Needed: A Greater Sense of Urgency Around Patient Safety & Culture Change in Healthcare

TSPRE9_Resident_Wk_2013_Grp_PhotoAfter spending a week with some amazing resident physicians at the Telluride Patient Safety Educational Roundtable & Student/Resident Summer Camp, I feel an even stronger need to create a greater sense of urgency around patient safety–as well as building patient centered care environments with a just culture as the foundation. The stories this passionate group carried with them to Telluride and shared with the group were the muse for this post.

For example, one physician, fighting back emotion, courageously told the group how she recently had to push a senior level care provider to finally acknowledge her concerns about an infant who later died. The physician sitting next to her, with emotional intelligence off the charts, not only acknowledged her pain, but that he also knew she had done everything she could in the best interest of her young patient. In a reflective blog piece, another Telluride alum expressed concerns about just how dangerous the academic medical environment is for patients. And more than one physician shared how coming together in Telluride, having an opportunity to compare similar experiences in an environment where open, honest communication was revered, was a reminder of why they went into medicine in the first place. But I wonder, how long can the Telluride influence last if the culture of our care environments these amazing, but human, care providers return to, does not change to embrace rather than ostracize those who truly put patient centered care before all other agendas?

Paul Levy, (Not Running A Hospital, and more), Telluride faculty for a second year, was equally as awed by the residents who attended. In a parting post on his blog, Not Like Too Many Hospitals, he also expressed the understanding that while this patient safety journey takes time, that time includes costs. Those costs are the lives and well-being of patients across the country. Here is an excerpt from his post:

As I have said before: Sometimes, I remind myself to be patient.  It is hard to change the medical system quickly.  But, more often,  I find myself agreeing with the words of Captain Sullenberger: “I wish we were less patient. We are choosing every day we go to work how many lives should be lost in this country. We have islands of excellence in a sea of systemic failures. We need to teach all practitioners the science of safety.”

I hope and trust that our attendees these last few days in Telluride will have the commitment and courage to make a difference during their careers.

I came across an old post on the Transparent Health blog, Stand Up-Stand Out, as I was reading resident and student reflections from this year and last. In this post, I had referenced Dr. Don Berwick’s essay in JAMA, To Isiah. Following is an excerpt I shared with Telluride 2012 alumni to carry with them as they returned to those who have yet to learn what they have, or worse, those who create barriers to progress. It remains true — even more so today.

…There is a way to get our bearings. When you’re in a fog, get a compass. I have one—and you do too. We got our compass the day we decided to be healers. Our compass is a question, and it will point us true north: How will it help the patient?

TPSER9_Residents_Jump_for_JoyThe faces of this year’s Telluride 2013 Class are reflective of all the good that the healing profession has to offer. Anyone reading this post who is in a position to Stand Up and Stand Out–to clear the way and allow their passion to expand and elevate, not only patients, but the spirit of colleagues as well, please help. Today —

Meanwhile, the Telluride alumni network continues to grow, building a critical mass of voices who believe patient centered care comes first, above all else. We are here for you–reach out, continue to share your stories — they can move mountains!

Collateral Damage

I once heard Don Berwick say, shortly after taking over as Director for CMS, that he originally thought quality and safety where the biggest challenges facing healthcare today. But after spending time in the district, he quickly came to realize he was wrong. It was fraud that was the biggest challenge.

Collateral DamageHis message came to mind after recently reading a book given to me by Rosemary Gibson, entitled “Collateral Damage”, written by Dan Walter. I can honestly say that after reading the book, I felt embarrassed to be working in healthcare.

In the book, Mr. Walter shares the story of his wife, Pam, who underwent a cardiac catheter ablation procedure for an abnormal heart rhythm known as atrial fibrillation. He describes what went wrong during Pam’s procedure, and then details the pain, suffering, lack of transparency and denial of accountability that followed for both he and his wife. The procedure was performed at what is considered to be one of the best hospitals in the country, which makes the reader wonder what is going on at the “not so great” hospitals across the country, as well as who is defining what makes a hospital “great”. His aim in writing the book was to, “accurately portray what happened to my wife…without detracting from the skill, kindness and compassion of the majority of the people who work there…and to prove to Pam that she does matter, and to tell her that despite what the leadership of that hospital says, her life is important – and her story is important – and it deserves to be honestly told”.

The book is Mr. Walter’s account of the facts related to his wife’s care, so it is only his side of the story. However, it is remarkably well written, and gives a deeply researched account of the cardiac catheter ablation “business”. He includes information:

  • Taken from numerous publicly available FDA transcripts and testimonies on how unsafe these catheters were thought to be.
  • Promotional materials from companies making these catheters who were trying to get them through the FDA approval process hyping the wonderful results being seen in patients who were the first to be “experimented” on.
  • Transcripts from advisory panels and cardiology meetings where leading experts acknowledged the lack of evidence that these catheters even worked.
  • Conclusions from peer-reviewed journals showing complication rates much higher than what was being shared with patients.
  • Medical records highlighting a lack of real informed consent related to the risks and benefits of these procedures.

Mr. Walter also shares numerous other patient stories and holds nothing back. Not only does he name names, but he includes pictures of physicians and others who he and Pam encountered along their journey.

In one section of the book, the author shares thoughts on the difference between a “witness” and an “accomplice”, a witness being one who sees wrong and reports it.  He raises the question that if we as caregivers witness something wrong and don’t report it, aren’t we really accomplices to the wrong when we turn our back and walk away?  His statement caused me to reflect back on my career. As an anesthesiologist, I remember days when I was assigned to provide anesthesia for a catheter ablation case. Although I spoke with the patient about anesthesia related risks and benefits – I never thought of questioning the merits of the procedure I was to be a witness to. It was challenging enough keeping up with all the new findings in my specialty let alone comprehend everything being published in the numerous specialties anesthesiologists support. But after reading Pam’s story, I felt that I too may have been an “accomplice” to possible wrong doing.

I applaud Mr. Walter for sharing Pam’s story. I also struggle to understand why this book has not received similar attention, or the same hype experienced by authors of recent books published on medical error. Collateral Damage goes much deeper in highlighting problems facing healthcare today…a reason why I believe this book should be required reading for all resident physicians and health science students entering the field.

As quality and safety leaders and educators, our daily efforts are built around things like standard work processes, shared best practices, care bundles, checklists and universal protocols–“things” we do in the best interest of our patients. The bigger picture, as Don Berwick alluded to, requires that we overcome the personal, political, legal and financial agendas inherent within many high-level stakeholders. Otherwise, I sometimes feel we are just moving chairs around the deck of the Titanic.

For those interested, Dan’s book is available free on Amazon Kindle as of June 12th

McDonald and Mayer Receive ACMQ Founders Award For Body of Work in Patient Safety and Quality

Last week, Dave Mayer MD, the host of Educate the Young, and Tim McDonald MD/JD, were honored for the quality and safety contributions they have made throughout their careers. The pair received the American College of Medical Quality (ACMQ) Founders Award–an award shared by an esteemed group of luminaries in patient safety and quality, such as Carolyn Clancy, Brent James and Don Berwick.

Because of their dedication to students, residents and care providers and their constant premise of “Educating the Young”, many have joined the patient safety movement along the way using their teachings as touchstones for change. Here are excerpts from the shared acceptance speech they gave last week:

All of us working in the quality and safety domain move at such an urgent pace, trying to implement new ideas or best practices that can reduce harm or increase the quality of care for our patients. Because of this, there is little time to reflect on the past and much work still to be done.

Everything we’ve accomplished was made possible by many other thoughtful, clever, original, and wonderful people who invested their passion, soul and expertise in this work.

Whatever we may have accomplished came as a result of our focus always staying true to three things…

First, the importance of the Patient Voice. We have learned more about safety and quality from patients and family members than we have from many of our colleagues. Ten years ago through Rosemary Gibson’s mentorship, we brought patient and family advocates to our Telluride Patient Safety Roundtable long before the term “patient partnership” was a common phrase in quality and safety. They have been a huge part of our work through the years – helping design and implement the Seven Pillars program, being members on our safety and quality committees, creating and teaching in our quality and safety educational programs from our medical school up through our Master’s Program – their support and partnership with us has been so critical to our mission and a classic demonstration of a partnership for patients as CMS envisioned

Second, the importance of Honesty. We did it wrong for too many years. Deny and Defend models when harm occurs don’t work – it is a morally and ethically wrong approach – and it stifles learning and improvement. As Rick Boothman the CRO from Michigan says” “we don’t need a court system to tell us when we have done wrong – we know when we have done wrong.” This isn’t rocket science. We need to be honest and transparent at all times – when we do things well and when we don’t do things so well.. Through the seven pillars we have learned that the honest approach is just not the right thing to do but the smart thing to do for physicians and patients alike.

Third, the importance of a Learning Organization. We are and will always be educators – why this award means so much to us. “Educate the Young” has been an important mission for both of us through the years. The investment ACMQ has made to medical education demonstrates their commitment to “Educating the Young”. The College’s Quality Scholars program that brings students and residents to this meeting is a great example of ACMQ’s commitment to producing the next generation of physician leaders who hopefully always begin each day with their quality and safety compass pointing north.  We congratulate and applaud the scholars who are here today for your interest, commitment and leadership to high quality patient care.

ACMQ Leadership also asked that Dave and Tim share some of the highlights of their work over the years. I will share these highlights in a subsequent post so that others can benefit and build on this work, moving the needle even further in the direction of transparent, safe, patient-centered care for all of us, and our families.

John Harbaugh, Don Berwick, Lance Secretan and the Principles of New Leadership

Having moved to Baltimore about a year ago, I couldn’t help but enjoy watching last Sunday’s AFC Championship game. While the Chicago Bears will always be my number one football team, I have enjoyed following the Baltimore Ravens through their relatively short NFL history because like the Bears, the Ravens have a “blue collar” work ethic–built on strong, physical defenses led by all-pro middle line-backers.  Plus my wife’s family is from Baltimore so our Sundays have always had some element of purple to them–even while living in Chicago.

What really struck me though was the trophy presentation and interviews in the Baltimore locker room after the game. Winning teams always talk about the “great chemistry” the team shares–players and coaches expressing admiration for each other–but this locker room was different. It felt different from the 1985 Super Bowl-winning Chicago Bears, different from last year’s New York Giants’ press coverage. I could feel something more powerful coming through the Ravens players’ interviews. From the owner, to the coaches and down through the players, they all talked about the love and respect they had for each other, and how they always had one another’s back–in good times and bad. It was different…

John Harbaugh and Danny

John Harbaugh and brother-in-law, Dan Crouse and family

Having had the opportunity to meet and talk with John Harbaugh, the Ravens coach, at a fundraiser right after moving to Baltimore, it was clear he is the “real deal”. Coming from a family of great football coaches (John will face brother Jim and his 49er’s en route to a Superbowl championship in what sports pundits are calling the Harbowl or Superbaugh), one could easily tell that being an NFL coach was his true “calling” in life, and what he loved doing most. But it was more than just coaching–it was clear his passion was leading from the heart and serving as a role-model and mentor to the young men on his team. He was humble, caring, and passionate about football–and by the smile on his face when he told stories about his players, you could tell he really loved them. He had no ego, a wonderful sense of humor, and repeatedly poked fun at himself and his own weaknesses. By the end of that evening, I could see why the Ravens players also loved and respected him, and took to his leadership style. It was clear he could be a great leader at any Fortune 500 company.

The Ravens post-game locker room celebration this weekend reminded me of my encounter with John Harbaugh, and about my recent discussions on 21st century healthcare leadership. As in football, it starts with higher ground leadership qualities, and the increasing call for leadership from the heart that inspires others to greatness, and in so doing, brings joy and meaning back into the patient care environment. Those of us that have attended any of the annual Institute for Healthcare Improvement (IHI) meetings over the last 10-12 years understand the power of these John Harbaugh-like qualities each time Don Berwick takes the stage for a keynote talk. Be it his Escape Fire story, or the year he shared his wife’s personal health experience, he was and remains, a consummate storyteller who leads from the heart, knows his calling and inspires all of us to reach a higher level in patient care (see Leadership and Love). His talks elevate others, making everyone in the audience feel as though their work has more meaning after listening to him speak. He is truly one of the multipliers that Darrell Kirch referred to in his keynote at last years AAMC meeting, and as discussed in our recent post, #AAMC12 Calls for New Vision of Leadership. Many safety experts believe high quality, low risk patient care cannot be accomplished unless more leaders possessing these qualities join the healthcare improvement journey.

We have been discussing Lance Secretan, an executive leadership coach who believes it is the following eleven concepts that people are now searching for in those that lead organizations. His philosophy is based on leading from the heart, and his “Higher Ground Leadership” program is based on these concepts. More of his work can be found at:, and I agree that it is these principles, and the examples set by the John Harbaughs, the Don Berwicks and the Lucian Leapes of the world, that we should strive to emulate when we are given the gift of leading others.

  1. Leadership. Many of us are yearning for an alternative to business-as-war and leaders-as-warriors. We yearn for spirit in the workplace and for servant-leaders—people who lead with their hearts as well as their heads and wills.
  2. Values. Business has more opportunity to influence the future than any other institution in the world. New Story Leaders choose to make business an instrument for positive change.
  3. The End of Competition. The root meaning of ‘compete’ is to strive together—exactly the opposite of its usual meaning. The New Story Leader respects our interdependence—our oneness—and sees how it opens opportunities for growth, both within the organization and out in the marketplace.
  4. The Cause. People want to work for a Cause that inspires the soul. A Cause acts as a magnet for passion. It articulates the higher purpose of an organization, it describes how we serve.
  5. The New Customer. The New Story Leader devotes even greater attention to meeting the needs of employees as they do for customers. This goes beyond the usual incentive and reward systems —to practices that awaken passion and satisfy the soul. The result is a dramatic improvement in profitability.
  6. Integration. The New Story Leader creates an environment in which “work” and “life” are not just “balanced,” but blended into an integrated, seamless whole.
  7. The Calling. People are looking for more than a paycheck. They seek joy, meaning and fulfillment from their work. A Calling results in work that engages, nourishes and expresses our souls. The leader’s mission is to enable each follower to find, grow and excel in her or his Calling.
  8. Soulspace. We ask people to contribute to the highest standards of which they are capable while putting them in the dreariest, most uncreative environments in their lives. Imagine the extraordinary work that could flow from sacred workspaces designed to inspire the soul.
  9. Technology. The Internet, as an example—can be a medium for the web of human consciousness, described by Pierre Teilhard de Chardin as the noosphere. New Story Leaders will reinvent their organizations within this context.
  10. Learning. The most important ‘fringe benefit’ is no longer healthcare or a pension; it is the right to learn. Learning inoculates against irrelevance and positively feeds the soul.
  11. Inspiration. The role of the New Story Leader is to inspire others. This ability grows organically from one’s own inspiration.

Developing Storytelling Skills via TEDxEaling

On ETY, we have mentioned more than once the power of sharing patient stories to further the patient-provider connection, as well as deliver teachable moments that touch the soul of a student or colleague and remain with the learner in ways statistics or outcomes data cannot. While some are just natural storytellers, others have to work at it by learning to let go of linear, fact driven reality and follow characters of our own creation or observation down a path out of our control. Don Berwick, has shared his stories of Isaiah, his grandson Nathaniel and Dr. Gruzenski in ways that have stirred a growing healthcare soul to action, making his message of healthcare quality and safety take new life. Having been a student of story most of my life, this new collective energy put toward finding healthcare solutions through storytelling is delightful. We cannot have too many good stories, or good storytellers, in the world–and looking at new ways to solve old healthcare challenges is encouraging.

So in the spirit of helping others develop their own storytelling muscles, I want to share the following TEDxEaling talk by Julian Friedmann, a literary agent, who was one of many in a lineup of storytelling experts that spoke at this TEDx Event in September. If you want to spend a day indulging your creative side, or just learn more about the structure beneath a good story, I suggest clicking over to their website and picking any of the videos from the day’s events (found here). Friedmann’s talk is a good one to start with, as he, like others who make a living creating, developing and selling stories, continues to emphasize how the creation of characters that audiences emotionally connect and engage with gives the writer control over an audience. By then throwing obstacles into the path of a character we now love, writers invite their audience on a rollercoaster ride of pity, fear and catharsis. The higher the stakes, the stronger the catharsis. And catharsis, according to Friedmann, is more than just an intellectual experience–it’s also physical, occuring as a result of the release of  phethylamine or PEA (aka the “happiness drug”) into the bloodstream. The same release and resulting feelings of ecstasy can be achieved by indulging in your favorite chocolate bar or having sex. So literally–we could be addicted story!

For additional TED talks on storytelling, you can find “The Best of TED on Story” here.

Leadership and Love

Those of us in the patient safety field have had the great experience through the years of listening to Don Berwick’s keynote speeches and writings. Be it his Escape Fire talk at one of the IHI Annual Meetings, the speech he gave at his daughter’s medical school graduation, or his personal story published in JAMA, entitled, To Isaiah,–the stories he tells and the important messages he shares move and inspire all of us. As the power of storytelling to create change across industries continues to rise to the forefront, Don Berwick has been doing this naturally through the years. And his audience has grown over the years as well–perhaps as a result of his gifted ability to share the stories of his life and career in ways that move others, but also because his passion for improving healthcare sets a true north all can follow. Here is his Harvard medical school address from 2012, where he advises that in confusing times, it is even more important that a physician’s true north remains his/her oath to care for all patients:

I read a beautifully written piece on leadership and love this past week that was right up there with many of Dr. Berwick’s powerful messages, and felt it was important to share it with the health science students, resident physicians and medical educators following our ETY blog. For those of you that enjoy Paul Levy’s blog like I do, this past week we were treated to Peter Pronovost’s message to Parkland Hospital regarding the choice of their next CEO, in a post entitled, Pronovost advises all boards and CEOs. Having recently moved to the Baltimore/DC region in assuming my new role as Corporate Vice President for Quality and Safety at MedStar Health, I have had the great pleasure of spending some time with Peter (a fellow anesthesiologist), as both our integrated health systems make up a significant portion of patient care in the Mid-Atlantic region. His passion, commitment and accomplishments in the field of patient safety are unrivaled, as is clearly displayed in some of his comments I share below–truly Berwick-like and extremely powerful, inspiring words for all of us in healthcare:

Historian Rufus Fears [right] notes that great leaders — leaders who changed the world — have four attributes: a bedrock of values, a clear moral compass, a compelling vision and the ability to inspire others to make the vision happen. Parkland needs one of these great leaders.

The key values of the next CEO should be humility, courage and love — and these values must guide the leader’s behavior…The leader must be able to live with the paradox of being humble yet confident.

Yet perhaps the greatest value will be love. Avedis Donabedian, one of the fathers of quality improvement, was interviewed on his death-bed by a student. The student asked, “Now that you have been a patient and devoted your life to improving care, what is the secret of improving quality?” Donabedian told him, “The secret of quality is love. If you love your God, if you love yourself, if you love your patients, you can work backwards to change the system.”

The next CEO must recognize this and seek to understand rather than judge, to learn and improve rather than blame and shame.