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!

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Healthcare Transparency As A Blockbuster Drug

“If transparency were a medication, it would be a blockbuster, with billions of dollars in sales and accolades the world over. While it is crucial to be mindful of the obstacles to transparency and the tensions—and the fact that many stakeholders benefit from our current largely nontransparent system—our review convinces us that a health care system that embraces transparency across the four domains will be one that produces safer care, better outcomes, and more trust among all of the involved parties. Notwithstanding the potential rewards, making this happen will depend on powerful, courageous leadership and an underlying culture of safety.”

Screen Shot 2015-02-02 at 10.35.49 PMThe previous paragraph comes from the fifth and final National Patient Safety Foundation’s Lucian Leape Institute (LLI) White Paper entitled, “Shining a Light: Safer Health Care through Transparency”. Each of the five white papers address key issues that healthcare stakeholders will need to successfully manage if healthcare is to achieve zero preventable harm. I was honored to be part of the panel that helped create this paper and the 39 recommendations for greater transparency throughout healthcare.

Defining transparency as “the free, uninhibited flow of information that is open to the scrutiny of others”, the paper provides recommendations in four different domains of transparency:

  1. Transparency between clinicians and patients (illustrated by disclosure after medical errors)
  2. Transparency among clinicians themselves (illustrated by peer review and other mechanisms to share information within health care delivery organizations)
  3. Transparency of health care organizations with one another (illustrated by regional or national collaboratives)
  4. Transparency of both clinicians and organizations with the public (illustrated by public reporting of quality and safety data)

I encourage everyone to visit the LLI website and download the White Paper (click here for a copy). Increased transparency is critical to any Patient Safety mission. Greater transparency throughout the system is not only ethically correct, but will lead to improved outcomes, fewer errors, more satisfied patients, and lower costs.


Leading From the Heart

NYE_Lights

Leadership is not so much about technique and methods as it is about opening the heart…about inspiration–of oneself and of others. Great leadership is about human experiences, not processes…it is not a formula or a program, it is a human activity that comes from the heart and considers the hearts of others. It is an attitude, not a routine.
Lance Secretan

Secretan’s teachings are based on the core principle of connecting the soul with what we consider as “work”– the two becoming intertwined in a way that redefines our “work-life” balance, making both truly fulfilling. It combines our inner passion to make a difference in someone’s life with our reason to get up each morning and go to “work”.

Each day in healthcare we are given the opportunity to make the world  a better place—for our patients, our colleagues and our communities. As healthcare providers, we entered into our profession to care for others–to keep our patients safe at all costs while under our care. Think of the healing power that could occur not only in our healthcare workforce, but also in our patients, if leaders created care environments that were truly places that nurtured the soul.

Rosemary Gibson said it best when she paraphrased Gandhi, reminding us: “A patient is the most important visitor on our premises. They are not dependent on us – we are dependent on them. They are not an interruption in our work – they are the purpose of it. We are not doing our patients a favor by serving them, they are doing us a favor by allowing us to serve them.”

Can healthcare leaders create a work environment that reflects and honors the creative spaces of the soul and brings passion back into our daily work? Can healthcare leaders inspire caregivers to connect with their own inner values in helping health systems achieve the highest quality, safest care possible for both patients and caregivers?

As we move into the New Year, I am hopeful we can all “lead from the heart” in ways that inspire ourselves and others to achieve the highest quality, safest care possible for our patients and our caregivers.

Wishing everyone a healthy and happy new year.


Calling for Responsible Healthcare Journalism

IMG_20140729_162034As the Ebola virus lands closer to home, it has been disappointing to watch the hype, inaccuracies and blame circulating in various media on what continues as a yet-to-be controlled humanitarian and health crisis in West Africa. Those who have been aware of this evolving issue, such as many well-trained, conscientious infection prevention professionals around the country, know this disease has been threatening the West African countries of Liberia, Sierra Leone and Guinea with increasing magnitude since March of this year, taking the lives of far too many West Africans over the last 7+ months. As a result, Ebola abroad, and now for the first time in the US, is also a very dynamic situation, like much in healthcare. As such, responsible healthcare journalists, weekend warrior bloggers or persons with a Twitter account might want to take into account that as more is learned, protocols and best practices will, as expected, evolve.

An excellent Infectious Disease (ID) blog sharing good information about Ebola is Controversies in Hospital Infection Prevention, hosted by three ID physicians from the University of Iowa: Mike Edmond MD,  MPH, MPA, Chief Quality Officer, Eli Perencevich MD, and Dan Diekema MD, Director, Infectious Disease. In July, Edmond (@Mike_Edmond) posted, Ebola Hemorrhagic Fever: A Primer, which contains foundational information about the virus, much of which is based on CDC Ebola interim guidances, that are also evolving. And to put Ebola in a more realistic perspective and take away some of its horror film power, it is a very slow-moving infectious disease per Eli Perencevich MD (@eliowa), who writes in an October 9th post, Traveling with Ebola is not traveling with influenza:

The…most important difference between the current Ebola outbreak and the 2009 H1N1 pandemic is that Ebola is very slow-moving….the first case of Ebola is thought to have occurred 307 days ago on December 6th in a two-year old boy. Since that time there have been an estimated 8,032 cases …If you compare a similar 307-day period for 2009 H1N1, April 12, 2009 to February 12, 2010 CDC estimated between 42 million and 86 million cases occurred in the US with a mid-level estimate of 59 million people infected…7300 times more cases of H1N1 using the mid-level estimate

Fast Company staff writer, Rebecca Greenfield (@rzgreenfield), in Ebola Deeply is the Only Place You Should Be Getting Ebola News, directs those in search of Ebola related content without the hype, turn to the single source news website, Ebola Deeply, started by Lara Setrakian (@Lara) a former ABC News and Bloomberg reporter. After clicking onto the site, readers are immediately drawn to the NYTimes video story by video journalist, Ben C Solomon, also embedded below. The story shows what life is like on the streets of Monrovia for Gordon, a Liberian Ebola ambulance driver, separated from his family as a safety precaution for over five months. What he describes sounds like going to war against an invisible opponent, with limited armor and safe harbors. Certainly in a resource rich country like ours, we should be able to handle what courageous true front line Ebola warriors are fighting with much less.

While healthy critique of those charged to create solutions in the US provides a good check and balance, it’s disappointing to watch the finger pointing that rears up in such a well-resourced, educated country, especially as those in West Africa have far less time to discuss and instead are using that energy to improvise and stay alive while caring for their thousands of ill patients vs our limited number of cases to date. In fact, more people died in the last week due to all medical harm in the US than to an outlier of an infectious disease like Ebola. To add even greater perspective, a recent New York Times article by Elisabeth Rosenthal MD, For Ebola Health Workers Risks and Duty Collide, closes with the following:

…Meanwhile, Dr. Cooke said she has tremendous admiration for the doctors in West Africa: “It’s been inspiring to hear African health care workers saying ‘I’m a doctor, these are my people. There’s no choice.’ It’s a fundamental reminder of what it means to be an M.D.”

And with the arrival and death of an infected patient to a Dallas hospital, and the subsequent infection of two nurses who treated him, many of the existing cracks in our healthcare system are being exposed by the media on the larger stage that is now practicing medicine. In an interview on the Today Show last Thursday, a nurse working at the hospital spoke with Matt Lauer, sharing the need to come forward knowing full well she might lose her job. Not knowing the full story, the fact that this could happen comes as no surprise to those working in healthcare. However, it is important to note we still have one of, if not the, very best systems in the world–cracks and all. A safe healthcare system has a just culture, and when a nurse “voices concern” about his/her own safety, as well as that of patients and colleagues, he/she is heard, even thanked, by those who can fix and address those concerns. Many healthcare organizations across the US are creating environments that welcome this voice, yet others are still far from adopting this culture. While not at all familiar with the culture at this particular hospital, nor the institution’s side of the story, it appears from the Today Show interview this nurse voiced concerns that initially went unaddressed. To this end, we see how failure to embrace elements of a just culture could affect patient and provider safety in real-time. This could be an unfortunate example of a long existing need for greater urgency around culture change in healthcare.

And despite the “he said, she said” or “they should of…” thinking, there are many looking for solutions to stop the outbreak in Africa. In a recent @FastCoExist article, Can Better Design Stop Ebola? How Creative Minds Can Help, Jessica Leber writes:

…On just one day’s notice, almost 200 people crowded an auditorium at Columbia University’s engineering school on a Thursday evening in early October. Engineers, designers, and public health researchers were there to learn and brainstorm, and do so quickly…Columbia isn’t the only institution interested in applying design thinking to the health and humanitarian disaster. On October 9, USAID, partnered with the innovation platform OpenIDEO, the CDC, the Department of Defense and the White House, announced its sixth in a series of “grand challenges for development” focused on crowdsourcing ideas for better tools to fight the virus. Anyone can contribute to the brainstorm, and the government hopes to begin funding the strongest ideas in a more formal challenge competition “in a matter of weeks.”…

Getting to the other side of this real-time test of our infection prevention and containment abilities at home, the hope is that we will rise to the challenge and become that much stronger as a national healthcare system for having gone through the experience. As Edmond writes in a Controversies in Hospital Infection Prevention post on October 14th, Ebola: The Questions Keep Coming:

…the Ebola crisis is challenging us in many ways and will likely continue to do so for quite some time. But perhaps we’ll emerge from this with a more thoughtful approach to patient care that improves safety without sacrificing quality.


What Does Transparency in Healthcare Mean to You?

Yesterday’s afternoon discussion at Telluride East was focused on “Transparency”, a buzzword for many in healthcare today, but a concept that holds tremendous meaning for patient safety and caregiver well-being for those who walk the talk. Dave Mayer started the conversation by asking the group to share what transparency meant to them, and then breaking up the larger group to discuss:

  1. What are the barriers to transparency in healthcare?
  2. What are the barriers to being transparent with patients?
  3. What are the benefits to having a transparent culture in place?

In our small group, several themes emerged, and surprisingly, not the least of which revolved around leadership and culture being the primary drivers of the “shades of transparency” experienced by both providers and patients in any given health system. One of our student scholars shared how he feels his excellent intuition, or spidey senses, need to be kept in check so as not to appear a “pain in the butt” to senior physicians–physicians who set grades and can directly impact his medical career. Those same spidey senses activated in the mindful physician during the delivery of care, or as he coined it, hypervigilence, are exactly what is being called for in healthcare organizations seeking to become high reliability systems. Here was someone who clearly was acting in the best interest of a patient, and because of hierarchy and poor leadership, was made to feel as though his intuition was a bad thing.

In a related and revealing post, I’m sick and tired…but far from done, Telluride faculty and colleague, Richard Corder, shares his ire related to watching the bad eggs of healthcare remain in place, to continue to harass and cripple the well-meaning efforts at culture change. While he comes from a position of understanding “the why” of the situation, he’s also sick and tired, as are many well-intentioned caregivers who have chosen to remain silent in the face of leadership that fails to lead–and worse yet–infuses toxicity into a culture and careers of those less tenured. When I hear stories like these I know we still have a long way to go to create a healthcare that is safe for all who work within it, or enter it as a patient.

The silver lining to all this is the medical and nursing students who have chosen to come to Telluride this year. The same medical student mentioned above also stated, “when I’m an attending, I will encourage questions about the care being delivered.” And I believe him, but I also know the real world sometimes takes that passion, that resolve, and turns it into “shades of the self” that if not careful, can turn even the most well-meaning individual into someone who has to rationalize or tone down the goodness within. It’s our job as healthcare leaders to support those young learners in any possible way we can. This is a recurring theme that comes to light at the Telluride Patient Safety Summer Camps…


Communication at Center of #TPSER10 Day One Discussions

Helen_Dave_Lead_discussionEach year in Telluride, we kick off the week’s conversation on open and honest communication in medicine by showing the Lewis Blackman Story. For the 10th year in a row, Helen Haskell, Lewis’ mom, was part of the Telluride faculty and for the third year, led the post-film discussion along with Telluride Patient Safety Student and Resident Summer Camp founder, Dave Mayer MD. Many of the resident scholars commented on the various levels of communication failure that occurred during Lewis’ care. Doctor to patient communication, provider to provider communication, power gradient communication challenges–it has been clear for some time that being uncomfortable communicating with anyone in the circle of care to patients puts the patient, and also caregivers, at risk. Lewis’ case is an unfortunate example of what goes terribly wrong when open, honest communication is not valued in a health system.

For those of you who haven’t heard Lewis’ story–he is someone you would have loved to have met. He would be 28 years old this year had his path not crossed that surgical suite almost 14 years ago. An actor, a scholar, an athlete — a lover and friend of the underdog–Lewis was the teen you hoped your kid was hanging out with when you weren’t around. By all accounts, Lewis’ was poised to do wonderful things and he left his mark on life early through his caring, thoughtful nature, a witty sense of humor, a loving son and brother, and now an inspiration to many of us trying to make care safer for patients today. He is one of many who serve as an example of continued and senseless loss in our slow movement toward zero preventable harm in healthcare. We need to decide today, that it’s time to take action in new ways to prevent the same stories from repeating.

For example, what can we do to improve our professional communication skills among healthcare teams so that we ensure families like Lewis’ do not suffer a similar loss? So that good, conscientious caregivers are not put through the traumatic experience of harming a patient out of fear of speaking up in a toxic culture? Which medical education programs are stepping up to incorporate interpersonal communication skill building into their core curriculum from the first day of medical school? Please share best practices in teaching medical and nursing student communication, and start an open conversation about better ways to teach communication to care providers at every level.

 


Using Twitter to “Live Tweet” a Kidney Transplant @UofUHealthCare

University of Utah Health Care (@UofUHealthCare) pushed the healthcare social media agenda forward yesterday, as well as heightened the bar for transparency in healthcare, as they “live tweeted” a kidney transplant. Not only were they tweeting progress of the surgery, they were posting photos and interacting with the media to answer questions. The team also engaged their patients in this process, even posting photos of the donor in recovery. While I have seen surgeries tweeted in the past, I have not seen anything on this scale, or so inclusive of every person — patient and provider — during the actual delivery of care in such a high-stakes surgery. Kudos to them!

Below is a screen shot of a story aggregated on Storify captured before, during and after the event (click here for full version), but for those interested in, or leading healthcare social media, I highly recommend seeking out @UofUHealthCare’s twitter feed from May 20th, 2014. It provides a textbook lesson in new media and healthcare transparency!

@UofUHealthcare Kidney Transplant