Academy for Emerging Leaders in Patient Safety Kicks Off in US for 2017

As many of us begin our regular summer pilgrimage to Telluride, Colorado, it is hard to believe that thirteen years have passed since a small group of passionate healthcare leaders came together in Telluride to design a comprehensive patient safety curriculum for future healthcare leaders. As a result of that work, many wonderful and highly committed patient advocates and safety leaders will once again convene in Telluride the next two weeks to continue our mission of Educating the Young. For those not from Colorado, summertime in Telluride may be one of the best kept secrets in the United States. Be it the old west feel of the town, or the hypoxic “magic” that happens at an elevation of 9,500 feet, Telluride has always been an educational mecca for everyone that joins us during these memorable weeks of high altitude learning led by the MedStar Institute for Quality and Safety and the Academy for Emerging Leaders in Patient Safety (AELPS).

Over the past thirteen years, about 1,000 students and resident physicians from across the world have attended one of our AELPS Telluride Experience workshops. Many of our past alumni have gone on to lead work that has inspired real change at their home institutions–change that is helping make care safer and more transparent. We look forward to meeting yet another class of emerging patient safety leaders these two weeks who will also stand up for patients, transparency and a true culture of safety during their careers.

Through the generous support of The Doctors Company Foundation (TDCF), Committee of Interns and Residents (CIR), COPIC and MedStar Health, about 180 health science students and resident physician leaders will be attending one of four, week-long Patient Safety Summer Camps being held in the United States this summer. The US camps are held each year in Telluride CO, Baltimore MD, and Napa CA. In addition, another 100 future healthcare leaders will be attending one of our AELPS International Patient Safety Summer Camps this year in Sydney, Australia and Doha, Qatar.
A new generation of caregivers – young physicians, nurses, pharmacists and other allied health professionals – are stepping up and starting to make a difference in healthcare. Many of them understand and appreciate they will soon be the gatekeepers for safe, high quality, high value patient care. They are taking this responsibility seriously – more seriously than I and my colleagues did when we were their age. These young leaders are the future of healthcare…and the future is bright.

We hope you will follow our activities and learnings through our student, resident and faculty blogs, found here on ETY or The Telluride Blog, found here. Please comment and join our conversation on the blogs or on Twitter (@TPSSC and #AELPS13).


The 80-20 Rule and Disruptive Healthcare Professionals

80_20_Rule_ImageA colleague forwarded on a momentarily disheartening clip from the Washington Post last week. The article, entitled Anesthesiologist trashes sedated patient–and it ends up costing her, included an audio clip from the patient’s cell phone that he had inadvertently left running during a colonoscopy in which healthcare professionals charged to care for him instead chose to act like grade school bullies. The anesthesiologist, who was one of two physicians named in a lawsuit for medical malpractice and defamation, is clearly heard on the audio clip belittling and taunting the patient while sedated. Additional staff is heard laughing as the proceduralist and anesthesiologist continue their disturbing banter. No one in the room, or at least no one on the audio clip included in the Post article, told them to stop. I will bet, however, there was at least one person in the room who wanted to say something.

I say momentarily disheartening because as I sat listening and briefly wondering how any of the work we do educating the young–teaching them to stand up to bullies and disruptive healthcare “professionals” like this in the workplace–was going to overcome the still so well-ensconced medical culture, I quickly found solace in the fact that we like to elevate the train wrecks in all walks of life. And the Post was most definitely covering the story of a train wreck.

Knowing that our culture is comprised of the stories we share, I just as quickly recalled multiple stories of the great work being done in my small corner of healthcare alone. Take, for example, the weekly Good Catch stories shared throughout the MedStar Health system showing exactly how the 80-20 rule can be applied to the prevalence of healthcare bullies. I was comforted by the fact that for the 2 physicians mentioned in the Post story, I knew of at least 8 good people protecting patients in just one health system. Stories of visiting nurses who ensure the safety of those in the home, or of the local security guard who sits with a soon-to-be patient until help arrives. Stories of nurses who speak up when care does not seem to be going in the needed direction, and stories of physician leaders who actually lead, setting the stage for those often silenced to share their voice. Yes, the 80% is alive and well!

Those who aren’t convinced it is just good form or good karma to treat patients and/or colleagues with dignity and respect can turn to a growing body of formal research that contends bullying and incivility in the workplace has many costs, including patient safety and workforce overall well-being. An opinion piece in the New York Times on June 19th entitled, No Time to Be Nice At Work, by Christine Porath refers to a survey of more than 4,500 doctors, nurses and other hospital personnel of which “…71 percent tied disruptive behavior, such as abusive, condescending or insulting personal conduct, to medical errors, and 27 percent tied such behavior to patient deaths.”  Porath also references work recently published in the American Journal of Management, Does Rudeness Really Matter? The Effects of Rudeness on Task Performance and Helpfulnesswhich showed people working in an environment that lacked civility missed information directly in front of them and offered fewer creative solutions to tasks before them. The same was true if individuals simply witnessed an exchange of rudeness.

It matters not whether it ends up being the data or the stories that drives us to treat one another, especially patients, with dignity and respect in the healthcare environment. And maybe stories like the one in the Post last week are needed in some strange way, if only so that they might discourage the next bad actor who has failed to mature themselves from lashing out at the vulnerable. I do know, however, that we need to add at least five stories of the good work healthcare professionals are doing each day to counteract the negative force a story like this carries into the mainstream. In the meantime, we need to continue to empower those healthcare professionals who want to do better, especially young healthcare trainees. There are many within healthcare who look at the Post story and are embarrassed to be part of a profession that would allow this to continue but have yet to find their voice or platform. Here’s to the good guys and gals–the 80%–we know you’re out there. It is up to healthcare leaders to give them a pen…or a mic!


Patients and Care Teams: Working Together at MedStar Health

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


Telluride Alumni and Faculty Continue to Leave Their Mark on Healthcare

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

WineWisdom_Paul_Lauren_Shelly_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.


Telluride “Old West” Ski Town Embraces Patient Safety in Our Tenth Year Anniversary Celebration

TPSSC_Logo_v3June 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.

Screen Shot 2013-06-02 at 10.46.03 PMThrough 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:

  1. 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.
  2. 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.
  3. 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.
  4. 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.

DSC_0684This 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.


Patient Advocate Sherri Loeb on Navigating Healthcare

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.


An Addendum to Annie’s Story

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: