As in Doha, SolidLine Media was along to capture the stories being told at The Telluride Experience: Sydney! Thanks to Greg, Michael, John, Ali and team for pulling this short video together utilizing movie magic across the continents in time for the Minister of Health herself to view it live in Sydney, at the Clinical Excellence Commission’s reception for students and faculty before we returned home last week.
Truly a great team effort by all to bring the reflections and voices of change to life.
Taking the Telluride Experience global continues to equally educate our faculty on what both the delivery and culture of healthcare around the world is really like. While many cultural differences exist, it is the similarities in our human experience throughout that connects us all. The local challenges may create the obstacles, but returning to the patient, no matter the locale, grounds every care provider in “how to proceed”. Reflections from yet another impressive group of Academy for Emerging Leaders in Patient Safety alumni follow:
I work in emergency medicine. A buffer for the undifferentiated, where time-poor workers battle a “controlled” chaos. It’s also where patients come. Patients who have a stubbed toe, sprained ankle, a cough or a heart attack. By practicing the virtues of patient-centred care we can appreciate that these aren’t patients who have presented to be an inconvenience, but have come because there was nowhere else to go. Ask why. Why did they present. There are many reasons why they present including health literacy and healthcare infrastructure. The truth distills down to the fact that, in their mind, we are their only hope.
Viet Tran, Emergency Medicine, Registrar
It was very important today to see face to face the huge impact that medical errors can have in a person/family’s life; it has certainly touched me and I wish that every health professional I work with got to experience and see the testimonies I have been able to experience today. Seeing a mother with two children who suffer from chronic illness and how their lives have been shaped by this, and how a mother who lost a child in a way that could have been prevented has the courage and strength to re-live this painful experience in order to teach and change in some way how we practice and how we deliver care. This for me was the highlight of the day. Anyone can make mistakes, it can happen to any of us, but we never think that in reality we are going to be in that position. I have been touched by Susan’s and Carol’s talks, they have been just life changing.
Lina Belalcazar, Medical Student
We talk and even joke about aha moments but the past is marked by many such moments that go on to spark movements and eventually change the face of history. In years to come we will look back on the negligent attitudes towards patient safety the same way we look back on segregation and gender inequality, in disbelief. Doctors of the future simply wont believe that patient safety was not always highly valued, well taught and at the forefront of everybody’s mind during each patient encounter.
I am so pleased to have met the leaders in this field and feel privileged to be one of the first followers. Now let’s not stop till everyone is dancing with us.
Anna Elias, Medical Student
I will continue to strive for excellence in patient safety and I will utilise whatever means on hand to achieve our primary goal. A safe and highly satisfactory patient journey. We cannot perform without our patients and they should be central to what we do. This I feel we as a cohort of professions fail to achieve. I am a professional. I am an expert. These excuses create barriers which have become ingrained in our culture. I hope that as evidenced by this conference with the Australians bucking the trend we can continue to do so and continue to strive towards excellence and truly take place as advocates and global leaders in healthcare.
Ben Gross, Nursing
Today another lived experience was shared. It was that of a widowed husband, this time from the UK, who shared the experience of his wife, undergoing what was a routine surgery but ended up not making it to surgery and having a fatal consequence as a net result of an adverse event and subsequent accrual of system failures, particularly those of a human factor nature. This brings to the light the many human factors that we continually witness in practice, which may be harmful especially when aligned in particular contexts, notably in situations that are unfamiliar or deviate from the norm. One of the things I particularly reflected on is how we as humans are fallible to task focus and makes us become situationally unaware. It is something we need to keep in mind when retrospectively analysing incidents. Even I have to admit that I have been unaware on occasion. It is important to be conscious that we can become like that. This emphasises the importance of teamwork, communication and dynamics, which are able to overcome authority gradients and their pertinence to allow goals to be met.
Kym Huynh, Pharmacy
After a very successful Academy for Emerging Leaders in Patient Safety: The Doha Experience (#AELPS16) workshop in Qatar last month, our faculty will now head to Sydney, Australia mid-April to continue sharing our Telluride Patient Safety Summer Camp curriculum with future healthcare leaders from around the world. Through the years, many Australian patient safety leaders, such as Cliff Hughes, Peter Kennedy and Kim Oates, have been regular attendees and teachers at our patient safety workshops in Telluride CO, Washington DC and Napa CA. The Clinical Excellence Commission (CEC) in New South Wales has also supported a number of young Australian physicians to attend our US patient safety immersive workshops. These young physicians have then gone on to assume quality and safety leadership roles at their institutions upon returning home.
Kim Oates, emeritus professor and Director, Undergraduate Quality and Safety Education at the University of Sydney and Carrie Marr, Chief Executive, at the CEC are the visionary leaders bringing the Academy for Emerging Leaders in Patient Safety: The Sydney Experience program to Australia. The Sydney Experience team includes fellow CEC and Australian healthcare leaders such as Telluride Alum Sarah Dalton MD, and first time attendees, May Wong and Teresa Mastroserio. Thanks to the generous support of the Avant Mutual Group, the major medical defense group in Australia, the Division of Midwifery and Nursing, New South Wales Health, and the CEC, over thirty young medical and nursing leaders will be able to attend #AELPS16: The Sydney Experience, an immersive, four-day patient safety education program. The program has also received significant support from Minister Jillian Skinner, New South Wales Minister for Health, who will attend the last day of The Sydney Experience, and will address both learners and faculty.
We are both honored and energized by the opportunity to distribute our patient safety education curriculum to those at home and around the world who have similar passion of finding new and better ways to deliver the highest quality, safest care to patients. In just two months time, we will welcome Qatari and Australian healthcare professionals into our now global Telluride Experience Alumni network. In 2016 alone, over 700 future healthcare leaders will attend one of many Telluride Experience Patient Safety Summer Camps around the world and become part of this growing network of dedicated and caring patient safety leaders.
Today’s Guest Author is Dr. Roger Leonard, retired cardiologist, past ACC Governor for Maryland, & previous hospital CMO, who now volunteers his time with MedStar Health’s Quality & Safety Department. Roger helps to lead MedStar’s Patient & Family Advisory Councils for Quality and Safety and participates in The Academy for Emerging Leaders in Patient Safety: The Telluride Experience
As part of our journey toward becoming a High Reliability Organization at MedStar Health, we begin every meeting with a safety moment. Recently, we shared an opinion piece in JAMA written by Dr. Marjorie Stiegler, an anesthesiologist at UNC, titled “What I learned About Adverse Events From Captain Sully: It’s Not What You Think” (JAMA, Jan 27, 2015, Vol 313, No 4, 361-362). Rather than paraphrase, let me quote Dr. Stiegler:
“The aircraft touched down in the middle of the Hudson River…no one was killed or critically injured. There was no glaring error, no misstep, no panic. By all accounts, this was an incredible save. So why did Captain Sully tell me they all had PTSD for several months thereafter? Why, if Captain Sully’s years of experience had all been a cumulative preparation for this most unlikely event, and if he did just about everything right (and quickly), could he not sleep or concentrate for three months? Why did he not return to the skies for nearly half a year.”
In medicine, we respond to life threatening emergencies regularly. Many are successful with precision teamwork, no lapses, no panic…by all accounts an incredible save. Yet, I have never observed any resuscitation team voice their emotional reaction to what they just accomplished. The thought of PTSD doesn’t exist. Is the difference between the flight crew and the medical crew simply that the former has their lives at stake? If so, then the air traffic controller at La Guardia should not have experienced PTSD as described in his testimony before Congress. Perhaps it is the frequency with which these events occur…rarely in commercial aviation and regularly in medicine. Does practice make perfect?
If we seem to be immune to PTSD after saving a life, then why do we so commonly ignore our emotional response to failed emergency care? I believe that a significant explanation rests in the culture of medicine where we are taught to control our emotions supposedly for the benefit of our patients, families, and colleagues. In the process we diminish our humanity and miss comforting a family or colleague who is hurting. I am unaware of the peer-reviewed study that proves lack of trust when patients and families see healthcare professionals cry.
When critical emergencies occur in medicine, often we fail to debrief and rarely do we take health care associates off-line. If an effective debrief asks: 1) What went well?, 2) What didn’t go well?, and 3) What can we do to improve?, then I would suggest a fourth question – “What are we feeling?” In essence as a team, we are sharing our cumulative emotional intelligence.
A step in the right direction is to share The Pause.The Pause was created by Jonathan Bartels, BSN, an emergency nurse at the University of Virginia Medical Center. In the article, Bartels describes caring for a woman who had been hit by an SUV going full speed through an intersection. The 45-minute attempt by his team to revive her was both elegant and futile, and he watched his colleagues leave the room walking back into the ED readying themselves for the next trauma victim to enter. For Bartels, this “day of the young woman” was different–it marked a turning point in how he would manage the emotional aftermath of traumatic care. He says:
I remember defeat and exhaustion, but also more than that: a kind of vacancy, a space where the pull of emotion gets tamped down by time, fatigue, and grief, leaving an empty numbness in its place…There is no time for a breath, or thought or tears. A death that gives us pause as humans leaves us as clinicians with no time to pause. Maybe, I think, that’s the problem.
It was on the day of this girl’s death that I changed my response to and ceremony around death. Her death wasn’t our first, and it would not be the last, but I remember it because it did mark the end of the old way and the beginning of the new—our pause —and my determination to speak up, to ease up on the tamping down of emotion, to be brave.
When our best efforts cannot sustain life, sharing a moment of quiet reflection among the team can be powerful. As we honor the life lost, we reconnect our humanity with the patients and families we serve and reaffirm our obligation to uphold our special professional responsibilities with humility and grace. I encourage each of you to read his article. (Crit Care Nurse, Feb 2014, Vol 34, No 1, 74-75).
One of the key principles of a High Reliability Organization is the commitment to resilience. There is no single path or checklist to accomplish this. Nonetheless, it is clear that taking our emotional pulse, such as we learn from Captain Sully, and using tools such as The Pause are meaningful. They can recharge our physical and emotional batteries as we reaffirm our humanity and privileged profession.
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!
I’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.
This 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!
Today’s post is by Guest Author, John Nance, Telluride Experience Faculty, Author and ABC Aviation Consultant
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.
And 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.
It is happening…and it is growing. A newer generation of caregivers – young physicians, nurses, pharmacists and other allied health professionals – are stepping up and starting to make a difference. Many of them understand and appreciate they will soon be the gatekeepers for high quality, low risk, high value patient care. They seem to be taking this responsibility seriously – more seriously than I and my older generation colleagues did at their age. They stay connected reading new information shared through social media outlets. They are doing regular literature searches for new articles on quality, safety and value. They want to learn and understand.
The reflective post shared below by Rajiv Sethi is just one of many similar posts that come from our Patient Safety Summer Camps. These young learners don’t just write reflections…they take their reflections and use them to research and learn best practices related to the topic in question. They want to learn, they yearn to learn.
There are days when many of us feel we are slogging uphill, going nowhere and will never live to see the changes so badly needed in healthcare. Working with these young caregivers revitalizes the faculty, just as much as the students are energized and educated around patient safety. Spending time to both educate and learn from the young is so important to the future of healthcare, but also our future and the future of every patients.
Published July 28, 2015 | By Rajiv Sethi
Having only been at Telluride Experience: #AELPS11 for a day, I hadn’t imagined I would have learned so much. We covered a variety of topics with important patient safety learning points. I am so grateful for the opportunity to be here and share the experience with so many motivated individuals keen to be change agents.
I wanted to focus on one of the key moments for me: The Story of Lewis Blackman (http://qsen.org/faculty-resources/videos/the-lewis-blackman-story/). We were very lucky to have Helen Haskell (Lewis Blackman’s Mother) with us and I am so grateful to her for sharing her story. So many issues were raised during the video and I was able to draw many parallels to health care in the UK. For example, the issue of reduced staffing levels on the weekend (see link). The consequences of this can be severe as was found in a study published in the BMJ, Day of week procedure and 30 day mortality for elective surgery… where patients undergoing planned surgery were more likely to die if they have their operation at the end of the week. The new plans proposed by Jeremy Hunt (Health Secretary) to increase staffing provision at the weekend in the UK are causing much controversy, recently culminating in the hashtag #IminworkJeremy (staff posting pictures of themselves at work at the weekend).
Another issue I wanted to focus on may seem rather obvious, but as a student I believe is one of the easiest things to incorporate in daily practice; the importance of health care professionals and students introducing themselves fully to patients. In the story of Lewis Blackman, there was a lack of communication and identification of the team involved in the care of Lewis. As a result his family were unaware of who best to raise issues with.
There is so much to learn from this story but I want to end reflecting on Dr Kate Granger’s hashtag #HelloMyNameIs campaign. On her blog she describes herself as a doctor and terminally ill cancer patient musing about life and death (Click here for story). She has done remarkable work in encouraging health care staff to introduce themselves to patients, with support from over 400,000 staff in over 90 health organizations including many NHS trusts. Only recently did I see a lot of the standard hospital name badges at Guy’s and St. Thomas’ NHS Foundation Trust (where I train as a medical student at King’s College London) being replaced with bright and colorful #HelloMyNameIs name badges. Although it may sound simple, the impact on the patient experience is phenomenal.