Our final session of the 2015 Telluride Experience kicks off in Napa, CA this week. Once again, the learning began by sharing the Lewis Blackman story, and we were fortunate to have Helen Haskell as part of the faculty to lead discussion after the film, along with Dave Mayer. Having been part of the team who created the film, and having viewed it more times than I can count, I am always in awe of the new ideas each viewing inspires. A large part of that inspiration arises from the conversations and stories that are shared by attendees after they hear the story.
Today, there were many excellent comments but it was something Natalie B, a nurse practitioner and educator, mentioned about the fear junior healthcare professionals hold of getting chewed out by healthcare leaders that often prevents them from speaking up when they are unsure. (See her post Transparency and Vulnerability=Scary! on the Telluride Blog). The second inspirational comment came from our newest faculty member, Kathleen Bartholomew, also a nurse, who pointed out the need for a greater sense of urgency around adopting a culture of safety above all else. She continued by pointing out that 900 similar case like Lewis’ occurred in the single day and a half since our group arrived at this meeting.
This begs the question that, shouldn’t delivery of care always be about putting the patient first versus the care provider’s ego or fear of jeopardizing a career? This phenomenon is far from limited to trainees too, which is of even greater interest. Perhaps an interesting model to consider would be to have medical and nursing schools recruit, train and accept only the most courageous students versus those with the best MCATs or test scores. It would be nice to weed out those who would/could put their own professional well-being before that of their patient at any level.
The reminder of the need for a greater sense of urgency was both valuable and validating. There have been times when it has been hard to watch Lewis’ story yet again, knowing errors related to healthcare hierarchy and culture continue to occur again and again. Helen shared that on November 6th, it will be 15 years since Lewis died–was killed–if we’re being honest. She pointed out that all too soon he will have been gone from her life longer than he was alive. This is a hard fact for all of us to hold.
One of the greatest values to the Telluride Experience is infusion of the mindfulness and ire into the minds of young healthcare trainees that comes from hearing these stories. It is both that will be needed for real change. We need providers at all levels of training who are more afraid of harming a patient than of being chewed out by a dysfunctional healthcare mentor. I would challenge those going into healthcare, as well as those already in healthcare, to be prepared to put the patient first, always. Those who are unsure this is something they can do might want to consider a different career path.
Hero – a remarkably brave person; somebody who commits an act of remarkable bravery or who has shown an admirable quality such as great courage or strength of character especially under difficult circumstances; somebody admired.
Carole Hemmelgarn is a hero.
In the video that follows, Carole poignantly shares her daughter Alyssa’s story, and why their family’s loss has been the driving force behind the change Carole is fighting for – the delivery of safer care for all patients and families. Every person lost to preventable medical harm is a tremendous loss. Carole, and other courageous heroes like her, including Patty & David Skolnik, Helen Haskell, Victoria & Armando Nahum and Sorrel King give their time, their heart and their stories so we never forget these unfortunate events are not just statistics.
They are my heroes.
I have been very fortunate through my career to have met, learned from, and become friends with many patient advocates from across the country. People like Helen Haskell, Patty Skolnik, Linda Kenney, Sorrel King, and Carole Hemmelgarn to name just a few. Their ability and willingness to turn personal loss into a life-long commitment to make care safer and of higher quality is quite inspiring…they are the true heroes of this mission.
The same holds true for Victoria and Armando Nahum who I was so fortunate to meet about two years ago. Over a period of 10 months in 2006, the Nahums had three family members stricken by hospital acquired infections, at three different hospitals in three different states, culminating in the death of their 27-year-old son, Josh. Like the families I mentioned above, they also turned their own personal loss into a crusade to reduce and hopefully eliminate hospital acquired infections by starting the Safe Care Campaign.
Last week at the Quality Colloquium, I moderated a morning long session on quality and safety at the bedside. Because patient partnership is a critical piece to any quality and safety mission, I asked Victoria and Rosemary Gibson, author and healthcare advocate, to be part of the panel and lead a patient partnership discussion with the audience. Both Victoria and Rosemary (as usual) were outstanding speakers, and had the audience fully engaged. However, during Victoria’s presentation, something truly special happened. Victoria shared the following video that she and her husband Armando created. Lke most in the auditorium, I had not seen the film before. The video delivered its message that morning in a unique and quite remarkable manner. Few times have I seen an audience as captivated at a medical meeting as they were last Thursday while we watched the Nahum’s two-minute film. The audience burst into spontaneous applause at the conclusion of the video, even though Victoria was still in the middle of her talk. It was an inspiring moment. The Nahum’s creativity and message captured us all that morning. Take a look for yourself:
The Nahum’s courage is powerful, and their message so very important if we are to escalate the fight to reduce risk and improve the quality of care providing to our patients. We need a greater sense of urgency around all of these efforts, especially at a time in the evolution of healthcare when competing agendas vie for attention and funding. Like Don Berwick, Carolyn Clancy and other healthcare quality and safety leaders who have inspired us to do better, patient advocates like Victoria, Rosemary, Helen, Patty, LInda and Sorrel are leaders who inspire us with their passion and commitment to help us get it right. It is encouraging to see them with a seat at the hospital conference or board room, as keynote speakers at national conferences, and included in hospital quality and safety improvement committees. How we thought we could do this important work without them still befuddles me.
Every three months, Dave Mayer MD, Larry Smith and MedStar Health host a quarterly Quality, Patient Safety & Risk Management Retreat, inviting leaders and innovators across the health system to spend a morning discussing topics such as high reliability organizations, transparency and patient centered care. For the last year, two speakers–also healthcare thought leaders from across the country–have been invited to share their expertise with MedStar associates during the retreat. (An archive of retreat videos can be found on the MedStar Patient Safety & Quality website here).
Today’s retreat included:
- Denise Murphy: A Carole DeMille Lifetime Achievement Award winner for infection prevention and now Vice President of Quality & Safety at Main Line Health in Philadelphia. She is leading her health system on the journey to becoming a high reliability organization.
- Helen Haskell: Mother, patient advocate, healthcare policy driver and founder of Mothers Against Medical Error (MAME).
Those who follow our blogs (ETY & Telluride) might already be familiar with the story of Lewis Blackman, Helen’s 15-year-old son of great promise who was taken far too soon by medical error. Helen and her family have gifted healthcare communities around the world by sharing their loss so that others can learn with the hope that similar harm can be prevented. Both speakers emphasized the need to personalize every healthcare encounter, keeping patient stories at the front lines of care. Both Denise and Helen’s presentations also have been made available on the MedStar Health website. Following are useful takeaways from this quarter’s retreat for use in your own health system.
Denise referenced John P. Kotter’s Harvard Business Review article, Leading Change: Why Transformation Efforts Fail, as a resource, and shared the following tips for successful creation of a culture of safety:
- Patient safety trumps all else
- Keep leadership uncomfortable
- Keep patient stories up front — put a face on all harm
- Leaders lead from the front versus push from behind
- Provide tools for the critical conversations patient centered care requires
- Engage all care providers in the journey
- Flatten authority gradient and reduce power distance (i.e. Everyone’s voice matters, title irrelevant)
- Include daily “Safety Huddles” to assess progress, update colleagues on patients at risk, share stories and any concerns.
And finally, here is the trailer for The Story of Lewis Blackman. If interested, there is a YouTube version of the entire film available in the creative commons, and a DVD copy available for a nominal fee that includes learning materials. If interested in acquiring a copy of the educational film please reach out.
Reflections from students across all areas of the health sciences continue to come in after two pivotal weeks of education in Telluride, CO. The following reflection is by Quyen Nguyen, a University of Illinois-Chicago Pharmacy student. Additional reflections can be found here.
One of the most important lessons I have learned from the past three days is the urgency in which we need to act to bring ethics back to the forefront of healthcare systems. Too often the best interests of the patients and their families are put behind financial, legal, and personal factors. It may never be possible to prevent every error, but we have a professional duty to take responsibility and put patients’ and their families’ needs first in the aftermath of a medical error. I wish to express a sincere thank-you to Carole for your courage in sharing your personal story so that future healthcare professionals can learn from it. I hope that each of us will continue this conversation of patient safety to make a difference in patient care when we return to our institutions.
Today I also learned about the concept of anchoring. Anchoring is a practice in which a person’s perspective is biased by the first information given. The tendency of anchoring increases significantly when one becomes tired, fatigued or distracted by any other human factors. The heartbreaking tragedy we have seen in Carole’s and Helen’s stories stems from anchoring bias. As a caregiver, we have to be mindful and avoid bias when dealing with patients. However, after several talks with several medical students and nursing students, I learned that many residents may have to work up to 80 hours/week on average and many times they have to work more than 8 hours in a shift (please correct me if I am wrong). I wonder whether it is possible for one to maintain a clear mind with an objective perspective under these working conditions. Should there be a change to reduce such long working hours in residency programs?
Yesterday, I went shopping and talked to a cashier in a souvenir shop in downtown Telluride. After I asked her whether she offered any discount for Telluride scientists, we started having an interesting conversation. On being asked what I was there for, I shared with her that I was in a 4-day summer school with medical students, nursing students, and pharmacy students to learn more about patient safety and how to improve healthcare quality. She then told me that since we were learning about patient safety, we should make sure that nursing school teaches nurses how to take blood sample of a patient without pricking her patient five or six times. She suggested that doctors should invent some kind of X-ray imaging on a patient’s arm so that they can test the blood without pricking a patient. We both laughed and I said, “Yeah, why not?” Such an invention may be possible in the future and it would increase the ability to deliver high quality patient care. I thought this is an interesting anecdote of those outside the medical profession on how they perceive those inside.
Each new session of the Telluride Patient Safety Summer Camps, Dave Mayer and Tim McDonald share the Tears to Transparency educational documentary films — stories of harm that befell Michael Skolnik and Lewis Blackman–both promising young men–and the impact that harm had on their two families. As a result, Patty Skolnik and Helen Haskell (Lewis’ Mom) have dedicated their lives to changing healthcare for the better, and have become nationally recognized patient advocates. Through their new careers, both Moms have recognized the need to both “educate (and empower) the young”. The medical and nursing students and resident physicians who attend Telluride often have the opportunity to talk with both parents after each film in an open Q & A. Many students express this being a first exposure to the dysfunctional side of medicine. On the flip side, many also express having witnessed similar poor behavior by those entrusted with leadership positions in an academic medical environment.
Through the generosity of both Michael and Lewis’ families with the sharing of their stories, Telluride attendees are able to practice the difficult discussions focused on in the films in a place where open and honest communication is not only encouraged, but also modeled and set as the baseline. This also re-emphasizes the power of story to change behavior, and as a result, culture. Hopefully this sets a “new normal” for all Telluride alumni – a mindset they can take back to workplaces and educational systems where bullying or a lack of respect prevails and infuse new ideas. Or simply to carry these stories home in their heart, along with the power of the resulting discussions to further embolden environments where a just culture is the norm.
A trailer to the film, The Story of Michael Skolnik, played yesterday morning for our resident scholars is included above. We have been told more than once that the value of the conversations that follow these films each year are unmatched by anything yet to be experienced in the educational experience of health science students. The resident reflections on the Telluride blog today (found here) share some of the takeaways both The Lewis Blackman Story and Michael’s story have inspired this year. The theme from Michael’s story is “Can a conversation change an outcome? Can a conversation save a life?” Based on the enthusiasm for a new normal in Telluride this week, I am happy to report back that the answer to both questions is a resounding YES! When healthcare professionals and patients authentically share their stories and experiences it becomes contagious, inviting others to do the same. I’ve watched this yet again take hold in Telluride. Let’s take this idea viral along with the courage to do the right thing for patients, no matter how difficult, every time.
Patient and Family Advisory Councils – The Importance of the Patient Voice in Our Safety and Quality WorkPosted: November 26, 2012
Patient and Family Advisory Councils are forming in many hospitals across the country. Some institutions, like the Dana Farber Cancer Institute and Cincinnati Children’s Hospital have had “Patient Partnership” Council’s in place for over a decade, inviting the patient into healthcare decision-making and strategic planning, setting examples for those just starting the process. Aurora Health in WI, who received AHRQ funding to look at best practices around the formation of a Patient Safety Advisory Council for outpatient medication safety has provided guidelines for all to follow if they so desire to set up their own Patient Advisory Council.
But with many now rushing to engage patients, a few leading patient advocates have become a bit skeptical. Engaging patients is more than just addressing the call from the Institute of Medicine in their September report. It’s more than gathering people in a boardroom, serving lunch and feeling good about ourselves. It’s more than just checking the patient council box when the Joint Commission comes visiting. And it’s more than just asking patients about hospital room colors. It’s about true partnerships that define, and then measure, patient safety and quality improvement outcomes from projects that directly result from the time invested in these types of meetings. When done correctly, these partnerships become powerful and lead to positive changes in a number of areas. The culture of medicine is in transition, and like any industry, changing culture takes time, courage and the ability to take action outside our normal comfort zones.
This week, I had the great pleasure of spending time with a number of leading patient advocates – people who have devoted their careers to helping patients, caregivers and health systems better understand what is needed to lower risk and improve quality in patient care. Many are good friends and have been personal mentors to me through the years. People like Helen Haskell, Carole Hemmelgarn and Patty Skolnik, three remarkable women who continue to share their personal stories of loss so others can learn, and make care safer. People like Rosemary Gibson, Michael Millenson, Sorrel King and Victoria Nahum who have touched us all through their writings, educational materials and collective call for change. They have graciously agreed to help us at MedStar Health better understand and appreciate what terms like patient-partnership, shared decision-making, and transparency really mean to our patients. Their definitions and perspectives can be quite different at times from those I have thought were correct and published in the literature through the years. Many times I think I get it, only to realize that “I don’t know what I don’t know”. Tim McDonald, a good friend, mentor and patient safety leader, always likes to say we can be “unconsciously incompetent” when describing this phenomena.
We all met as a group last week, and the conversation took on a life of its own. With the advocates asking the tough questions, the conversation and discussions evolved organically and led to the open, honest discourse we all know is critical if real change has a chance to occur. Rosemary challenged the leadership in the room to measure our success by striving for the day when every healthcare provider working in our system was one that we as caregivers would refer a family member to – no hidden secrets on who we know is good, and who we would take our loved ones to for care. A second recommendation focused on outcomes data, and how to present it in a meaningful way–in a way that patients could truly understand, and then use it for decision-making. And more than one of our advocates implored us to create educational tools that patients could not only use to guide them through their hospital stay, but also make it clear they were a welcome and engaged part of the care team. Many health systems like MedStar already have different patient educational tools in place, but the group pushed us to think differently and be even more innovative in our approach to patient education.
The day ended with excitement around the different opportunities to create change right in front of us, and in fact, work has already begun on more than one consensus recommendation resulting from the meeting. We all look forward to the continued sharing of ideas with our council members, and graciously thank them for their insight and resolve to push us past our limits in the best interest of our patients.