John Nance Reflects on The Telluride Experience and Need for Patient Safety Immersive Learning

Today’s post is by Guest Author, John Nance, Telluride Experience Faculty, Author and ABC Aviation Consultant

JNance_Napa

Having had the delightful experience of attending and working with all of the sessions of the Telluride Experience this summer,  I’ve spent some time since returning from Napa thinking through the scope and the effectiveness of what we all came together to advance: The goal of never again losing a patient to a medical mistake or nosocomial infection.

It may well sound hackneyed, but in fact I think all of us as faculty mean it to the depth of our beings when we say that the medical students and residents and nurses – all of those who joined us – are truly the best hope of changing the course of a noble but tattered non-system that slaughters people at the rate of 50 per hour.  That does not mean that existing healthcare professionals cannot or will not embrace the dramatic changes that are required to keep patients safe, because, indeed, thousands are passionately involved in just such efforts.   It does mean, however that the opportunity for leadership from the newer members of this profession will be critical, from the small and subtle gestures, to the grand and sweeping reforms.

And the potential for meaningful  leadership, of course, is why those who joined us were selected in the first place, and what we expect of them from here on:  Courageous leadership steeled against the oppressive influence of the status quo.

Having participated in this battle for patient safety for nearly a quarter of a century, I can say with some degree of authority that no matter how many presentations, discussions, articles, consulting hours, or other efforts are thrown at the problem nationally, creating a major cultural change is perhaps an order of magnitude more difficult when you’re surrounded by the very environment you’re needing to alter.  Coming together at a distance – especially in a resort atmosphere, or in the incredible beauty of Telluride itself – is an important element in achieving transference of ideas, concepts, goals, and determination as free of dogmatic and traditional thinking as possible.  And, of course, catching people at the beginning of their careers before the insidious influence of cultural rigidity has been allowed to take root and oppose change,  is an equally important key.  I know of no better forum than this, and I’m truly honored to be a part of it.

John Nance BooksAnd so we came together and told you horrifying stories that made us all cry, exposed young learners to the realities and predictability of professional human failure,  and rubbed all our noses in the reality that a profession whose routine operations count as the third leading cause of death in America does not possess the ethical choice to resist meaningful change.

But at the end of the day – and our time together – it all comes down to taking those small sparks of understanding and recognition and fanning them into flames back home,  never forgetting that every hospital room,  scheduled surgery, ambulance arrival,  admission, or diagnostic test involves a fellow human who is as entitled to the highest standard of care and caring as your own family.

From a very personal POV, I thoroughly enjoyed meeting each of our participants this season and pushing the quest forward, and I look forward not just to next year, but to hearing how the seeds we all helped sow will sprout and change the landscape of American healthcare.

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Telluride Experience Deadline Extended: Apply by 2/15/15

The deadline to apply for 2015 sessions of The Academy for Emerging Leaders in Patient Safety: The Telluride Experience has been extended to February 15th! Medical students, nursing students with less than 10 years experience, and resident physicians can apply online at The Telluride Experience website by clicking here. Dates and locations include:

  • In Telluride, CO: For Health Science Students-June 7th-11th and for Resident Physicians-June 12th-16th.
  • In Napa, CA: For Health Science Students-July 26th-30th.
  • At Turf Valley Resort in Ellicott City, MD: A combined session for Resident Physicians and Health Science Students-July 8th-12th.

Students who are accepted receive a full scholarship covering room, board, transportation voucher & all educational costs. Resident physicians accepted to attend should be sponsored by their program. Expected faculty for 2015 include healthcare and patient advocate thought leaders:

  • Founder–David Mayer, MD
  • Curriculum Director–Anne Gunderson, PhD
  • Aviation Consultant and Author–John Nance
  • Leadership Coach and Author–Paul Levy
  • Founder, Josie King Foundation–Sorrel King
  • Director, Foundations of Doctoring Program at University of Colorado–Wendy Madigowsky, MD
  • Healthcare Advocate and Author–Rosemary Gibson
  • President, Mothers Against Medical Error–Helen Haskell
  • Founder, Citizens for Patient Safety–Patty Skolnik
  • Director of Undergraduate Education, Clinical Excellence Commission–Kim Oates, MD
  • And more…

Join us in our 11th year and become part of a preeminent and growing alumni network while developing the skills and knowledge to be a patient safety leader of tomorrow!


So Many Heroes Among Us – A Thanks to All Caregivers

John_Nance_charting-bookJohn Nance, a leader and pioneer in both aviation and medical safety and quality–and for the past 18 years, a familiar face to television audiences as the Aviation Analyst for ABC News and Good Morning America–joined us this year in Telluride for our Patient Safety Summer Camps. John, along with other international patient safety leaders, have come to Telluride over the last 10 years to share their knowledge and passion for patient safety and patient-centered care with the rising leaders of healthcare. It is with a heart full of gratitude that we have welcomed Lucian Leape, Cliff Hughes, Paul Levy, Helen Haskell, Rosemary Gibson, Kim Oates, Richard Corder, David Classen, Carole Hemmelgarn, Bob Galbraith, Gwen Sherwood, Patty Skolnik, and so many other wonderful “teachers” each year to our faculty. Many come to CO every summer because they believe so strongly that we must Educate the Young if we are to deliver the highest quality, safest care possible to our patients.

At this year’s Summer Camp, John spoke about the similarities between aviation and healthcare, highlighting the importance of Teamwork, Effective Communication, Leadership, and the power of Debriefing after all activities. His educational messages came to life when one of our faculty, Dr. Roger Leonard, boarded his flight back to the east coast. Roger’s story, shared below, exemplifies almost every skill John spoke to our group about just days ago. While there is still much work ahead for those of us on the Quality and Safety mission, we sometimes forget all the good things our professional caregivers do in the face of very dysfunctional health systems and decreasing resources. Thank you Roger, and a heartfelt thank you to all caregivers who make a difference each and every day in the life of another.

Not Retired,” Previously posted on the Telluride Summer Camp blog, by Roger Leonard MD

My flight from Denver to Washington Dulles was late to depart due to thunderstorms.  We left at 10:30 pm and I tried to sleep, but was sufficiently alert to hear the page at approximately 2 am: “Any medical personnel on board?”   The flight attendant escorted me to first class where a passenger had what she thought was a seizure.  And she was probably right – only it was due to sudden cardiac death.  No pulse, no breathing, unconscious.  Male, perhaps 45 yo, looked fit, no companion.

The flight crew assisted me in lifting him into the aisle.  Because of their training, by the time that I started CPR, one of the attendants had the AED out and started handing me the pads for placement.  V.Fib.  We shocked once and got a rhythm.  He started to breathe and the oxygen tank was right there.  He had a rhythm, he had a strong pulse, he was breathing.  I said: “This is good.”

I tried to get a BP, but the sphygmomanometer was broken.  We got another emergency kit and it had a cuff that worked – BP ~115 systolic.  I admit that I struggled to get accurate BP recordings because my ears felt like I was 12 ft underwater from the altitude change (and probably a need to see an audiologist).  We sorted through the medical kits and I finally found the NS under the neatly packed top layer of drugs.  Found the tubing, tried to maintain sterile technique, and got a decent IV in his forearm while fighting postural movements of his upper extremities.  Then came VF arrest #2 and #3.  Shock, shock, back to NSR.  I was able to push lidocaine 100mg IV.

While scrounging around the medical kits, I found an endotracheal tube.  To me great relief, he kept breathing on his own and had good color.  I hadn’t intubated anyone in 40 years.  Meanwhile, the pilot was diverting us to Louisville where the EMS team met us.  You know how tight the aisles are.  We managed to get him onto a back-board, but then had to tilt him to nearly 90 degrees to turn the corner.  He was on his way to the hospital and after refueling, we were on our way to Dulles.

I got applause and handshakes as I returned to my seat.  How strange!  After our 4 days together, I could only think that “it’s about the patient, not about me.”  I was particularly aware of the calm and effective work of the flight attendants on our team.

In Louisville, we needed new fuel and a new flight plan.  So, with the extra time I asked to gather all the attendants and debrief.    What went well?  1) We successfully resuscitated a passenger with SCD at 30,000 feet.  2) An AED was mission critical and the staff was trained in its use.  3) Our treatment lasted about 45 minutes; we were calm; we explained what we were doing among the team; no one panicked including the other passengers.  4) EMS personnel were at the door upon the Captain’s diversion.

What didn’t go well?  1) the first BP cuff malfunctioned.  2) I struggled with obtaining accurate BPs.  3) I was slow to get what I needed out of the medical kits; the IV bag, couldn’t find a tourniquet  4) The patient had not regained consciousness upon departure, but groans were evident.

How can we improve?  1) preventive maintenance (PM) on medical equipment.  2) I suggest a digital BP cuff that reads the result without my impaired use of the stethoscope.  3) We should ask nearby passengers to vacate their seats so that we might spread out the medical equipment and drugs.  4) have EMS use an entrance that avoids tight turns, if possible.

We become physicians to heal the sick, relieve suffering, comfort those in need, and occasionally we may save a life.  I do not know the outcome for this gentleman.  I am worried; yet, I am hopeful.  I strive to role-model humility.  Yet, transparency reveals that I am proud to be a physician and proud of our team of strangers at 30,000 feet.


John Nance: Culture Change in Healthcare Starts By Facing Reality

John Nance BooksA pilot in Vietnam and Desert Storm, John Nance has been working to share the wisdom and results of culture change experienced by the aviation industry with those of us in healthcare for 22 years. His book, Why Hospitals Should Fly, was pre-reading for our Telluride Patient Safety Summer Camp students, residents and faculty this year because it tells the story of a fictitious hospital, St. Michael’s, that has made the cultural transformation necessary to truly put the patient at the focal point of care.

I was fortunate to hear Nance speak live this past Tuesday night, as MedStar Franklin Square Medical Center invited him to share his experience with a packed auditorium of associates and outside guests. Using humor interspersed with hard facts and stories from his fieldwork in healthcare and as a Lieutenant Colonel in the Air Force, Nance was masterful in capturing the hearts of many in the room. Throughout his talk, he continually asked the audience to raise the sense of urgency around this culture change. The cultural transformation he experienced while in aviation lasted a quarter of a century, but he emphasized healthcare doesn’t have that amount of time. There is an urgency to this challenging journey. Paraphrasing from Nance’s talk:

Cultural change is so profoundly difficult if you think one inoculation is enough you are doomed to fail…the journey is not complete until there is no one left who remembers what it used to be like. 

Not everyone can make this journey—you have to look for skills that nurture human nature of people on the frontlines. Too often we make excuses for colleagues and say “they’re very good at what they do” but the human connections just aren’t there.

So much of our training, as Nance pointed out, has been based on the fallacy that we are infallible. As Will Smith said in the movie Men In Black, we are supposed to be “the best of the best of the best”. Our failure, according to Nance, has been our inability to accept the reality of our humanness–our capacity for error–and build functional systems to mitigate that reality. The culture new caregivers have entered into has dictated that a single individual be given all the power in a patient care interaction. He often referenced the Star Trek Captain Kirk “commander” model cited in his book where one person knows everything, sees everything and seldom if ever makes a mistake – a concept totally impossible in healthcare today. Physicians need to lead people, not be commanders who bark out orders and make others feel subservient and disrespected. For some, this is second nature. Leaders like Lucian Leape, Don Berwick, Gary Kaplan, Harlan Krumholz and many others across the country have been talking about, and modeling, patient-centered care for many, many years. We now need to get to that tipping point. Healthcare is requiring newer leadership skills be developed by all of us, asking the we learn:

  • To be team players
  • To be good communicators with all colleagues and patients
  • To listen with respect and value the input of all team members
  • And to invite patients and families into shared decisions about their care.

Many who have started this journey understand it takes courage and fortitude. For students and residents who have been bullied because they were honest in admitting they didn’t know something and called their attending for help,  for nurses and support staff who have watched in silent horror as those “leading” acted in an unprofessional and disrespectful manner–it’s time to raise the volume of our collective voice, drown out the last of the naysayers and the “narcissists” who have taken healthcare down a self-serving and dangerous path, and help lead the change John Nance is urging us toward.