I think big and dream bigger but have been told many times in my life to stop doing so. My grade 10 careers advisor told me to aim lower when I expressed an interest in studying medicine, a male physician once told me that training a woman was like training half a doctor and I’ve even had a family member tell me that women joining the workforce are responsible for the downfall of modern society. Despite this, I’m now in medical school and will one day soon achieve my dream of becoming a doctor.
Over the last few days I’ve been given the skills and knowledge to undertake projects that improve outcomes for all patients; I’ve been empowered to make a change. Unfortunately these things take time, you need to carefully plan, analyse, monitor and assess. You need a specific problem to tailor your specific, well researched solutions and I am sure in the months and years to come I will use the things I’ve learned and the frameworks provided to make change happen. However, at this point in time, my goal is big and broad, it’s in no way specific and while I’m prepared to to do my due diligence and execute some high quality, quality improvement projects once I find my focus, right now I just need to do something. Improvements to patient safety education shouldn’t have to wait for me to specifically define the problem in a measurable way or wait to get ethics approval. It can’t wait, not while I know there are things I can be doing that will have some impact right now.
Don’t get me wrong, I know we need to improve patient safety, safely by following the right processes and procedures but today I am going rouge, I am not going to wait. Like a hungry Roundtable delegate on the hunt for a burrito I am going to take action. Tonight I will email my contacts and state my case to ensure that patient safety is on the agenda of every student-run educational conference in my state this year. Additionally, I will push to have a safety moment at the beginning of each event my medical society hosts. Lastly, because I can’t be everywhere at once, I will make a time to train others in my medical society so they too can be safety coaches and start getting the word out about this important issue.
One day soon (when step 1 is behind me), I will start the research and do it the right way but I won’t sit ideally by in the mean time. Watch this space.
Each of our Telluride Scholars adds their own voice and passion to the patient safety movement that continues to need attention. The following are most likely words of unintentional inspiration from Anna Elias who shows what one individual can accomplish when they care deeply about a cause, and dare to dream they can make a difference. Anna is absolutely right — Watch this space! — her space, because she is on her way to great things!
You can also link to the Telluride Blog where Anna originally posted this piece.
It was only a matter of time before the Telluride Experience, which began as a labor of love by healthcare leader, Dave Mayer MD, almost twelve years ago came to Sydney, Australia. Kim Oates, MD, a local healthcare leader, Telluride faculty member and another who leads with love in the healthcare workplace, championed the experience for young healthcare professionals on the third continent this year.
Dave and Kim are two healthcare leaders who know what it means to put the patient first, what patient centered care really means, and they put that knowledge to the test in real life practice. Another gift both leaders possess is the ability to gently teach and guide, without sacrificing principles. They understand how hard it is for healthcare learners to rise above the medical culture because they have lived it. Today, Kim shared that the three hardest words in medicine are, “I don’t know,” and “Please help me.” Dave openly shares his own experience of being on the wrong side of medical harm when he was a resident physician. They both care deeply about patients. They also care deeply about educating young healthcare professionals to not only protect patients, but to also ensure these well-meaning nurses and doctors stay safe as well.
Healthcare needs more leaders like Kim and Dave, who lead with love. They never have to question the right and the wrong of a situation. Their hearts are their true north.
For more information on how to learn alongside healthcare leaders like Dave and Kim, as well as take home the lessons of the Telluride Experience, go to www.telluridesummercamp.com.
The Telluride Experience faculty has arrived at Q Station Sydney Harbour National Park, an idyllic Telluridesque location in Manly, Australia. The Telluride Experience: Sydney faculty and students will be tucked into this retreat location in Sydney’s National Park just across the water from the lights and cosmopolitan city of Sydney. Q Station and the National Park has a little bit of all Australian terrains, including Manly cove beachfront, bush land and the protection of a canopy of rainforest-like red gum trees.
These spectacular trees serve as home or rest to 150 different types of birds, and resemble our collective efforts at changing healthcare culture by also renewing themselves each year, as they shed their bark presenting a fresh, new salmon colored skin to the surrounding environment.
An old Quarantine Station protecting Australians from smallpox or other contagious disease potentially carried by those seeking to become citizens during the 1830s through 1984, this could not be a more fitting location to host what will be the epicenter of local of patient safety learning over the next four days. Last night, the group shared conversation, introductions and local food and wine to start the week, welcoming one another to yet another intimate and
International patient safety Telluride Experience. Join the conversation on social media, using #AELPS16.
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.
On 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 Safety…The Sydney Australia Experience!
What if this was the norm in healthcare? At the frontlines between and among colleagues, and maybe most importantly, the feeling conveyed to patients when they walked onsite? Could it restore joy and meaning? Could it make care safer? Isn’t it worth a try?
Something to put a smile on your face as we kick off the new week and season!
Today’s post is by guest author, Carole Hemmelgarn, who generously shares a reminder to all on why patient safety work is so important, and why National Patient Safety Week will continue to matter even after we get it right. Carole continues to give her time as a patient advocate, coaching healthcare organizations across the country on the power of words, as well as a better understanding on what it means to truly communicate with patients.
March 8th starts National Patient Safety week and it is with great irony that I write this blog because it is the anniversary of the day my daughter, Alyssa, died from medical errors. I am grateful for the focus being made in the field of patient safety. We need to become High Reliability organizations, enhance our communication skills, offer communication and resolution programs, implement bundles and the host of other programs that impact safe patient care.
However, I want to bring the focus back to the human side of patient safety and that is the patient and family after harm has occurred. There is this aftermath, which is rarely spoken of, and it is what happens to those survivors living without their child, spouse, parent or sibling years down the road.
I’ve come to realize grief is my twin. It will never go away and we have learned to coexist. Please understand grief is not always bad. I find solace in my grief because we speak the same language. We laugh and cry together and there is no judgment. At other times, my twin is like an anchor weighing me down causing me emotional pain and draining my often limited resources. So you may ponder why the dichotomy? Well, because life moves on, but it is different for us now. I’m a different person. My beliefs, values and what I held to be true have turned upside down.
What most people don’t realize is loss of a loved one, and in particular, a child, changes so many things.
- Marriage changes. I’m no longer the person my husband married and trying to figure out who we are in this new space is exhausting. Parents grieve differently and the one thing they don’t want to do is hurt their spouse because they know they are already in pain. This just opens up the door for communication problems.
- Your children are affected, but rarely do we talk about the impact it has on them. My husband and I often ask the question “Is this who our son is, or is this who he became after his sister’s death”? It is difficult to watch your son cringe when asked if he has any brothers or sisters and he says “no” because he can’t go there and talk about his sister.
- Your relationship with family members change. Sometimes they become stronger with certain members of your family, and others, a riff occurs because they expect you to move on or be the person you were before, and that individual no longer exists. Partaking in family events that once use to be enjoyable can be extremely emotional. You are there, but only as the great pretender, when underneath you are screaming to be set free. Why? Because you are watching their children progress through life, and do the very things, your child will never get to do.
- Friendships change…..
The most difficult are the milestones your child will not experience: moving through elementary, middle, and high school, not graduating from college, getting a job, married or having children. These events go on for years and this is the aftermath not seen.
I share this with you because I want you to see the importance of the work you do in the area of patient safety. So as you participate in the 2015 National Patient Safety Week, your goal is to make sure we minimize and mitigate the aftermath of harm I discuss above, and my goal is to help others avoid having grief as their twin.
Trying to get and keep the attention of busy healthcare professionals with content related to new initiatives can be a challenge to those leading culture change in healthcare. So many healthcare organizations are choosing the path of high reliability, greater patient engagement and shared decision-making, and a 5-star patient experience–all areas which will help us achieve zero preventable harm for patients. With the adoption of a new agenda comes the acquisition of new knowledge for all involved in executing and delivering on the programs. SolidLine Media has been a partner in developing award-winning healthcare content just south of ten years, and continues to hit the mark most recently with their Minute for Medicine series which includes (52), one-minute episodes containing quick, entertaining hits on several different domains key to providing the safest, highest quality care to patients. Knowing all too well the value a simple, turnkey solution can provide to so many looking to share information without having to start from scratch or develop it themselves is the driving force behind sharing this tool. And in the interest of full disclosure, I am a partner in the series.
Check out the following, or go to Minute for Medicine for more information on how to take part yourself! Share feedback on the series, and/or please share additional tools your teams have found effective in sharing and creating meaningful content within your healthcare organization! We don’t have time to recreate the wheel — it’s time to pick up the pace for patient safety!
A friend sent the following link to the post, 7 Cultural Concepts We Don’t Have in the US, over the holidays this year and it was a nice break from my regular reading. The author, Starre Varten, highlights seven cultural concepts originating in other locales around the world, such as “Kaizen” from Japan, which many in healthcare have already adopted with resounding results. I especially liked the Danes practice of “hygge”, or the idea of togetherness, coziness as a mental state versus physical one. She describes “hygge” as being akin to family and friends, gathered around the warm crackle of a fireplace enjoying good food and drink together as the first winter snow falls outside. Denmark is repeatedly rated as one of the happiest countries despite the long, cold winters they endure. Given the extent and brutality of our last two US winters, I would be more than willing to adopt hygge as a core part of my own culture!
Varten also reminds readers:
Culture is ours to do with as we choose, and that means that we can add, subtract, or edit celebrations or holidays as we see fit — because you and me and everyone reading this makes up our culture, and it is defined by us, for us, after all.
Culture change is admittedly not an easy or quick event, especially within healthcare. It takes time and commitment, and sometimes a game-altering nudge to the status quo! Changing the narrative and creating a new picture of an ideal healthcare environment is one place to begin–and while it may seem foreign at first, the benefits can very often outweigh any risk. There is a growing group of healthcare change agents embracing the uncertainty of change–certain that by taking the leap to innovate healthcare–patient and provider alike will be the beneficiary. This group is behind USA Change Day (@USAChangeDay), which is built off the pioneering work of the National Health Service (NHS). The NHS launched Change Day in 2013, and Helen Bevan (@helenbevan) has been a lead healthcare change agent in the UK, putting a refreshing and inspiring spin on something that began as a grassroots campaign, started by a small team and which has now taken flight. From the USA Change Day website:
…Its mission was simple—to challenge everybody within the organization to pledge just one thing that they would commit to doing in the next year to improve healthcare. This small initiative turned into a huge success, and now we’ve brought the movement to the United States of America.
You can follow their efforts @USAChangeDay, or better yet, join the cause!
What will you commit to doing in the next year to improve healthcare?