As the Telluride Patient Safety Summer Camp 2014 Sessions come to a close, we are buoyed by our ever-expanding network of young and enthusiastic health care providers in-training, turning patient safety into a creative science. The Telluride Summer Camp blog continues to receive comments and posts from alumni, and is increasing evidence of a positive healthcare culture on the rise. Mindfulness, a just and learning culture, open and honest communication and patient centered care are all foundational messaging of the Telluride curriculum, and keys to true culture change in healthcare. Colin Flood, an M2 from Rush Medical College in Chicago attended this year’s Telluride East Camp, and recently posted the following reminder that patient safety lessons exist all around us, especially when we are mindful and focused on the end goal of keeping patients safe.
Thanks Colin, for continuing the patient safety conversation:
On the way to the hospital this morning, I heard a report from NPR’s Dan Charnas about mise-en-place, the chef’s philosophy and discipline for organizing and managing a hectic commercial kitchen. The piece was a great reminder that many of the challenges we face in healthcare are shared by others. Chefs standardize their procedures, prepare meticulously for each workday, and read back instructions from their colleagues to keep orders straight in the hectic kitchen. They also “work clean” and practice “clean as you go” to keep their workspaces organized and their food safe. When something’s not right, the chef “slows down to speed up” by taking time to correct any problems before a dish reaches a customer. A few weeks after Telluride it was a great reminder that we can get inspiration and motivation for patient safety practices anywhere!
To hear the NPR story, click here.
Yesterday’s afternoon discussion at Telluride East was focused on “Transparency”, a buzzword for many in healthcare today, but a concept that holds tremendous meaning for patient safety and caregiver well-being for those who walk the talk. Dave Mayer started the conversation by asking the group to share what transparency meant to them, and then breaking up the larger group to discuss:
- What are the barriers to transparency in healthcare?
- What are the barriers to being transparent with patients?
- What are the benefits to having a transparent culture in place?
In our small group, several themes emerged, and surprisingly, not the least of which revolved around leadership and culture being the primary drivers of the “shades of transparency” experienced by both providers and patients in any given health system. One of our student scholars shared how he feels his excellent intuition, or spidey senses, need to be kept in check so as not to appear a “pain in the butt” to senior physicians–physicians who set grades and can directly impact his medical career. Those same spidey senses activated in the mindful physician during the delivery of care, or as he coined it, hypervigilence, are exactly what is being called for in healthcare organizations seeking to become high reliability systems. Here was someone who clearly was acting in the best interest of a patient, and because of hierarchy and poor leadership, was made to feel as though his intuition was a bad thing.
In a related and revealing post, I’m sick and tired…but far from done, Telluride faculty and colleague, Richard Corder, shares his ire related to watching the bad eggs of healthcare remain in place, to continue to harass and cripple the well-meaning efforts at culture change. While he comes from a position of understanding “the why” of the situation, he’s also sick and tired, as are many well-intentioned caregivers who have chosen to remain silent in the face of leadership that fails to lead–and worse yet–infuses toxicity into a culture and careers of those less tenured. When I hear stories like these I know we still have a long way to go to create a healthcare that is safe for all who work within it, or enter it as a patient.
The silver lining to all this is the medical and nursing students who have chosen to come to Telluride this year. The same medical student mentioned above also stated, “when I’m an attending, I will encourage questions about the care being delivered.” And I believe him, but I also know the real world sometimes takes that passion, that resolve, and turns it into “shades of the self” that if not careful, can turn even the most well-meaning individual into someone who has to rationalize or tone down the goodness within. It’s our job as healthcare leaders to support those young learners in any possible way we can. This is a recurring theme that comes to light at the Telluride Patient Safety Summer Camps…
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’…
When did someone last give you a tool that added more time in your day, or provided greater clarity or calm? What if you were told that to achieve this, all it would take would be a 10 minute investment each day? Would you believe it? If you have 10 minutes right now, you can decide for yourself by listening to Andy Puddicombe, whose TED Talk on mindfulness follows. I share his talk because in healthcare, we are constantly being told to do more with less. Incorporate one more initiative into an already busy day. See more patients in the same allotment of time. Hopping from one task to the next, we are rarely in the moment for very long if at all, and in order for health systems to become highly reliable, mindfulness has been identified as a necessary standard operating procedure.
In this short talk, Puddicombe reminds us of the power in experiencing each moment exactly as it is–something we knew how to do innately as children, but have lost the ability to greater responsibilities over time. He refers to a recent Harvard study published in Science, A Wandering Mind Is an Unhappy Mind, by psychologists Matthew Killingsworth and Daniel Gilbert who used an iPhone app to track thoughts, feelings and actions of study participants. Results showed that participants spent almost half their time thinking about things they weren’t doing–missing out on life happening right in front of them, resulting in reports of greater unhappiness.
The good news is that through mindfulness practice we can learn to regain command over consciousness and return to the present–experiencing the moment without judgement. It is this type of awareness — of ourselves and our surroundings — that will improve healthcare, as well as our experience while working within it.
Please share with a colleague —
During our time in Telluride over the last eight years, preparing medical students and residents to handle the challenges that lie ahead–interpersonally, professionally and through patient care–we would make an annual hike up to the waterfall at Bear Creek mountain. The hike itself was an excellent environment to apply creative thinking to the material presented throughout the week. It also served as a physical metaphor for the professional challenges that the students will face once they graduate. A long hike like this that starts at 9000′ and rises to over 11,000′ is always safest with a buddy–and navigating the healthcare profession is no different–especially today.
Our hike is also a journey, not a race, taking almost four hours to complete. On the hike we talk about the similar “journey” healthcare is taking towards High Reliability. That’s why those like myself, leading change within healthcare systems, like my own MedStar Health, have focused our direction toward high reliability. We look to others who have already started down the road to high reliability for insight. Steve Muething MD and VP of Patient Safety at Cincinnati Children’s Hospital (CCH) has provided great insight through his online presentations, along with others who openly share their stories of transformation, such as Gary Kaplan at Virginia Mason Medical Center.
In 2010, Steve gave a talk on situational awareness at the 2010 Risky Business meeting. Risky Business is a non-profit collaborative between CCH, the Great Ormond Street Hospital for Children NHS Trust and others, and their goals are:
- To think outside our “box” and share new ideas about managing risk and human factors from other high risk industries.
- To understand why humans make mistakes, and how to mitigate and recover from them.
- To learn how to manage and add value from critical incidents.
- To learn from defining moments in other high risk industries.
- To share ideas about leadership and teamwork from the highest achievers in sport, business, politics, the arts, exploration, space and medicine.
- To hear about the experiences of well know whistleblowers when all else failed.
- To learn more about the importance of appropriate regulation, when, by who and by how much.
- To understand the role of the law and the media when things have gone wrong.
- To share pragmatic examples of excellence in improvement and transformation at individual and organizational level.
Steve’s talk at this meeting focused on how his organization was reducing Serious Safety Events by raising situational awareness with the use of a tool that could predict and catch children likely to deteriorate at a time care providers could intervene and have a chance at changing the outcome. He describes three levels of situational awareness and where they occur:
- At the bedside level: Where less experienced healthcare providers are caring for patients.
- At the microsystem level: Where more experienced providers are in charge and understand the need to act on data received.
- At the organizational level: Where hot spots in the hospital are known, and the ability to provide additional resources to be successful is available.
And he shared the five risk factors CCH identified, at least one of which they found to be present every time a child deteriorated:
- Elevated PEWS (Pediatric Early Warning Score)
- High risk drug or therapy
- Family expressed concern
- Communication breakdown
- Patient is a “watcher”–the gut says “something is happening”
To catch a child before they coded or needed to transfer to the PICU, each level of patient care was required to report up a level on each of these five risk factors every four hours, even if the answer was to report no concerns. They took the “let me know if there is a problem” mentality out of the equation, and simply made it policy to anticipate and catch a problem by being aware around the clock. He also shared insight from his visit to an aircraft carrier, and the resulting knowledge that taught him just how similar his hospital was to that environment. I encourage you to watch the video and share your thoughts.
For those embarking on their own high reliability journey, I welcome the trial and error discussion here–a place where those of us traveling the same road can share what is working, what presents challenges and who has found some answers we can all apply. We can both teach and learn together, as we each do our part to improve the system in which we have dedicated our lives to serve our patients.
Speaking of checklists and routine, Atul Gawande and colleagues put out an excellent example of a mindless execution of a surgical checklist on You Tube. As they say, a picture is worth a 1,000 words–in this case, a video of “how not to do it” eloquently makes the case for ‘how to do it’ correctly. Thanks Atul, for providing yet another example of true north to patient centered care.
And a more mindful, creative method of performing a surgical checklist follows. If you have a few minutes, it’s well worth it to watch this one–at least until the Remix portion:
In Gawande’s piece, The Velluvial Matrix, for the New Yorker in July of 2010, he writes:
…Doctors and scientists are now being asked to accept a new understanding of what great medicine requires. It is not just the focus of an individual artisan-specialist, however skilled and caring. And it is not just the discovery of a new drug or operation, however effective it may seem in an isolated trial. Great medicine requires the innovation of entire packages of care—with medicines and technologies and clinicians designed to fit together seamlessly, monitored carefully, adjusted perpetually, and shown to produce ever better service and results for people at the lowest possible cost for society…
Without mindfulness applied to daily practice, including routines that may seem to have little effect on outcomes, health systems will fail to reach the high reliability that will deliver the Triple Aim–better care, better population health at the lowest possible cost. It is imperative we start teaching these newer concepts of high reliability, mindfulness, teamwork, human factors and transparency to our students and residents. Our future caregivers should not have to struggle trying to provide care that is safe and low risk.
As mentioned, high reliability organizations (HROs) are built upon a state of mindfulness. The enemy of mindfulness is mindlessness, and in a dynamic environment like a hospital there are still many routine tasks that are done with every patient. The potential to perform the routine tasks mindlessly is something HROs successfully avoid. Instead, every task is approached with mindful questioning, “What’s the big picture here, and what is the worst thing that can happen?” As Weick & Sutcliffe point out in Managing the Unexpected:
…When operators execute operations mindfully, they tend to rework the routine to fit changed conditions and to update the routine when there is new learning. These small adjustments are the bane of a command-and-control system. But those same adjustments keep the system going even as they sustain the illusion that it is commands and rule compliance, not continuing
adjustments, that keep it going.
In the healthcare setting, checklists and surgical debriefs are two ways to introduce and incorporate mindful practice into daily routine. Ronald Epstein MD penned a must read article on Mindful Practice in JAMA in 1999, showing how mindfulness can further be applied to medicine. The table to the right itemizes characteristics of mindful practice, not currently taught in medical schools or tested on boards, but skills very necessary to complete a healthcare providers training in order to provide true patient-centered care. As Epstein writes:
…consider what a resident in a busy pediatric emergency department might do when he is unable to determine whether an ear examination is normal or abnormal and the attending physician is not immediately available…(s/he) weighs the consequences of misdiagnosis for the patient, the humiliation of having to call the otolaryngology resident…loss of self-esteem by having to admit incompetence…
…A mindful conscious approach would be to cultivate awareness not only of the correct course of action but also of the factors that cloud the decision-making process. The mindful practitioner is mentally and technically better prepared for the next situation.
Mindfulness shares a number of qualities embedded in emotional intelligence. Developed by Daniel Goleman, emotional intelligence embraces and draws from numerous branches of behavioral, emotional and communications theories. Forbes.com interviewed Goleman in September of last year, and provides an overview of his work in their piece, Daniel Goleman on Leadership and the Power of Emotional Intelligence. Key to his work are the identification of five emotional intelligence domains:
- Knowing your emotions.
- Managing your own emotions.
- Motivating yourself.
- Recognizing and understanding other people’s emotions.
- Managing the emotions of others in building strong relationships.
High emotional intelligence requires awareness and control of our own emotions, values, preferences and goals as well as those around us – for caregivers that includes not only our colleagues and peers, but most importantly our patients. Understanding and being mindful of a patient’s emotions, values, preferences and goals is critical to the provision of high quality, safe healthcare.
Throughout our series on High Reliability Organizations (HROs), we have been discussing the five defining principles Weick & Sutcliffe have described HROs to possess: 1) Sensitivity to Operations; 2) Preoccupation with Failure; 3) Deference to Expertise; 4) Resilience; and 5) Reluctance to Simplify. The five principles are interrelated and do not exist unless they are built upon an organizational “collective mindfulness,” which describes the way in which the scarce commodity of individual attention is applied to the health of the overall organization. They use Langer’s model of a mindful state at the individual level and then apply it to the group based on its application and interplay within the five principles above. According to Langer:
“…a mindful state is expressed at the individual level in at least three ways: active differentiation and refinement of existing categories and distinctions; creation of new discontinuous categories out of the continuous streams of events that flow through activities; and a more nuanced appreciation of context and of alternative ways to deal with it…”
But mindfulness for the sake of mindfulness will not transform an organization into a HRO. Awareness and vigilance without action will not keep patients safe in our hospitals. It is the ability of all within an organization to consistently focus awareness to that which has the potential to cause harm without losing the forest through the trees as they say, and then effectively act upon the data taken in that will effectively transform an organization. As Weick, et al share:
“…To grasp the role of collective mindfulness in HROs, it is important to recognize that awareness is more than simply an issue of “the way in which scarce attention is allocated” (March, 1994, p. 10). Mindfulness is as much about the quality of attention as it is about the conservation of attention. It is as much about what people do with what they notice as it is about the activity of noticing itself…”
Mindfulness empowers action that prevents potential harm, and can be appreciated with the high reliability mindset of crews on aircraft carriers. Stephen Muething, MD, Vice President of Safety at Cincinnati Children’s Hospital illustrated one such example of action in his post, Lessons From An Aircraft Carrier:
“A piece a paper floated up onto the deck. A young trainee raised his hand immediately, dozens of other hands went up on deck when they saw his, and the landing was aborted. During the commanding officer’s daily address that evening he called out the sailor by name and thanked him.“
The chart at the top of this post is adapted from Weick, Sutcliffe & Obstfeld, 1999 and was found in the AHRQ publication “Becoming a High Reliability Organization: Operational Advice for Hospital Leaders.” The visual further reinforces that without a constant state of mindfulness, an organization will not achieve high reliability, or if they do so, the accomplishment will be fleeting. How can organizations develop and institute a state of collective mindfulness within their organization? With practice, intention and a culture steeped in transparency and an openness to learning. More on mindfulness to follow. Please share your thoughts–
Weick KE, Sutcliffe KM, Obstfeld D. Organizing for high reliability: Processes of collective mindfulness. Research in Organizational Behavior. 1999;21:81-123.
Weick KE & Sutcliffe KM. (2007). Managing the Unexpected: Resilient Performance in an Age of Uncertainty. San Francisco: Jossey-Bass.