you participate in the 2015 National Patient Safety Week, your goal is to make sure we minimize and mitigate the aftermath of harm I discuss above, and my goal is to help others avoid having grief as their twin.


Virtual Stocking Stuffer for Storytellers

tracy3_FINALAfter a brief hiatus for the #IHI26Forum, and in preparation for launch of Using Stories to Influence Change in Healthcare as an Amazon eBook, we are back online! With all the repeat hits to our ETY storytelling posts, it seemed of value to put them in a collection along with some of the ‘how and why’ storytelling has become of even greater value in healthcare. Here is the link if interested in having all of the storytelling posts in one place along with new commentary. From the description:

…as long as there are patients who fall victim to preventable harm in healthcare, there are healthcare professionals who also have a story rich in learning material from the other side of the bedrail. Both sides of the patient harm story will need to be embraced by healthcare leadership in order to achieve the delivery of reliable, high-quality, safe care everyone desires. Because the numbers harmed by healthcare have at the very best plateaued, an urgent need to pick up the pace for change remains. Sharing the stories of patients and healthcare professionals on a larger and more strategic scale throughout the industry will allow others to learn vicariously from mistakes as well as successes, building upon the positive momentum found when utilizing storytelling as a medium for change. Once again, our stories can provide the guiding light leading us into a new world for healthcare—where the patient voice is welcomed, and healthcare professionals are allowed to speak their truth.

And finally, our healthcare stories also serve many masters. When patients share their story of illness, they heal. When families tell stories of loss, they grieve. When healthcare professionals relate stories of guilt or near misses, they unburden their souls and can fix what is broken in health systems, enabling them to once again care for others as intended. Freedom to tell our story has always been a way to health and happiness. Using Stories to Influence Change in Healthcare is a jumping off place for those interested in learning more about how stories are being used in healthcare, and why they hold the power over us that they do. Tips from expert storytellers on how to craft good stories, as well as a glimpse into the science of story round out this introductory collection on using stories in healthcare…


Informal Influence in Healthcare #NPSFLLI7

The 7th Annual National Patient Safety Foundation and Lucian Leape Institute Forum and Gala was held last week in Boston, gathering patient safety leaders together to share knowledge, recharge and re-energize their efforts in making care safer for healthcare professionals and patients. The opening keynote, Using Informal Influence to Drive Positive Change in Healthcare, was given by Andrew Knight, PhD. Assistant Professor, Organizational Behavior, Olin Business School, Washington University. Knight has studied innovation implementation, leadership and teams in high risk environments, such as the surgical suite, ICUs, Emergency Departments and the military.

Screen Shot 2014-09-21 at 8.51.32 AMKnight’s talk provided a number of take home tools for healthcare leaders to approach internal change with new power. He supplied a different lens through which to view company politics, one that allows for consideration of “the other” versus leaving a footprint on even your mother’s forehead to reach the top. He shared insight into the influence skills and the collaboration across teams necessary to move quality and safety initiatives forward. And, he stressed that data alone has not been the sole catalyst for the large-scale adoption of change needed to make the healthcare workplace as safe as we need it to be, using the tragic story of Ignac Semmelweis as evidence. Many are familiar with Semmelweis’ story–the doctor who discovered hand washing as a “cure” for the high number of deaths related to childbirth in Vienna clinics. His findings at the time went against the medical community’s thinking of the day, with physicians even taking offense at the request to wash their hands before caring for a patient. Unable to convince, or influence, others of his findings during his lifetime, Semmelweis was ultimately committed to a psychiatric hospital at the age of 47, and beaten by guards two weeks after his arrival. As the story goes, Semmelweis died shortly after from the same infection he was trying to protect patients from through hand washing. This simple, cost-effective step in the delivery of care at the desired 100% adoption rate still eludes health systems today.

Additional takeaways from Knight’s talk include the following. He is an excellent speaker and the topic couldn’t be more timely for healthcare.

  • When it comes to navigating the waters of company politics, do you consider yourself an innocent lamb, a straight shooter, a survivalist, company politician or Machiavellian? Knight asked the group to respond via a text message survey. Results showed a normal distribution, the majority claiming to be survivalists with one Machiavellian in the group, prompting Knight to tongue-in-cheek, warn all to watch their backs.
  • A more realistic view of company politics was offered, such as: Instead of considering what tactics might be used to influence someone, walk a mile in their shoes to understand exactly how what you offer might affect another. Or, instead of kissing up to those in power, feel free to compliment those you admire!
  • Driving positive change is hard work! A 2005 study showed more than 50% of attempts to implement innovations end in failure, and that over $500 Billion is wasted annually on new technology implementations, according to Morgan Stanley
  • To implement change, groups outside one’s direct circle of influence need to buy-in, collaborate, support, and supply resources to be successful. Influence skills can help gain the buy-in!
  • Informal influence at all levels of the organization is what makes for the successful adoption of new initiatives.
  • A numeric equation to map the political landscape related to change was provided, quantifying the amount of current support for any given project, by any given stakeholder, indicating likelihood of success.
  • “For most change initiatives we need commitment. Compliance is rarely enough.”

 


400,000 Gravesites

Arlington_Cemetery_White_GravesOne of the highlights of our Telluride East Patient Safety Summer Camp each year is our trip to Arlington National Cemetery. The cemetery serves as a burial-place for “laying our Nation’s veterans and their family members to rest with dignity and honor.” Numerous daily honors, such as a horse-drawn caisson carrying an American flag draped casket, the firing of three rifle volleys, and the long bugler playing Taps, remind visitors of the service, sacrifice and valor displayed by those in the military protecting our freedoms.

As we walked through the cemetery, it was hard not to grasp the magnitude of the gravesites beside us. Everywhere I looked, white gravestones dotted the landscape. The tombstones seemed to go on forever…in the lower areas of the cemetery close to the main entrance, walking up the hill to Arlington House, or following the signs to the Tomb of the Unknown Soldier. Everywhere I looked there were rows and rows of white tombstones – tens of thousands of them. Six hundred and forty-eight acres of tombstones marking burial sites with little room for much else–the cemetery is pretty much full, and needs more acreage. In fact, they recently chopped down a controversial 2 acres of trees to find a place for our more recent casualties of war. The informational brochure says the cemetery is currently the final resting place for more than 400,000 people.

400,000 people…the irony of that number struck me. That is the same number of patients who die every year due to preventable medical errors according to an article published in September 2013, A New Evidenced-based Estimate of Patient Harms Associated with Hospital Care in The Journal of Patient Safety. Lucian Leape brought some conceptual reality to the medical error crisis years ago by using the analogy of one jumbo jet crashing every day.  All those white tombstones that stretched to the end of the landscape and seemed to go on forever reflected the same number of patients who die each year from things like unnecessary infections, failure to recognize or rescue, medication dosing mistakes. We fill an Arlington Cemetery every year.

We have surpassed one jumbo jet per day. Standing at the top of the hill, looking in all directions…north, south, east, west…seeing the 400,000 gravesites spread out before me, and thinking this could be a preventable medical harm cemetery for just a single year is incomprehensible and unacceptable. What does it require for others to take this national epidemic seriously? When will we see the urgency needed to create meaningful change? It is a visual all Hospital CEO’s and political leaders should be required to experience.

Arlington_Cemetery_White_Graves3


10 Years Later: Patty & David Skolnik Share What They Feel Today

Patty and David Skolnik were again faculty at the Telluride “East” Patient Safety Summer Camp this week. They came to lead the discussion after sharing the educational documentary film, The Story of Michael Skolnik, and their family’s story, with almost 75 medical and nursing students and resident physicians. As always, and as quite an understatement, the film is part of the patient safety intensive curriculum that illuminates the need for change in healthcare and healthcare education–not only to make it safer for all, but to also cultivate the skill sets that engender meaningful conversations built on honesty and trust between patients and providers. Following are reflections shared by Patty and David today, ten years after losing Michael to medical harm. Thank you, Patty and David, for your continued presence within healthcare, serving as a reminder that we still have much work to do.

David and I feel many emotions 10 years after our son’s death:

  • Anger that we have lost our child unnecessarily
  • Strange relief that Michael is no longer suffering
  • Unexplainable sadness that Michael is gone and his dreams are unfulfilled
  • Guilt for making decisions we regret because we trusted the doctor and didn’t look further
  • Awe at the courage one young man could manage. Michael was a fighter; he had unbelievable strength to fight back
  • Admiration, immense admiration for the love and unstoppable caring he showed through his horrible ordeal
  • Appreciation for what we all learned from Michael, he had no room for weakness, failure or lies
  • Regret that we lost our best friend and a large part of our souls
  • Happiness that we had a child that never hesitated to participate in life or have any goal intimidate him
  • A love of Michael’s was sailing. Through sailing he learned: ingenuity, resourcefulness, trust, caution, adventure, discipline, and perseverance

Michael has also taught us many other lessons that I want to leave with you, namely that we all have choices, choices about how we live and how we die. If Michael were here he would tell all of us:

  • To smile always
  • To laugh daily
  • To sing every chance you get, whether others think you can or not
  • To dance, even if you have to do it in a wheelchair or bed
  • Not to feel guilty if you don’t know what you want to do with your life
  • To meet new people and make new friends everyday
  • To enjoy your body. Use it every way you can. It’s the greatest instrument you’ll ever own.
  • Get to know your family and especially your parents. You will likely discover that they are the best friends you will ever have.
  • Do one thing every day that thrills or excites you
  • Respect those that earn it
  • Be the Best medical professional you can

We are determined to make a difference for Michael’s life. This is what Michael would have wanted–to have his voice still heard and all the others that have no voice. Thank you for what you do and for helping us keep our promise to Michael–that we all leave the medical field better than he found it.