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!


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.


The Art of Negotiation in Medicine

A recent @NYTimesWell post, Teaching Doctors the Art of Negotiationby Dhruv Khullar (@DhruvKhullar), a dual degree candidate at Yale School of Medicine and Harvard Kennedy School, is a call to further arms on this specific communication skill so few receive formal training in–especially in medicine. Yet almost every day in a health providers’ life contains interactions with patients, colleagues and administrators that are opportunities to negotiate for better–adherence, outcomes, resources and systems’ improvements. He writes:

The medical profession is no longer one in which doctors dictate a given treatment course to patients, who are then expected to follow it. Rather, clinicians and patients deliberate about treatment options, weigh costs and benefits together, and determine the best course of action. This approach requires eliciting patient concerns and addressing underlying fears to arrive at the most effective strategy for maximizing health and well-being.

Screen Shot 2014-01-24 at 11.09.09 AMWhile medical schools have acknowledged the need to expand training around communication, training in negotiation specifically remains far from mainstream. One place the acquisition of this communication skill can be obtained, is the Telluride Patient Safety Summer Camps, where Paul Levy (@PaulfLevy) has joined the faculty the past two years, to teach a session on Negotiation to the health science student and resident physicians scholars. Levy, along with co-author, Farzana Mohamed, who recently published How to Negotiate Your First Job…, have led a favorite workshop by many attendees who have the opportunity to pick up what has traditionally been considered a business skill, though still not often taught to sales professionals in the real world.

As healthcare resources become ever more scarce, and the need to move from individual to systems’ thinking ever greater, so too does the need to influence the related necessary change. The ability to negotiate win-win outcomes are at the heart of Levy’s Telluride training session. Stereotypical sales scenarios where the polyester-suited fast talker takes advantage of the less armored victim is far from what it means to participate in a balanced negotiation, a discussion where one another’s BATNA (Best Alternative To A Negotiated Agreement) is the foundation for both parties being made more greatly whole by the final agreement. An almost zen-like approach to deal making, the single session sends Telluride alumni home with a tangible skill they can apply immediately–in “real” life and in healthcare.

As Khullar writes in the @NYTimes post mentioned:

Negotiation, in this context, is not about winning or losing, or haggling over price or scare resources. It’s about exploring underlying interests and positions to bring parties together in a constructive way. It’s about creative, innovative thinking to create lasting value and forge strong professional relationships. It’s about investigating what is behind positions that may seem irrational at first to understand the problem behind the problem.


Transparency in Healthcare: NYTimes Invitation to a Dialogue Continued

Paul Levy extended an open invitation to healthcare colleagues on the New York Times Opinion page in a letter to the editor entitled, Invitation to a Dialogue: When Doctors Slip Up. Here is an excerpt from that letter:

The tendency to assign blame when mistakes occur is inimical to an environment in which we hope learning and improvement will take place. But there is some need to hold people accountable for egregious errors. Where’s the balance?…People in the medical field are well-intentioned and feel great distress when they harm patients. Let’s reserve punishment for clear cases of negligence. Other errors should be used to reinforce a learning environment in which we are hard on the problems rather than hard on the people.

This has been a continued struggle, both spoken and unspoken, for years. As Paul points out, well-intentioned and hard-working physicians, nurses, pharmacists and other care team members come to work each and every day trying to help heal those in need. However, our current health care system fails them (and our patients) when they come to work. The system also fails to create a learning environment where well-intended caregivers can share potential areas of weakness or events because of fear for their own careers. Because the existing culture of medicine has been very slow to change, I have always believed that educating the young was a silver lining of sorts–or a way to rebuild our culture from the ground up. Educational content on open/honest communication with patients and colleagues has been the core curriculum at the Telluride Patient Safety Student & Resident Summer Camps for the last four years, and that has been shared with over 300 resident physicians, and medical, nursing, pharmacy and law student alumni. It was with great pleasure that I read Telluride alum, Stephanie Wappel’s following response to Paul’s NYTimes piece this weekend – one of the few selected from many responses (see additional comments, including MedStar’s Human Factors Engineering Director, Dr. Terry Fairbanks, & myself here):

I was fortunate to attend a conference on patient safety for which Mr. Levy was a faculty leader. I agree that we need to change the culture regarding the disclosure of medical errors. We cannot learn from what we do not know, and what we do not know can seriously harm our patients.

One strategy that has been implemented at my home institution is the celebration of “good catches.” Every Monday, all hospital employees receive an e-mail that features the “good catch” of the week, in which an error was detected and reported before it had the potential to cause harm. Any hospital employee can report these good catches.

They range from a nurse’s realizing she received the wrong dose of medication from the pharmacy to a medical student’s stopping her patient from getting a procedure that the physician thought he had canceled in the new electronic ordering system. Obviously, the institution is also working on discovering how that error occurred to prevent similar ones.

It is no easy task to change a culture, but this seems to be a good start.

STEPHANIE WAPPEL
Washington, Oct. 16, 2013
The writer is a resident physician at Georgetown University Hospital

The Good Catch Program Stephanie mentions has been a concerted effort of our Patient Safety team at MedStar Health to share some of the learning opportunities that arise on a day-to-day basis in healthcare, celebrate those for their courage to report them, and face them head on versus hiding from them.

If health care is to achieve safety successes seen in other high-risk industries such as aviation, we must learn to balance safety and accountability. For caregivers who knowingly and recklessly violate safe practice, discipline is the right course and much needed. But most errors that lead to patient harm occur because of bad systems or processes, not bad people. Until we can be open and honest about our mistakes, learn from them and support our well-intentioned colleagues, we will continue to struggle.


Would These Physicians Do a Time Out Before a Procedure?

My wife, Cathy, is extremely knowledgeable in safety, quality and accreditation for the non-acute healthcare arena which can make for very interesting dinner conversation. Recently one evening, she shared that after entering “Medicare fraud” in the website search engine of her favorite journal, Outpatient Surgery, the site returned 1178 hits. 1178 hits? You mean 178 hits, I had replied–or maybe, hoped. Unfortunately, 1178 was the correct number. I had to go online and read a few of the stories returned in the search. Following are just two examples from their site:

Spine Surgeon Charged With Medicare Fraud …Atiq Durrani, MD, billed Medicare for $11 million worth of anterior lumbar fusion surgeries between February 2010 and January 2013. According to federal prosecutors, those cases were medically unnecessary for his patients. They’ve charged him with healthcare fraud and making false statements. According to published reports, he has been named as a defendant in 150 medical malpractice cases filed by former back and neck pain patients, and no longer has privileges at the 4 Cincinnati-area hospitals at which he performed surgery.

Oakland County Doctor and Owner of Michigan Hematology and Oncology Centers Charged in $35 Million Medicare Fraud Scheme Dr. Farid Fata, 48, of Oakland Township, MI, was arrested and charged in a criminal complaint for his role in a health care fraud scheme…submitting false claims to Medicare for services that were medically unnecessary, including chemotherapy treatments….positron emission tomograph (PET) scans, and a variety of cancer and hematology treatments for patients who did not need them…Fata falsified and directed others to falsify documents. MHO billed Medicare for approximately $35 million dollars over a two-year period, approximately $25 million of which is attributable to Dr. Fata…The complaint further alleges that Dr. Fata directed the administration of unnecessary chemotherapy to patients in remission; deliberate misdiagnosis of patients as having cancer to justify unnecessary cancer treatment; administration of chemotherapy to end-of-life patients who would not benefit from the treatment; deliberate misdiagnosis of patients without cancer to justify expensive testing; fabrication of other diagnoses such as anemia and fatigue to justify unnecessary hematology treatments; and distribution of controlled substances to patients without medical necessity or administered them at dangerous levels.

About two weeks ago, Paul Levy posted in Kill This Monster, that The time has come to drive a stake through the heart of an oft-repeated assertion. How often have you heard something like the following when those of us in healthcare who want to stimulate quality and safety improvements draw analogies to the airline industry?” Well, in an airplane, the pilot has an extra incentive to be safe, because he will go down with the ship. In contrast, when a doctor hurts a patient, he gets to go home safe and sound.

I felt compelled to respond to Paul in Pilots and Physicians…Skin in the Game, expressing that, if you don’t believe the reason physicians are slower to adopt proven safety tools than pilots are because pilots have more personal “skin in the game” than physicians do, than perhaps the difference between pilots and physicians might be one, or a combination of, three other reasons: (1) misaligned financial incentives, (2) physician autonomy, and (3) a lack of medical accountability and oversight.

Screen Shot 2013-09-01 at 8.33.40 AMI am, and have always been, a big believer in Just Culture. Be it James Reason or David Marx, the concept is critical to achieving any true culture of safety. Over the last few years, I have followed the work of Sidney Dekker, Professor of Humanities at Griffith University in Brisbane Australia where great quality and safety work originates from (See Living Mindfulness). Dr. Dekker has a PhD in Cognitive Systems Engineering and is the author of  Just Culture: Balancing Safety and Accountability, a book I highly recommend, as he encourages us to ask:

What is responsible, not who is responsible. The aim of safety work is not to judge people for not doing things safely, but to try to understand why it made sense for people to do what they did – against the background of their engineered and psychological work environment. If it made sense to them, it will for others too.

After reading about the two physicians via the Outpatient Surgery website, I really struggle to understand how these actions made sense to any physician. The only answers I can come up with are: 1) These physicians had little, if any, regard for the patients who put their trust in them, or; 2) Believed the chance of getting caught for the alleged crimes committed was very slim. The perceived risk-benefit profile was heavily weighted towards personal financial gain, versus the consequences of inflicting significant patient harm. And if these physicians (and the many others referenced in my search) seem to have no fear of the law and possible legal repercussions, what chance do we, as safety leaders, have in getting them to perform Universal Protocol or employ risk reductions strategies before any procedure?

Like Dr. Dekker I believe that a Just Culture is all about balancing safety and accountability. Accountability in healthcare should never be lost.  If we as physicians don’t take personal responsibility and hold others professionally accountable, who will?  When we don’t, we lose the most important element of any patient-physician relationship, which is trust. As Dr. Dekker says:

Calls for accountability themselves are, in essence, about trust.  Accountability is fundamental to human relationships. If we cannot be asked to explain why we did what we did, then we somehow break the pact that all people are locked into. Being able to offer an account for our actions is the basis for a decent, open, functioning society.

To this I say “Amen”.

And…that I am happy my pilot has similar “skin in the game” (aligned outcomes) as I do when I board his/her airplane.


Pilots and Physicians…”Skin In the Game”

Over the past few years, I have really come to enjoy reading Paul Levy’s blog, Not Running A Hospital, especially when the focus is on quality and safety. I have found it educational, thought provoking, and timely. Paul’s post last Sunday, Kill this monster, was no exception, as he starts off by saying, “The time has come to drive a stake through the heart of an oft-repeated assertion. How often have you heard something like the following when those of us in healthcare who want to stimulate quality and safety improvements draw analogies to the airline industry?”

“Well, in an airplane, the pilot has an extra incentive to be safe, because he will go down with the ship. In contrast, when a doctor hurts a patient, he gets to go home safe and sound.”

Why Hospitals Should FlyHis story took me back in time, as I remembered first hearing that comment many years ago. A pilot remarked similarly to me as we walked off a stage together, having just concluded an “Ask the Experts” patient safety panel at a national medical meeting. To be honest, I was a little offended, feeling as though I had just been insulted for being a physician. He had challenged the essence of why the great majority of us enter the medical field, which is to help others and always put our patients above our own self-interests. Before I could respond and defend my chosen profession, he was off…running to catch his plane. But his comment stuck with me and forced me to think deeper into why it bothered me. While it is true that similar complexities exist in both professions–high stress, high risk, varying conditions forcing both pilots and physicians to adapt–why do we, as healthcare professionals, struggle to grasp simple elements–those repeatedly passed on by human factors engineers–that aviation seems to easily adopt and follow without push-back?

I first thought about my specialty – anesthesiology. Why is it that many surgeons will tell anyone who is willing to listen that anesthesiologists are overpaid. They complain that many of us read newspapers, answer emails on our handhelds, or talk on our cell phones with friends while a case is in progress. Would an airline pilot ever consider reading the newspaper, answering emails or using their personal cell phone while working in the cockpit?

How about the accepted practice of running our anesthesia machines through a set of safety checks before using them each morning for surgery? While the manufacturers have added many self-check features through the years, there are still a few things we as anesthesiologists are asked to do each morning. Unless things have drastically changed in recent years, this “recommended safety practice” is not being followed regularly, the assumption being the machine worked fine yesterday so it should be ok today. Would an airline pilot ever think of not doing a pre-flight, airplane walk-around, checking the plane he or she is about to fly, and instead say, “Lets skip the pre-flight walk-around this afternoon…the plane was flown earlier today and I am sure nothing happened during the previous flight”.

Wrong-sided anesthesia blocks have seen significant increases in the past few years as regional anesthesia has become an important element for pain management supplementation in the post-operative recovery period. With the Joint Commission mandating the use of human factor tools like pre-procedure site markings, time-outs, and the use of checklists designed to help eliminate the “humans will be humans and forget at times” factor, we still see over 90% of these wrong-sided, wrong-site, wrong patient procedures attributed to a lack of following Universal Protocol and the use of a checklist. Would a pilot ever think of saying “Let’s not do the pre-flight checklist today. The extra two minutes it takes to do it just kills my day”?

The same figures hold true for surgeons. Many refuse to use timeouts and checklists. They will be quick to point out they have never had a wrong-sided surgery in their ‘fifteen or twenty years of practice’ and don’t need to use these safety tools. As John Nance says, those are the physicians that scare him the most. They believe they are, and will always be, better than the rest of us who will under the right circumstances make a mistake when the holes of James Reason’s Swiss cheese all line up. Having interviewed a number of surgeons and anesthesiologists who were involved in a wrong-sided procedure, every single one of them said the same two things right after the event: (a) They never thought this could happened to them, and (b) They are always so careful. But after the event, they realize we are all human. So why do some physicians still choose not to adopt the same mindset as pilots, before a patient gets harmed?

If you believe Paul’s premise–that it isn’t because pilots have more personal “skin in the game” than physicians do (see More Skin in the Game…)–maybe it could be one, or a combination of, three of the following reasons why we see differences in safety adoption between pilots and physicians: (1) Physician autonomy, (2) Financial incentives, and (3) A lack of accountability by leadership in the face of less than “reckless” behaviors.

To be continued….


Making Connections for Change at #TPSER9

One of the most significant takeaways from the Telluride Patient Safety Educational Roundtables & Student/Resident Summer Camps has always been the new connections made with some truly amazing people from around the world. This year, we all were so very fortunate to meet Dr. Sarah Dalton, a pediatric emergency physician from Australia, visiting the U.S. on a Fulbright Scholarship. Sarah lives patient centered care in her daily work, and is here to study Clinical Leadership Development Programs.

As many following ETY and Transparent Health blogs may know, Paul Levy (Not Running A Hospital) has been on the TPSER faculty the past two years, and is also one of those amazing people working in the best interest of patients. Following is a link to his recent post, Monkeys and Bananas, which includes the following short video our new TPSER connection, Sarah, shared with him  — highlighting why “we’ve-always-done-it-this-way-thinking” is for monkeys — not the new leaders of healthcare!