Over the last five days in Telluride, I have gotten to know an awesome group of 26 medical and nursing students. You clearly will play key roles in changing patient safety in constructive ways. As Dr John Toussaint (ThedaCare Center for HealthCare Value, Appleton, WI) suggests: “How can we provide high quality care unless we provide a base of safe care.”
Various descriptors come to mind. Compassionate. Caring. Thoughtful. Very smart. Respectful. Self-reflective. Genuine listeners. Open to learning and sharing new ideas. Passionate. Willing to live your values in speaking up, decision making and problem solving. Mindful. Inclusive. Thirsting to know more about patient safety….and you did.
You became good friends, bonding, getting to know and care about each other as human beings without labels or titles or tribes. It is clear you are patient and team focused and became even more so during our indoor and outdoor classroom work, social times and the big hike.
Telluride and the mountains are beautiful. Y’all have an inner beauty that will continue to serve you very well in all you do.
I didn’t want our time together to end, especially when several commented that this experience has been life-changing. I am desirious of staying in touch as you take your individual learnings and feelings forward and to helping you in any way I can.
I continue to encourage you to always live and to role model your True North. You will be seriously tested.
I wish each of you many blessings! I am honored to call you friends….
Twelve years…that is how long it has been since we first traveled to Telluride, CO to kick-off our inaugural Patient Safety Educational Roundtable and Summer Camp. As we headed west again this weekend to meet with the 36 graduate resident physicians and future health care leaders who were selected from a large group of applicants, it is hard not to think back about all that has happened in those twelve years and the many who have contributed to make it happen.
Twelve years ago, those who came to Telluride believing in our Educate the Young mission consisted of patient safety leaders Tim McDonald, Anne Gunderson, Kelly Smith, Deb Klamen, Julie Johnson, Paul Barash, Gwen Sherwood, Bob Galbraith, Ingrid Philibert, and Shelly Dierking to name just a few. However, the smartest thing we ever did was invite patient advocates to the Patient Safety Educational Roundtable. People like Helen Haskell, Carole Hemmelgarn, Patty and David Skolnik, and Rosemary Gibson were active partners in our work from that first year and made our discussions more productive and our outcomes better.
Over the years, many new faculty joined us in our Educate the Young journey. Some of these additional patient safety faculty included Lucian Leape, Richard Corder, John Nance, Paul Levy, David Classen, Kathy Pischke-Winn, Joan Lowery, Roger Leonard, and Tracy Granzyk. We were also fortunate to have international safety leaders join our faculty, including Kim Oates and Cliff Hughes from Australia, who became regular attendees and popular “mentors” to the future healthcare leaders even though they had to travel almost 10,000 miles to join us each year.
Through all these years, two things remained constant – our commitment to Educating the Young and our partnership with patients. Helen, Carole, Patty, David, and Rosemary continue to be active participants each year but additional patient advocates have joined us including national advocacy leaders Dan Ford and Lisa Freeman.
Through the vision and support of Carolyn Clancy and the AHRQ, what began as a small educational immersion for twenty health science students has now exploded. We continue to grow because of the generous support of The Doctor’s Company Foundation (who provides full scholarships to close to 100 medical and nursing students each year), the Committee of Interns and Residents, COPIC and MedStar Health. This year, over 700 residents, medical students and nursing students will go though one of the Telluride Experience Patient Safety Summer Camps. Out Telluride Scholars Alumni network continues to grow – our future health care leaders staying connected through the years, sharing quality and safety project successes and learning from each other. And, for the first time, the Telluride Experience went International this past spring as we ran patient safety camps in Doha, Qatar and Sydney, Australia.
Thanks go out to the many passionate and committed faculty and others who have given so much to make our Educate the Young journey so very special. It has been an amazing twelve-year run…
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.
As we reflect on our continued commitment to eliminating preventable medical harm, it is important to never forget the lost loved ones that help keep us focused on our important mission. On this Father’s Day, as a proud parent and even prouder grandparent, I can’t help but reflect back this morning to last year’s Telluride Patient Safety Summer Camp and the personal story Caitlin Farrell shared with all of us on Father’s Day last year. Her story is also featured this weekend on http://runningahospital.blogspot.com/ It is one story I will never forget…
Published June 16, 2014 | By CFarrell
Yesterday was Father’s Day, 2014. I woke up before everyone else in my room. Rolling out of bed, I padded down the stairs and brewed a cup of much-needed coffee. Pouring my face over the steaming cup, I looked out my window to the inspiring landscape of endless white-capped mountains. This year marks the ninth Father’s Day that I have spent without my dad, but the mountains and my purpose this week made me feel as though he were standing there with me, sharing our cup of morning coffee, just as we used to.
After taking the gondola ride into Telluride, the students and faculty plunged into our work of expanding our knowledge in the field of patient safety. We watched a documentary outlining the tragic case of Lewis Blackman, a 15-year-old boy who died due to medication error, miscommunication, and assumptions made by his medical team. The film explored the errors in Lewis’s care that have become far too common in our medical system: the lack of communication between providers and families, the establishment of “tribes” within medicine who do not collaborate or communicate with one another, the lack of mindfulness of the providers, and the culture in which all of these errors were permitted to happen.
But what resonated with me the most were the feelings described by Lewis’s mother. She defined her experience as one of isolation and desperation. “We were like an island”, she said. There was no one there to listen to her concerns. Ironically, Lewis died as a result of being in the hospital, the one place where he could not get the medical care that he so desperately needed.
A pain hit my stomach as she said these words. My family also shared the feelings of isolation, uncertainty, and loss throughout my father’s stay in the hospital. After Lewis’s death, his mother was not contacted. Instead, she was sent materials about grieving and loss in the mail. After an egregious error occurred during my father’s medical care, a physician did not give us an apology, but a white rose by a nurse.
An interesting discussion arose after the film. Our faculty emphasized the need for physicians to partner with the families of the patients. This will create not only a team during the course of treatment, but will cultivate compassion, empathy, and trust in the case of a terrible event. I know that despite the growing number of “apology laws” that protect, and even mandate, physicians to apologize to families after catastrophic events, few physicians actually do apologize. This results in families feeling like the events were there fault. I can say from experience that this is a burden that you can carry with you for years to come.
As I got back to my room and put down my books, this conversation mulled in my mind. The death of my father has given me the fuel to pursue medicine and patient safety as my career. It has instilled in me passion, energy, and determination. Yet the one thing that I have not found in the nine years since my father’s death is forgiveness. Although I do not hold any one doctor or nurse responsible for the detrimental outcome in my father’s care, I have not been able to forgive the team for what happened. I have not been able to go back to that hospital. And as I sat on my beautiful bed in the mountains, I realized that I also harbored another feeling: fear. Fear of becoming a physician who does not practice mindfulness, who does not partner with my patients, who does not apologize for my mistakes. I am afraid that despite my best intentions, I will only continue the vicious cycle. A fear that I will allow my patients to feel as though they are “on an island”.
I put away my computer and got into bed. Lying awake, I took in the gravity of the day. I am so grateful to be here at Telluride among students and faculty who share my passion in patient safety. I could not have imagined a more perfect way to spend Father’s Day.
For the last twelve months, our health system has undertaken a system-wide initiative to join the ranks of healthcare organizations like Cincinnati Children’s Hospital, Poudre Valley Hospital, and Mainline Health on a journey that seeks high reliability. We have already seen the fruits of this journey, and believe that when the benefits of a High Reliability culture are combined with the expertise provided by our National Center for Human Factors in Healthcare, led by Terry Fairbanks MD, MS, along with the guidance provided by our National Patient and Family Advisory Council for Quality and Safety, exciting opportunities to improve quality and safety while reducing cost can be realized.
An important part of this journey includes creating a learning culture built on transparency that many in healthcare are still uncomfortable with. Overcoming these barriers requires consistent and repetitive role-modeling and messaging around core principles that help instill and reward open and honest communication in an organization. One of the ways we continue to reaffirm these important messages is through our “60 Seconds for Safety” short video series, which highlights different high reliability and safety principles. Each week, a video from the series is attached to our “Monday Good Catch of the Week” email, delivered throughout our system. The video highlights one important safety message all our associates can become more familiar with, and hopefully apply as they go about their daily work that week. Similar to starting every meeting with a safety moment, we want all of our associates to start each new week with an educational message reminding us that safety is our number one priority. The videos are available on MedStar’s YouTube Channel, under the Quality & Safety playlist. Please feel free to use any of these videos in your own Quality & Safety work — and please share ways you are getting the quality & safety message out to your front line associates.
Because so many of our readers are compassionate young physicians, and physicians-in-training, we wanted to share another opportunity for you to showcase that passion and commitment for keeping patients safe. The Doctors Company Foundation, an organization that also sponsors a number of medical student attendees to participate in our Telluride Student Summer Camps, is 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 deep personal insight into the significance of patient safety work.”
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 12-13, 2014. Nominations must be submitted by 5:00pm ET, Monday Feb 3, 2014.
- As of June 2013, applicants must be either a 3rd or 4th year medical student or a 1st year resident in hospital setting
- Award is for the best essay explaining your most instructional patient safety event during a clinical rotation-one that resulted in a personal transformation
- Award will be conferred by The Doctors Company Foundation in partnership with the Lucian Leape Institute at AAMC’s Integrating Quality meeting in Chicago
For an example of this year’s winning essays, click here. Please contact us or visit the websites if you have questions! 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!
If you want to succeed, double your failure rate.
Thomas Watson, Founder–IBM
John Seely Brown, often referred to as JSB and former Chief Scientist at Xerox and Director of the Palo Alto Research Center (PARC), co-authored A New Culture of Learning: Cultivating the Imagination for a World of Constant Change. In the book, JSB and Douglas Thomas, associate professor at the Annenberg School for Communication at the University of Southern California, discuss the need for learning in this century and beyond to be collaborative, welcoming questions, and challenging what we “know” to be answers. From the book:
…in the new culture of learning the point is to embrace what we don’t know, come up with better questions about it, and continue asking those questions in order to learn more and more, both incrementally and exponentially. The goal is for each of us to take the world in and make it part of ourselves. In doing so, it turns out, we can re-create it.
The authors also talk about the need to embrace change, “looking forward to what comes next and viewing the future as a new set of possibilities, rather than something that forces us to adjust.” We don’t have to look very far to see the world changing much more quickly around us. The technology being developed is so intuitive, kids 5- and under can easily pick up an iPad or smart phone and navigate their way through the latest version of Angry Birds. JSB and Thomas provide examples of the 70 years it took from the discovery of a color TV signal in 1929 by Bell Labs to color TVs becoming ubiquitous in American homes, versus the exponentially faster adoption of internet technology (18% of households with internet access in 1997 to 73% in 2008). The tools we use in all business sectors, especially healthcare, are now more capable of harnessing large amounts of data that can drive solutions to questions that years ago may have seemed ridiculous, too “far out”, or even crazy.
So how does this all fit in medicine and medical education? The quote that led this post–“If you want to succeed, double your failure rate,” has no place at the bedside. But now, more than ever before, healthcare has a real need to solve the problems that are burying the industry with new thinking that comes from new learning. Simulation training and redesign of curriculum are two ways to address the needs not currently being met in medical education. But it goes deeper than that–as so many have said, the culture of medicine needs to shift. Medical students and residents have not only been bullied in their training by know-it-all mentors creating a learning environment that not only kills creativity, but the spirit as well. With all the discovery yet to be made in the sciences, how could one person think they “know” all the answers–wouldn’t it be best to view what is known as a starting place, and use it as a springboard to invite other intelligent, knowledgeable people into the conversation to take that baseline knowledge further?
In my maybe not-so-humble opinion, learning should embrace the not-knowing as well as the knowing. How we accomplish that in healthcare will take a shift–not only in thinking but in long-held beliefs as well. We don’t have the luxury of waiting for those afraid of change to leave medicine, and we don’t want to continue a stilted learning process that has proven to limit options. This change needs to be embraced today, and John Seely Brown’s book is both a lifeline and a roadmap. Please take a look at his keynote at Indiana University below, or pick up the book–I barely scratched the surface of the wealth of content contained within.