As healthcare providers, we are given a privilege to care for others, and must always remember that we treat complex individuals, making choices that affect their lives, families and personal well-being. At the same time, our patients must recognize that care providers are people too– always trying to do the best they can while juggling numerous responsibilities on a daily basis and working in a system that still has too many flaws. The clinician-patient relationship is most effective when both sides meet in the middle–a “safe space” where each is able to truly see one another and achieve the mutual understanding needed to succeed as a care team.
High Reliability science is one area we are looking to for answers to systems failures in healthcare. High reliability organizations stress the importance of “Stopping the Line” when a worker senses something doesn’t feel right. The concept has been shown to help reduce harm in many high risk environments. What if something similar existed for communication concerns in the healthcare environment?
The following short video, entitled Please See Me, created by patients and caregivers for patients and caregivers, offers a possible solution. Can “Please See Me” become that safe space, where patients and family members can stop the line and share those words if they feel their needs are not being heard or addressed? At the same time, can caregivers use the same phrase when they feel they are not being understood by patients and family members?
Many of us believe the phrase “Please See Me” can be the start of something special, creating that safe space and providing a phrase that helps improve communication and understanding in every healthcare environment leading to better outcomes.
Patients and Care Teams
Working as Partners
In the Spirit of Healing and Compassion
Historically in healthcare, when an error occurred we focused on individual fault. It was the simplest and easiest way out for us to make sense of any breakdown in care – find the person or persons responsible for the error and punish them mostly through things like shame, suspension or remediation. Re-train, re-educate and re-policy were the standard outcomes that came out of any attempt at a root cause analysis. Taking that route was easy because it didn’t require a lot of time, resources, skills or competencies to arrive at that conclusion especially for an industry that lacked an understanding, or appreciation of systems engineering and human factors. High reliability organizations outside of healthcare think differently, and have taken a much different approach through the years because they appreciate that it is only by looking at the entire system, versus looking to place blame on the lone individual, that they can understand where weaknesses lie and true problems can be fixed. James Reason astutely said “We cannot change the human condition but we can change the conditions under which humans work”.
The following short video is about Annie, a nurse who courageously shares her own story…a story that highlights when we didn’t do it right, but subsequently learned how to do it better by embracing a systems approach that is built on a fair and just culture when errors occur. A special thanks to Annie and to Terry Fairbanks MD MS, Director, National Center for Human Factors in Healthcare who helps us make sure our health system affords the time, resources, skills and competencies necessary to do it correctly.
Each quarter, in the spirit of a learning culture inherent to high reliability organizations, MedStar Health Quality, Safety & Risk Management leadership, Dave Mayer MD and Larry Smith, host a retreat for quality and safety professionals, inviting outside speakers to share their expertise and discuss topics related to patient safety, risk management and improving healthcare quality. Those topics have included:
- Care for the Caregiver
- Human Factors Engineering
- High Reliability Organizations
- Patient & Family Stories
- Open, Honest Communication & Transparency
- Patient Engagement
- Baldrige Journey
MedStar Health has created a Video Learning Library on their website which includes a full recording of many of these sessions. The intention is to share the knowledge with all healthcare colleagues so that others can also benefit from the experience shared by these safety and quality thought leaders. The Library can be found on the MedStar Health website. Following is an example of the content, as Dr. Bill Neff, CEO & CMO, University of Colorado Health, shares the Baldrige Journey as experienced by Poudre Valley Hospital. Please share this resource with others!
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.
The success of our Telluride Roundtables and Summer Camps over the last ten years can be credited, in large part, to the generous time and participation of our faculty made up of patient safety leaders from around the world. The students and residents chosen to participate through the Telluride Scholars Program have been the beneficiaries of the knowledge and experience these great leaders and teachers all are so willing to share each year. Rosemary Gibson, Rick Boothman, Cliff Hughes, Kim Oates, Peter Angood, Kevin Weiss, Bob Galbraith, David Longnecker, Helen Haskell…the list goes on and on.
In the summer of 2011, students had the great fortune of working with Lucian Leape, who joined the faculty of our Telluride Patient Safety Summer Camp. It was an honor to have him with us, and something our alumni–young and old–will always remember. Lucian’s focus that week was managing disruptive behavior and returning joy and meaning to the healthcare profession. The photo included captures him in action doing what he does best–educating the young. As we begin a new calendar year still struggling with many of the issues Lucian called to light in his 1999 seminal work, I believe his teachings on Joy and Meaning in the workplace are more important today than ever before, and that those strategies will play an even greater role in preventing harm to our patients.
Caregivers at the frontlines consistently put considerable energy into achieving the highest quality, safest care possible for their patients in the face of considerable economic pressure and evolving healthcare models. We expect so much from our caregivers, and they far too often extend themselves beyond what is healthy–physically, emotionally and mentally–to meet the growing demands of the new healthcare. Lucian’s work on joy and meaning in the workplace is based on Alcoa leader Paul O’Neill’s premise that every employee should be:
As healthcare leaders, we need to clear a safe path for all frontline associates to be respected, supported and appreciated. At the same time, we also need to eliminate the disruptive behaviors that have plagued healthcare for far too long. This year, a driving focus should be on ensuring those well intended healthcare professional are elevated, their humanness not only accepted but also protected through just culture approaches and human factor partnerships that mitigate and finally eliminate the potential for patient and employee harm while embracing a workplace built upon the high reliability foundations of a true learning culture.
As Lucian continues to remind us, it is our dedicated caregivers working at the bedside that need to feel safe — to know that their effort is appreciated and celebrated, that they have our support, and are respected for the work they do.
On July 6th, Asiana flight 214, a B-777, hit the sea wall on approach to San Francisco airport (SFO). Three passengers died.
I recently received a well-written and insightful article describing what we in healthcare can learn from the cause-analysis findings coming forward from this unfortunate event. Richard Lockwood, AVP for Quality and Outcomes at MedStar Washington Hospital Center (MWHC) passed on the article, written by Steve Harden, as he found it useful given MWHC has been on a high reliability (HRO) seeking Journey the past two years. Richard’s experiences are guideposts as we embark upon the same journey for our entire health system. Having started his career in the commercial nuclear power industry, and having been a key contributor to the design and execution of the that industry’s HRO journey, Richard has proven an excellent resource to me and others when it comes to understanding some of the barriers healthcare organizations may face as they continue on their resilience journey.
Excerpts from the article follow, and more information on the author, Steve Harden, can be found here:
The effort to stop patient harm due to preventable medical error in healthcare can be assisted by examining some of the factors in the loss of life in aviation…Critical lessons for healthcare can be gleaned from…what is known about the training and culture that pervades the airlines in South Korea…Here are four lessons that healthcare can learn from the tragic accident.
1. Beware of over-reliance on technology: The pilot in command of the flight that day had over 10,000 hours of flight experience…However few of those hours were logged while in actual physical control of the airplane – what pilots call “hand-flying.”…Almost all of their flight time is accrued while the airplane is actually being “flown” by the computer.
Over-reliance on technology causes several issues including degradation in basic flying skills, and a tendency for a “lack of engagement and mindfulness” in monitoring the computer and the computer generated flight path.
The lesson for healthcare is clear…Electronic medical records, computerized physician order entry, and decision support tools will never replace “basic flying skills” in medicine.
How many times have we heard our informatics teams share that same advice when we ask them why our EMR’s are not solving many of our safety problems?
2. Culture eats initiatives for lunch: …Culturally, it is bad form to mention something that might reflect badly on the senior person of the group…During the last two minutes of the accident flight, the descent path to the runway was..clearly wrong, yet none of the other three crew members in the cockpit said anything to the Captain.
The lesson for healthcare? You may have a TeamSTEPPS program. You may have a great Lean process improvement program. Neither will yield the sustainable results you want if you don’t work on your organizational culture.
3. Protecting the powerful is counter-productive: …You can overcome 3000 years of culture, but it takes a concentrated effort by leadership to over-communicate the expectations, to reward the new behaviors, to celebrate the results, to personally model the new behaviors, and to eliminate those unwilling or incapable of change.
The lesson for healthcare? As Harden points out, allowing the mindset that “I know s/he is disruptive and hard to work with, but s/he is a big producer”, cannot be tolerated if an organization wants to achieve success in their HRO seeking journey. Disruptive and abusive behaviors are in direct conflict with high reliability seeking cultures which embrace respect and caring for fellow associates and team members.
For me, the following point referenced from Harden’s article is the most important take-away from this learning. We see many wonderful examples every day of caregivers speaking up and taking action when needed – similar to what Harden describes:
4. Even one person who can speak up and be assertive can save a life: Despite all the cultural barriers that might have prevented it, one of the Asiana flight attendants used a TeamSTEPPS behavior when it mattered most. After the crash and when the airplane had come to a stop, the Captain announced that the passengers should not evacuate. One of the flight attendants saw flames outside the window and called the Captain on the intercom to let him know they needed to evacuate. This willingness to speak up undoubtedly saved a lot of lives.
We know many of the answers, and what needs to be done to make healthcare safer–culture change, stop protecting the powerful especially when safety is at stake, and celebrate those remarkable caregivers who speak up even when they fear possible retaliation for voicing their safety concern. We hear these recommendations over and over. It’s not rocket science, but they are still challenging to put in place while many of the historical incentives remain misaligned.
The concept of “mindfulness” dates back more than 2500 years. In Sanskrit, it means awareness that, according to the teaching of the Buddha, is considered to be of great importance in the path to enlightenment. It is said that when we are enlightened, “greed, hatred and delusion have been overcome, abandoned and are absent from our mind and we are focused on the present moment and the reality of things around us”.
With the increased focus on High Reliability in healthcare over the past few years, we continue to hear more about the importance of mindfulness as a patient safety tool. I always thought of myself as being “mindful”. Anesthesiologists have to be “in the moment”, aware of the different cues happening around us in the operating room. However, through two simple examples recently, I learned a very important lesson from a longtime friend and mentor, Cliff Hughes MD, — that being mindful and aware of our surroundings is only half of the equation when applying mindfulness to safety.
For many years, I have had the great fortune of being a close friend and student of Professor Cliff Hughes. Cliff was a cardiothoracic surgeon for 25 plus years in Sydney, Australia before being elected CEO of the Clinical Excellence Commission (CEC) in New South Wales, Australia. From the CEC website:
(Cliff)…has been chair or a member of numerous State and federal committees associated with quality, safety and research in clinical practice for health care services. Prof Hughes has held various positions in the Royal Australasian College of Surgeons–including Senior Examiner in Cardiothoracic Surgery and member of the College Council. He has been a member of four editorial boards and has published widely in books, journals and conference proceedings on cardiothoracic surgery, quality and safety. Prof Hughes has a particular passion for patient-driven care, better incident management, quality improvement programs and development of clinical leaders.
Cliff, and his lovely wife Liz, were visiting from Australia this month, in part to attend our Telluride East Patient Safety Roundtable and Summer Camp in Washington, DC. As a result, my wife Cathy and I were able to spend some social time with Cliff and LIz, and with a consummate teacher like Cliff in the mix, the learning does not stop outside the four walls of a classroom or hospital. I share the following stories because they left such an impression on me, showing me that Cliff’s wisdom comes through living that which he teaches on a daily basis…
As we were walking through a local grocery store, we came across a small puddle of water on the floor in the produce section. I walked around the puddle, pointing out the potential safety hazard to Cliff following behind me. I continued walking, and it took about twenty more steps before I realized Cliff was no longer behind me. Instead of walking around the puddle like I had, Cliff had detoured to find the produce manager and show him the puddle so the safety hazard could be cleaned up. While I was mindful of Cliff’s safety in pointing out the puddle, Cliff was mindful of all others who would be following our same path and could suffer harm by slipping on the wet floor. Cliff acted on his mindfulness, and by reporting the event, helped prevent possible harm to others. I was mindful but didn’t act.
The very next day, Cliff and I were walking through a parking lot after a quick stop at a local Starbucks. I was in deep thought about our upcoming meeting. As we walked, we passed a parked car which I vaguely noticed had a back tire that was quite low…not completely flat, but would most likely soon be so with some extended driving. Momentarily noting the car, I kept walking, thinking about our upcoming meeting, Once again, Cliff disappeared and was no longer behind me. Instead, he was standing by the side of the car with the low tire, writing on a piece of paper. I walked back to where he was standing, and asked what he was doing. He said he was writing a note to the car’s owner, alerting the driver of the possible safety concern. Finishing the note, he placed it under the windshield wiper, clearly visible to the driver. Again, I noticed the potential safety hazard but was distracted by my own thoughts and priorities, and kept walking. I wasn’t fully “in the moment”, a prerequisite of mindfulness. Cliff, however, was fully in the moment. As such, he was able to not only notice potential safety risks, but also to report each incident and act to prevent possible harm to the driver and grocery shoppers.
Two simple, but thoughtful, actions became perfect learning moments for me, role-modeled by a masterful safety “Sensui”. Mindfulness without action is stasis.
Healthcare needs more Cliff Hughes’…