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
As the Telluride Patient Safety Summer Camps prepare to expand in 2015, adding a third session for health science students to be held in Napa, CA (and fifth summer camp week overall when we include the two weeks for resident physicians) , our alumni continue to leave a lasting mark on healthcare. Most recently, Jennifer Loeb MD, former Telluride alum and now an internal medicine resident at the University of Illinois Hospital, published her thoughts in Hospital Impact, on how the need to provide patient-centric care drives her work at the bedside. She writes:
For me, safe patient care is more than adherence to checklists and standard operating protocols. It is a consequence of an approach to treating patients that’s characterized by applying medical evidence in a patient-centric way, by ensuring that compassion enters into care decisions and by listening with purpose to a patient’s articulated needs and, often helping them identify what those needs may be. I look forward to becoming a caregiver who can bring those attributes to my patient interactions…To say that I have evolved over many years to this point may be true, but it took a personal family challenge for me to truly appreciate all that it takes to achieve safe care. It’s not easy, it’s not one thing, it’s not just being careful or diligent — rather, it’s the way we deliver care, it’s how we see our role as part of a healing process, it’s how we put “care” into the word”caregiver.”…click here to read entire article
Resident physicians from MedStar Health and medical students from Georgetown University SOM each held gatherings of their own local Quality and Patient Safety Councils inspired by leaders who spent time in Telluride as well. The MedStar Resident QIPS Council, co-founded by alumni Shabnam Hafiz, MD, and Stephanie Wappel, MD, has grown to over 40 members and is focused on inspiring the change needed to make care safer and of the highest quality. The QIPS Council sponsored its first educational event in September at The French Embassy in Washington DC, led by QIPS Council member (and also a Telluride alumni) Lauren Lobaugh, MD, QIPS Education Committee Chair. The event, entitled “Wine and Wisdom,” was standing room only, and the guest speaker was nationally recognized safety expert (and Telluride faculty–there’s a theme here…), Paul Levy, who spoke about “the art of persuasion”. Guests from all over the region (Univ. of Maryland, MedStar Georgetown University Hospital, MedStar Washington Hospital Center, Johns Hopkins, INOVA, Walter Reed, and more) were invited to join the Council for a cocktail hour, lecture, and small group discussions about where we are today, and where we see our healthcare communities going in the future. The event also piqued the interest of local news outlets, and a story ran in the Washington Business Journal in September. Lobaugh was quoted in the article as below, and the rest of the story can be found here:
Making a mistake that harms a patient can be shattering for a doctor, said organizer Dr. Lauren Lobaugh, a fourth-year resident in MedStar Georgetown Hospital’s anesthesiology department. Over the summer, she headed to a patient safety boot camp held in Telluride, Colorado, and said she was impacted by the idea of “caring for the caregiver” instead of “shaming and blaming” them when an error is made.
And finally, Engagingpatients.org recently asked us to comment on their blog about how our patient advocates contribute to the Telluride Experience. Our patient advocates, and their stories, are such an integral piece of the Telluride Experience, it is hard to imagine the workshops without the depth of their contributions. From the post:
The Power of Storytelling
The power of stories is called upon regularly during the Telluride Experience. Patient and healthcare advocates continue to return as Telluride faculty to share their stories—stories that leave a lasting imprint on the hearts and minds of the alumni and faculty audience…The films are a foundational piece of the TPSSC curriculum, and in each session, they stimulate emotional conversations around what was missed, how to avoid future similar harm, and the hidden curriculum of medicine…
The Human Side of Medicine
When Helen or the Skolniks lead the group conversation after the film, an additional element is added to the learning. Young medical students who have yet to even see this side of medicine are exposed in vivo to the impact their future decisions will have on the kind, loving people before them. The patient becomes more than a procedure, and the audience realizes first-hand just how human both patients and healthcare professionals are. Time and time again, we have seen how these stories change people in the moment…For more, go to EngagingPatients.org
Applications for the 2015 Telluride Patient Safety Summer Camps will soon be announced open. Thanks once again to the generous and continued support of our sponsors–The Doctors Company Foundation, COPIC, and CIR–our patient safety army continues to gain reinforcements in hospitals and in medical/nursing schools across the country with now over 400 alumni scholars making patient safety contagious. For more information, go to www.telluridesummercamp.com.
June has always been a very exciting month for me. For the last nine years, I and many others have journeyed west to Telluride, CO, a beautiful mountain town known by many for its skiing as opposed to summer activities. For those outside CO, Telluride may be one of the best kept secrets in the United States. Many of us often choose to take the scenic six-hour journey from the Denver airport to Telluride each year, making our way up the mountain to run our annual Telluride Patient Safety Roundtable and Summer Camps. The trip provides an up close view and reminder of the silent power held within the peaceful surroundings in which we will be teaching for the next two weeks. Over the years, people have asked me “Why Telluride?” My response has always been the same – “Why not?” Be it the “old west feel” of the town, or the “hypoxic” magic that happens at an elevation of 9,600 feet, Telluride has always been a learning mecca for everyone that joins us during these memorable weeks of high altitude education.
TSRC hosts about 30 scientific programs each summer. We have been fortunate to be one of those chosen each of the last ten years. In fact, out Patient Safety Roundtable and Summer Camps has now become the longest consecutive running meeting that TSRC has agreed to host. The smaller, roundtable format using small group breakouts and learner-centered activities is designed to foster creative thought and consensus building through lively conversation in a relaxed and informal setting. We purposely limit the use of power-point slides to ten each day so learners are fully engaged in the work but not spoon fed the information by people who like to lecture. The students and residents especially love this interactive format. This non-traditional learning environment also attracts patient safety leaders from around the world to Telluride each summer, to “break bread” and share ideas on current issues and challenges. Because of this unique venue and format, a lot of our discovery, sharing of ideas and learning happens on the walking paths, hiking on the mountain trails, in a coffee shop, or over a glass of wine.
Through the generous support of The Doctors Company Foundation (TDCF), COPIC, Committee of Interns and Residents (CIR) and MedStar Health, about 130 health science students and resident physician leaders will be attending one of four, week-long Telluride Patient Safety Summer Camps this summer. The first two weeks will be held in Telluride and the final two weeks will be held in the Washington DC/Baltimore MD region (“Telluride East”) later this summer. In the summer of 2015, thanks to the continued support of The Doctors Company Foundation, an additional Patient Safety Summer Camp will be held in CA – our new home for “Telluride West”.
Our objectives for the Telluride Patient Safety Summer Camps are the same each year:
- To identify and help develop future healthcare leaders and champions in patient safety, transparency and open, honest and professional communication between patients, families and caregivers.
- To develop a growing number of Patient Safety Summer Camp alumni that serve as role models and mentors to (a) health science students and resident physicians at their respective medical centers and health systems, and (b) health science students and resident physicians enrolled in future Patient Safety Summer Camps.
- To create a social networking community where Patient Safety Summer Camp health science students, resident physicians and past alumni can interact with international leaders in patient safety, education and patient advocacy on issues pertaining to patient safety, transparency and open, honest and professional communication between patients, families and caregivers.
- To help create risk reduction and quality improvement collaborative projects between Patient Safety Summer Camp alumni, faculty and patient advocates that are implemented within the Patient Safety Summer Camp alum’s institution and beyond.
This coming weekend, many wonderful and highly committed patient safety advocates and safety leaders will once again convene in Telluride, CO to continue our mission of “Educating the Young”. Over the past 10 years, we now will have had over 400 Telluride student and resident alumni scholars attend one of our Patient Safety Summer Camps. As you have read on our ETY blog, many have done amazing work in leading change that is helping make care safer and more transparent.
Next week, we will kick off this year’s Patient Safety Summer Camps by welcoming thirty resident physicians into our Telluride Scholars club. They are future physician leaders from all across the country who will be immersed in learning about transparency, patient safety, and patient partnership. It truly is an amazing experience that always leaves me and many others energized for months to follow.
Please welcome our latest guest blogger, Sherri Loeb. Sherri is a nurse of 30 years and the wife of Jerod Loeb, Vice President for Healthcare Quality Evaluation at Joint Commission, who she, and the entire patient safety community, lost to prostate cancer last year (see Experiencing Both Sides of the Quality and Safety Chasm…) . Since losing Jerod, Sherri’s passion for patient centered care has only gathered more urgency, as she works to share their story and her nursing experience in a way that inspires change. She is also a member of the MedStar Health Patient and Family Advisory Council for Quality and Safety, as well as a member of the National Quality Forum steering committee for person- and family-centered care. Following is an excerpt from a recent blog post she wrote for HospitalImpact.org, What it takes to navigate healthcare: Engagement, compassion.
Patient engagement, patient-centered care, shared decision-making, patient experience and centers of excellence–all the latest buzzwords in healthcare. But do our industry leaders really understand what they mean or how to implement them, and how critical they are not only to the patient and family, but also to the ultimate goal of patient safety? From my recent experience I would say it’s rare.
I’m a nurse of 30-plus years who has worked in various healthcare settings. I have always been patient-centered and treated each patient as if they were family. Then, on Aug. 4, 2011, my life changed dramatically when Jerod, my husband of 25 years, as well as an internationally known patient safety and quality expert, was diagnosed with stage IV metastatic prostate cancer…
To read the rest of Sherri’s post, please click here.
Following is additional information from our team who helped share Annie’s Story, led by RJ (Terry) Fairbanks (@TerryFairbanks), MD MS, Director, National Center for Human Factors in Healthcare, MedStar Health, Tracy Granzyk (@tgranz), MS, Director, Patient Safety & Quality Innovation, MedStar Health, and Seth Krevat, MD, Assistant Vice President for Safety, MedStar Health.
We appreciate the tremendous interest in Annie’s story and wanted to respond to the numerous excellent comments that have come in over YouTube, blogs and email. The short five minute video sharing Annie’s story was intended to share just one piece of a much larger story–that is, the significant impact we can have on our caregivers and our safety culture when the traditional ‘shame and blame’ approach is used in the aftermath of an unintended patient harm event. At MedStar Health, we are undergoing a transformation in safety that embraces an all-encompassing systems science approach to all safety events. Our senior leaders across the system are all on board. But more importantly, we have nearly 30,000 associates we need to convince. Too often in the past, our Root Cause Analyses led to superficial conclusions that encouraged re-education, re-training, re-policy and remediation…efforts that have been shown to lack sustainability and will decay very shortly after implementation. We took the easy way out and our safety culture suffered for it.
Healthcare leaders like to believe we follow a systems approach, but in most cases we historically have not. We often fail to find the true contributing factors in adverse events and in hazards, but even when we do, we frequently employ solutions which, if viewed through a lens of safety science, are both ineffective or non-sustainable. Very often, events that are facilitated by numerous system hazards are classified as “nursing error” or “human error,” and closed with “counseling” or a staff inservice. By missing the opportunity to focus on the design of system and device factors, we may harm individuals personally and professionally, damage our safety cultures, and fail to find solutions that will prevent future harm. It was the wrongful damage to the individual healthcare provider that this video was intended to highlight.
In telling Annie’s story, we chose to focus on one main theme–the unnecessary and wrongful punishment of good caregivers when we fail to cultivate a systems inquiry approach to all unfortunate harm events. This is the true definition of a just culture…the balance between systems safety science and personal accountability of those that knowingly or recklessly violate safe policies or procedures for their own benefit. Blaming good caregivers without putting the competencies, time and resources into truly understanding all the issues in play that contributed to the outcome is taking the easy way out. We wanted our caregivers to know we are no longer taking the easy way out…
You will be happy to know that the patient fully recovered, that Annie is an amazing nurse and leader in our system, the hospital leaders apologized to her, and all glucometers within our system were changed to reflect clear messaging of blood glucose results. We believe we have eliminated the hazard that would have continued to exist if we had only focused on educating, counseling and discipline that centered around “be more careful” or “pay better attention”. We also communicated the issue directly to the manufacturer, and presented the full case in several venues, in an effort to ensure that this same event does not occur somewhere else.
This event, which occurred over three years ago, gave us the opportunity to improve care across all ten of our hospitals. It also highlighted the willingness of our healthcare providers to ask for help because they sensed something was not right and wanted to truly understand all the issues–they also wanted to find a true and sustaining solution to the problem using a different approach than what had been done in the past. Thanks to everyone for sharing your thoughts and for asking us to tell the rest of the story. We have updated the YouTube description as well.
And, thanks to Paul Levy for opening up this discussion on his blog, Not Running A Hospital, and to those of you who continue to share Annie’s story.
For those who have yet to see the video, here it is:
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.