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!

Residents as Sentinels and Change Agents for Safer Care

This coming Saturday, April 26th, the Committee of Interns and Residents (CIR) will be hosting its next QIIQ Conference titled, “How to be a Lead Agent of Change: From Bedside to Transformative Care“, in NYC. Rosemary Gibson, Carole Hemmelgarn, Shelly Dierking and I have the honor of joining leaders from CIR to help facilitate the all-day interactive session. While many faculty will be attending, the major focus of this educational meeting will be on the residents, both from CIR Hospitals as well as other GME programs, and aligns with the “Educating the Young” mission.

Residents can be change agents for safer, higher quality care. There are now numerous examples across the country of this fact–residents leading important quality and safety initiatives that have reduced risk and raised the quality of care provided–and they have done this work despite internal challenges and long work weeks. Those that have followed our ETY blog for the past two years will remember my post on the work of David Leach, the former CEO for the ACGME (see The Canary in the Coal Mine…).  In one of his publications, Dr. Leach shared the most important role of graduate resident physicians was to act as the “moral agent” for their patients. Residents must be the gatekeepers for safe, high quality care–a sentinel on watch for the many unsafe conditions they might encounter while trying to provide optimal patient care, prepared to alert faculty and leadership to these unsafe conditions, and then work with their institutions to find solutions to remove risk from the patient experience. The analogy Dr. Leach used was the canary in the coal mine, taking on the role of guardian and protecting others from harm before it was too late. I loved this “moral agent” concept. It is so simple, yet so important in the quest for safer, higher quality, patient care. In academic medical centers, resident physicians spend more time in the hospital, have more direct contact with patients, and see many more unsafe conditions during days, evenings and weekends than most other caregivers, except possibly nurses. And they do it many times with little, if any, direct supervision. Resident physicians can be those sentinels and serve as excellent change agents for safer care.

We need more conferences like CIR’s QIIQ focused on our next generation of caregivers.  Please help spread the word about the conference. Below is some additional background information with the links to register. The third link is the conference brochure which has additional details.  We appreciate the support and as always, thank you!!

Background Info:
The one-day conference on How to be a Lead Agent of Change will be held Saturday, April 26th in New York City. Given the importance of the patient experience and the desire for more patient-centered care, the Committee of Interns and Residents conference is meant to empower medical residents to develop and execute high-value care projects in their hospitals and health systems, and better equip them with the competencies they need to work in a rapidly changing delivery system.

To register for this conference, please click here. There will also be a webcast, and people can sign up for that here. The agenda and conference brochure can be found here (this includes logistics on location and timing, as well as goals for the day and additional contact information). Please feel free to share this information, as well as the links to register, with your organization and networks.

*CIR has also been tweeting about the conference with the #QIIQ hashtag. Here is a sample tweet you are more than welcome to share with your followers: What’s your #QIIQ? Join @cirseiu & @EinsteinMed in NYC on 4/26 for the next #QIIQ conference. Register now!

Palindromes and Patient Safety

I have been very fortunate through my career to have met, learned from, and become friends with many patient advocates from across the country.  People like Helen Haskell, Patty Skolnik, Linda Kenney, Sorrel King, and Carole Hemmelgarn to name just a few. Their ability and willingness to turn personal loss into a life-long commitment to make care safer and of higher quality is quite inspiring…they are the true heroes of this mission.

The same holds true for Victoria and Armando Nahum who I was so fortunate to meet about two years ago. Over a period of 10 months in 2006, the Nahums had three family members stricken by hospital acquired infections, at three different hospitals in three different states, culminating in the death of their 27-year-old son, Josh. Like the families I mentioned above, they also turned their own personal loss into a crusade to reduce and hopefully eliminate hospital acquired infections by starting the Safe Care Campaign.

Screen Shot 2013-09-22 at 1.54.18 PMLast week at the Quality Colloquium, I moderated a morning long session on quality and safety at the bedside. Because patient partnership is a critical piece to any quality and safety mission, I asked Victoria and Rosemary Gibson, author and healthcare advocate, to be part of the panel and lead a patient partnership discussion with the audience. Both Victoria and Rosemary (as usual) were outstanding speakers, and had the audience fully engaged. However, during Victoria’s presentation, something truly special happened. Victoria shared the following video that she and her husband Armando created. Lke most in the auditorium, I had not seen the film before. The video delivered its message that morning in a unique and quite remarkable manner. Few times have I seen an audience as captivated at a medical meeting as they were last Thursday while we watched the Nahum’s two-minute film. The audience burst into spontaneous applause at the conclusion of the video, even though Victoria was still in the middle of her talk.  It was an inspiring moment. The Nahum’s creativity and message captured us all that morning. Take a look for yourself:

The Nahum’s courage is powerful, and their message so very important if we are to escalate the fight to reduce risk and improve the quality of care providing to our patients. We need a greater sense of urgency around all of these efforts, especially at a time in the evolution of healthcare when competing agendas vie for attention and funding. Like Don Berwick, Carolyn Clancy and other healthcare quality and safety leaders who have inspired us to do better, patient advocates like Victoria, Rosemary, Helen, Patty, LInda and Sorrel are leaders who inspire us with their passion and commitment to help us get it right. It is encouraging to see them with a seat at the hospital conference or board room, as keynote speakers at national conferences, and included in hospital quality and safety improvement committees.  How we thought we could do this important work without them still befuddles me.

Remembering Those Lost to Medical Harm at #TPSER9


A Day 3 tradition during the Telluride Patient Safety Educational Roundtable & Student/Resident Summer Camps has been for students and faculty to join in a team building trek up the Bear Creek trail in the San Juan mountain range of Colorado. The hike has always played an important part in the week, allowing students and faculty to collectively reflect in a relaxed, awe-inspiring environment on the conversations and concepts around patient centered care, new to some and a career choice for all. This week, the Telluride experience moved east to Washington DC, and the Bear Creek hike transformed into a crosstown journey from the Georgetown University campus on foot and Metra to the Arlington National Cemetery. While the threat of bears and the physical challenges of altitude and mountain terrain were absent, the group was left to navigate east coast summer drizzle, a big-city subway system and an unfamiliar routine to overcome together.

As we made our way across Washington DC, organic conversations between students and faculty grew throughout the largest Telluride gathering in nine years. I was fortunate to get to know a number of students on the walk to and from this national landmark, many of those conversations each deserving a blog post all their own. Like Rose Ngishu for example–a nurse and mother of four from Kenya now in Galveston, TX, and in her third year of medical school. Rose shared how she knew at 7 years old, living in a country where any healthcare was a luxury, that she wanted to become a doctor and change the conditions in her country of origin. A woman, who despite many personal obligations, continues to push stubbornly toward her goal of improving the lives of those less fortunate and become a physician.

Saturday’s hike culminated on the hill beneath Robert E. Lee’s house with Dave Mayer and Rosemary Gibson centering the group around the fact that it would take less than two years to fill Arlington National Cemetery with the victims of medical harm. Less than two years to fill a cemetery that holds over 100 years worth of US Military casualties and their family members. Rosemary then encouraged us to break up into groups of 3-4 and remember by name, if possible, patients or family members that we personally knew affected by medical harm. The group then came back together and honored those we had discussed in our smaller groups. A new Telluride tradition began this week–one that connected the head with the heart, patient with provider.

Following are a few of the names remembered on Saturday. I can only hope that the efforts of our group, all the Telluride alumni, and healthcare stakeholders working in the best interest of patients, will result in the ability to recall fewer names in the future.

Collateral Damage

I once heard Don Berwick say, shortly after taking over as Director for CMS, that he originally thought quality and safety where the biggest challenges facing healthcare today. But after spending time in the district, he quickly came to realize he was wrong. It was fraud that was the biggest challenge.

Collateral DamageHis message came to mind after recently reading a book given to me by Rosemary Gibson, entitled “Collateral Damage”, written by Dan Walter. I can honestly say that after reading the book, I felt embarrassed to be working in healthcare.

In the book, Mr. Walter shares the story of his wife, Pam, who underwent a cardiac catheter ablation procedure for an abnormal heart rhythm known as atrial fibrillation. He describes what went wrong during Pam’s procedure, and then details the pain, suffering, lack of transparency and denial of accountability that followed for both he and his wife. The procedure was performed at what is considered to be one of the best hospitals in the country, which makes the reader wonder what is going on at the “not so great” hospitals across the country, as well as who is defining what makes a hospital “great”. His aim in writing the book was to, “accurately portray what happened to my wife…without detracting from the skill, kindness and compassion of the majority of the people who work there…and to prove to Pam that she does matter, and to tell her that despite what the leadership of that hospital says, her life is important – and her story is important – and it deserves to be honestly told”.

The book is Mr. Walter’s account of the facts related to his wife’s care, so it is only his side of the story. However, it is remarkably well written, and gives a deeply researched account of the cardiac catheter ablation “business”. He includes information:

  • Taken from numerous publicly available FDA transcripts and testimonies on how unsafe these catheters were thought to be.
  • Promotional materials from companies making these catheters who were trying to get them through the FDA approval process hyping the wonderful results being seen in patients who were the first to be “experimented” on.
  • Transcripts from advisory panels and cardiology meetings where leading experts acknowledged the lack of evidence that these catheters even worked.
  • Conclusions from peer-reviewed journals showing complication rates much higher than what was being shared with patients.
  • Medical records highlighting a lack of real informed consent related to the risks and benefits of these procedures.

Mr. Walter also shares numerous other patient stories and holds nothing back. Not only does he name names, but he includes pictures of physicians and others who he and Pam encountered along their journey.

In one section of the book, the author shares thoughts on the difference between a “witness” and an “accomplice”, a witness being one who sees wrong and reports it.  He raises the question that if we as caregivers witness something wrong and don’t report it, aren’t we really accomplices to the wrong when we turn our back and walk away?  His statement caused me to reflect back on my career. As an anesthesiologist, I remember days when I was assigned to provide anesthesia for a catheter ablation case. Although I spoke with the patient about anesthesia related risks and benefits – I never thought of questioning the merits of the procedure I was to be a witness to. It was challenging enough keeping up with all the new findings in my specialty let alone comprehend everything being published in the numerous specialties anesthesiologists support. But after reading Pam’s story, I felt that I too may have been an “accomplice” to possible wrong doing.

I applaud Mr. Walter for sharing Pam’s story. I also struggle to understand why this book has not received similar attention, or the same hype experienced by authors of recent books published on medical error. Collateral Damage goes much deeper in highlighting problems facing healthcare today…a reason why I believe this book should be required reading for all resident physicians and health science students entering the field.

As quality and safety leaders and educators, our daily efforts are built around things like standard work processes, shared best practices, care bundles, checklists and universal protocols–“things” we do in the best interest of our patients. The bigger picture, as Don Berwick alluded to, requires that we overcome the personal, political, legal and financial agendas inherent within many high-level stakeholders. Otherwise, I sometimes feel we are just moving chairs around the deck of the Titanic.

For those interested, Dan’s book is available free on Amazon Kindle as of June 12th

Highlights From A Patient Safety and Quality Journey

Dave Mayer and Tim McDonald are two of the early adopters of the patient safety movement supported by luminaries and other early adopters like Lucian Leape, Don Berwick, Rick Boothman, and Cliff Hughes. Recently, I wrote on their acceptance of the American College of Medical Quality Founders Award, and promised to share some of the highlights of their collective body of work. Here are a few of those highlights:

  1. The creation of the University of Illinois at Chicago’s Institute for Patient Safety Excellence, one of the first of its kind in the US focused on the tripartite mission of clinical care, education and research. It is an interprofessional “confederacy” with membership from six health science colleges all working together with a medical center, leaving their personal agendas at the door, in efforts to make patient care safer and of higher quality. They recognized that the problem of patient safety and less than optimal quality is an interdisciplinary problem requiring an interdisciplinary solution. The Institute strives to discover and validate such solutions.
  2. The Telluride Patient Safety Roundtables and Summer Camps. The Telluride Roundtable is an annual retreat now going on nine years, where experts in safety, quality and health science education come together with patients, family members, residents and students to develop and refine health science education that supports a culture of quality, safety, and transparency in patient care. In 2013, over a span of three weeks, Dave and Tim will be bringing resident physicians leaders as well as medical, nursing, pharmacy and allied health student leaders – over 100 of them – to Colorado and Washington DC for educational immersion in quality, safety and the importance of open and honest communication in healthcare so they can go back to their schools and residency programs and “infect” others, sharing the importance of high quality, transparent patient care.
  3. UIC’s Masters in Patient Safety Leadership program – the first online, adult learning, interprofessional Master’s level degree program in the country where physicians, nurses, pharmacists, hospital administrators, lawyers and even patient advocates can come together and learn together. Dave shares that healthcare is a team sport today, and that all healthcare providers need to learn and practice together.
  4. A comprehensive response to patient harm that includes extreme honesty, full disclosure and early offer was created at Telluride in 2005 with input from Patients and Families. It has become known as The Seven Pillars Program and is the foundation of a multi-million dollar AHRQ grant that has allowed the pair to connect more than 1000 hospitals to these concepts. From a personal level, Tim shares that the program also includes their Best Practice – Physician Peer Support Program that is provided 24/7 for all physicians involved in emotionally challenging harm events.
  5. An award-winning educational film series entitled “The Faces of Medical Error…From Tears to Transparency”. The films are being used in medical schools, residency programs, hospital grand rounds and board rooms across the world to create conversations on how to make care safer and of higher quality. Many years ago Rosemary Gibson, a very wise woman, wonderful friend and mentor to both Tim and Dave, taught us the power of connecting the brain – the learning – with the heart – the emotion. Tim and Dave produced these movies with Rosemary’s words in mind and dedicated them to the families who have lost love ones due to unintentional harm. As Dave shares, they are the true heroes, the patent and family advocates who, despite their tremendous loss, give back every day in efforts to make care safer for others.

And what I’m personally thankful for is that they stuck with it — this is not a journey for weak of heart — and it’s not something for those driven by instant gratification. Changing an entire culture of an industry takes those like Dave and Tim, who can take their lumps along the way and keep moving forward because they care so deeply about the well-being of patients and the profession they have dedicated a lifetime to.

The Value of Inviting Patients to Participate In Their Care–Rosemary Gibson at MedStar Health

As a holiday gift to our readers, we would like to share a talk given by Rosemary Gibson, noted author and patient advocate, who was just named in a recent Forbes article as one of 13 to Watch in 2013: The Unsung Heroes of Healthcare.  Rosemary was kind enough to share her expertise with the Patient Safety and Quality leadership at MedStar Health this past October. In an earlier post, Dave Mayer provided highlights from her keynote address, found here. The following video is a copy of her talk, as she outlines the value of ensuring patients are included in all aspects of their care.

Please share Rosemary’s wisdom with your own institutions, as we take a break from blogging this week to reflect and recharge for 2013!

Patient and Family Advisory Councils – The Importance of the Patient Voice in Our Safety and Quality Work

Patient and Family Advisory Councils are forming in many hospitals across the country. Some institutions, like the Dana Farber Cancer Institute and Cincinnati Children’s Hospital have had “Patient Partnership” Council’s in place for over a decade, inviting the patient into healthcare decision-making and strategic planning, setting examples for those just starting the process. Aurora Health in WI, who received AHRQ funding to look at best practices around the formation of a Patient Safety Advisory Council for outpatient medication safety has provided guidelines for all to follow if they so desire to set up their own Patient Advisory Council.

But with many now rushing to engage patients, a few leading patient advocates have become a bit skeptical. Engaging patients is more than just addressing the call from the Institute of Medicine in their September report. It’s more than gathering people in a boardroom, serving lunch and feeling good about ourselves. It’s more than just checking the patient council box when the Joint Commission comes visiting. And it’s more than just asking patients about hospital room colors. It’s about true partnerships that define, and then measure, patient safety and quality improvement outcomes from projects that directly result from the time invested in these types of meetings.  When done correctly, these partnerships become powerful and lead to positive changes in a number of areas. The culture of medicine is in transition, and like any industry, changing culture takes time, courage and the ability to take action outside our normal comfort zones.

This week, I had the great pleasure of spending time with a number of leading patient advocates – people who have devoted their careers to helping patients, caregivers and health systems better understand what is needed to lower risk and improve quality in patient care. Many are good friends and have been personal mentors to me through the years. People like Helen Haskell, Carole Hemmelgarn and Patty Skolnik, three remarkable women who continue to share their personal stories of loss so others can learn, and make care safer.  People like Rosemary Gibson, Michael Millenson, Sorrel King and Victoria Nahum who have touched us all through their writings, educational materials and collective call for change.  They have graciously agreed to help us at MedStar Health better understand and appreciate what terms like patient-partnership, shared decision-making, and transparency really mean to our patients. Their definitions and perspectives can be quite different at times from those I have thought were correct and published in the literature through the years. Many times I think I get it, only to realize that “I don’t know what I don’t know”. Tim McDonald, a good friend, mentor and patient safety leader, always likes to say we can be “unconsciously incompetent” when describing this phenomena.

We all met as a group last week, and the conversation took on a life of its own. With the advocates asking the tough questions, the conversation and discussions evolved organically and led to the open, honest discourse we all know is critical if real change has a chance to occur. Rosemary challenged the leadership in the room to measure our success by striving for the day when every healthcare provider working in our system was one that we as caregivers would refer a family member to – no hidden secrets on who we know is good, and who we would take our loved ones to for care. A second recommendation focused on outcomes data, and how to present it in a meaningful way–in a way that patients could truly understand, and then use it for decision-making. And more than one of our advocates implored us to create educational tools that patients could not only use to guide them through their hospital stay, but also make it clear they were a welcome and engaged part of the care team. Many health systems like MedStar already have different patient educational tools in place, but the group pushed us to think differently and be even more innovative in our approach to patient education.

The day ended with excitement around the different opportunities to create change right in front of us, and in fact, work has already begun on more than one consensus recommendation resulting from the meeting. We all look forward to the continued sharing of ideas with our council members, and graciously thank them for their insight and resolve to push us past our limits in the best interest of our patients.

Author Rosemary Gibson Keynotes MedStar Health’s Quality and Safety Retreat

Author Rosemary Gibson was kind enough to keynote our MedStar Safety and Quality retreat yesterday with her talk entitled, The Patient Perspective in Patient Safety: Can It Make A Difference? With almost 100 MedStar leadership associates in attendance, her message, and her ability to bring the patient’s voice into the auditorium, was the very best way we knew to accelerate what MedStar Health established as rule number one years ago…that is, “The Patient is Always First”. The patient is the very reason caregivers do what they do–and that can sometimes be forgotten in the push to get things done, or in the many details of the day.

As Rosemary spoke, the room was silent. I did not see her compete with even one handheld device in the audience. “Patients make the invisible, visible,” she said, as she shared stories of patient harm, but also gave examples of how far we’ve come in healthcare. To the left is a photo of Diana, a mother who fought a surgical site infection throughout the last months of her pregnancy. Two days after giving birth, Diana’s body could no longer fight the infection and she died. This photo is the only one of mother and daughter together. Diana’s mother is now raising her granddaughter, and understandably was devastated after her own daughter’s death. Rosemary shared how Diana’s grieving mother was able to eventually become a resource to healthcare providers by sharing their families’ story so that others would not experience the same senseless loss. She has used her personal loss to help others by becoming a national leader in infection control awareness. This is the power of welcoming patients into the safety and quality conversation–many have unique insights and ideas that caregivers often lack – they see things we don’t which adds significant opportunity for improvement to any quality and safety mission.

There were many excellent takeaways from yesterday. Rosemary reminding all of us the great value patients add to the caregiving environment, both during excellent provision of care and also at times when things do not go as planned, was most definitely one of the key messages. Her comments, along with the additional thoughts shared by many attendees follow, emphasizing the value of having patients and families on different healthcare teams–something being done more and more throughout the MedStar Health System.

  1. Patients and families can help make care safer by working with care providers in a structured way (Advisory Boards, Panels, Committees)
  2. Patients and families bring a different perspective and new areas of expertise that complements what we do as caregivers
  3. Patients and families are additional eyes present at times caregivers are not. They provide additional data points we don’t necessarily collect but are of great importance to the healthcare team.

When harm does occur, Rosemary shared that her anecdotal research has shown patients do not want to resort to litigation, and that those who seek legal council have done so because they have been blocked by the medical establishment’s Wall of Silence, also the title of her first book. They file claims out of anger…not out of greed because we as caregivers have historically built those walls of silence around us, keeping the truth from them. As Rosemary pointed out, patients and families don’t want to spend 4-6 years of their lives in courtroom battles, depositions, listening to expert witnesses (a.k.a. hired guns), and not being able to move on, or put the harm behind them…always having to relive the event over and over with no sign of closure. Instead, she has found, along with increasing peer-reviewed research performed at the University of Michigan, University of Illinois and others who have adopted an open and honest approach to medical harm, patients just want to know what happened. They want to be absolved of the guilt they feel–that they could have done something to prevent the harm to their loved one. They don’t want to be billed for, or pay, for poor quality care. And they want to know this same event will not happen to another person–that the hospital has learned from the unfortunate event and made the necessary changes that make the care system safer.

There are pockets of greatness occurring across the country. MedStar is one of those bright spots. The organization has had a policy of open and honest communication after patient harm and has been doing it right for over ten years.  After the session, Rosemary shared with me that she saw the eyes of understanding and readiness looking back at her from the audience yesterday, and I could also feel the eagerness to achieve quality and safety greatness in the room.