So Many Heroes Among Us – A Thanks to All Caregivers

John_Nance_charting-bookJohn Nance, a leader and pioneer in both aviation and medical safety and quality–and for the past 18 years, a familiar face to television audiences as the Aviation Analyst for ABC News and Good Morning America–joined us this year in Telluride for our Patient Safety Summer Camps. John, along with other international patient safety leaders, have come to Telluride over the last 10 years to share their knowledge and passion for patient safety and patient-centered care with the rising leaders of healthcare. It is with a heart full of gratitude that we have welcomed Lucian Leape, Cliff Hughes, Paul Levy, Helen Haskell, Rosemary Gibson, Kim Oates, Richard Corder, David Classen, Carole Hemmelgarn, Bob Galbraith, Gwen Sherwood, Patty Skolnik, and so many other wonderful “teachers” each year to our faculty. Many come to CO every summer because they believe so strongly that we must Educate the Young if we are to deliver the highest quality, safest care possible to our patients.

At this year’s Summer Camp, John spoke about the similarities between aviation and healthcare, highlighting the importance of Teamwork, Effective Communication, Leadership, and the power of Debriefing after all activities. His educational messages came to life when one of our faculty, Dr. Roger Leonard, boarded his flight back to the east coast. Roger’s story, shared below, exemplifies almost every skill John spoke to our group about just days ago. While there is still much work ahead for those of us on the Quality and Safety mission, we sometimes forget all the good things our professional caregivers do in the face of very dysfunctional health systems and decreasing resources. Thank you Roger, and a heartfelt thank you to all caregivers who make a difference each and every day in the life of another.

Not Retired,” Previously posted on the Telluride Summer Camp blog, by Roger Leonard MD

My flight from Denver to Washington Dulles was late to depart due to thunderstorms.  We left at 10:30 pm and I tried to sleep, but was sufficiently alert to hear the page at approximately 2 am: “Any medical personnel on board?”   The flight attendant escorted me to first class where a passenger had what she thought was a seizure.  And she was probably right – only it was due to sudden cardiac death.  No pulse, no breathing, unconscious.  Male, perhaps 45 yo, looked fit, no companion.

The flight crew assisted me in lifting him into the aisle.  Because of their training, by the time that I started CPR, one of the attendants had the AED out and started handing me the pads for placement.  V.Fib.  We shocked once and got a rhythm.  He started to breathe and the oxygen tank was right there.  He had a rhythm, he had a strong pulse, he was breathing.  I said: “This is good.”

I tried to get a BP, but the sphygmomanometer was broken.  We got another emergency kit and it had a cuff that worked – BP ~115 systolic.  I admit that I struggled to get accurate BP recordings because my ears felt like I was 12 ft underwater from the altitude change (and probably a need to see an audiologist).  We sorted through the medical kits and I finally found the NS under the neatly packed top layer of drugs.  Found the tubing, tried to maintain sterile technique, and got a decent IV in his forearm while fighting postural movements of his upper extremities.  Then came VF arrest #2 and #3.  Shock, shock, back to NSR.  I was able to push lidocaine 100mg IV.

While scrounging around the medical kits, I found an endotracheal tube.  To me great relief, he kept breathing on his own and had good color.  I hadn’t intubated anyone in 40 years.  Meanwhile, the pilot was diverting us to Louisville where the EMS team met us.  You know how tight the aisles are.  We managed to get him onto a back-board, but then had to tilt him to nearly 90 degrees to turn the corner.  He was on his way to the hospital and after refueling, we were on our way to Dulles.

I got applause and handshakes as I returned to my seat.  How strange!  After our 4 days together, I could only think that “it’s about the patient, not about me.”  I was particularly aware of the calm and effective work of the flight attendants on our team.

In Louisville, we needed new fuel and a new flight plan.  So, with the extra time I asked to gather all the attendants and debrief.    What went well?  1) We successfully resuscitated a passenger with SCD at 30,000 feet.  2) An AED was mission critical and the staff was trained in its use.  3) Our treatment lasted about 45 minutes; we were calm; we explained what we were doing among the team; no one panicked including the other passengers.  4) EMS personnel were at the door upon the Captain’s diversion.

What didn’t go well?  1) the first BP cuff malfunctioned.  2) I struggled with obtaining accurate BPs.  3) I was slow to get what I needed out of the medical kits; the IV bag, couldn’t find a tourniquet  4) The patient had not regained consciousness upon departure, but groans were evident.

How can we improve?  1) preventive maintenance (PM) on medical equipment.  2) I suggest a digital BP cuff that reads the result without my impaired use of the stethoscope.  3) We should ask nearby passengers to vacate their seats so that we might spread out the medical equipment and drugs.  4) have EMS use an entrance that avoids tight turns, if possible.

We become physicians to heal the sick, relieve suffering, comfort those in need, and occasionally we may save a life.  I do not know the outcome for this gentleman.  I am worried; yet, I am hopeful.  I strive to role-model humility.  Yet, transparency reveals that I am proud to be a physician and proud of our team of strangers at 30,000 feet.

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Dates Announced for 10th Annual Telluride Patient Safety Resident Summer Camps

Applications are now being accepted for the 2014 Telluride Patient Safety Resident Physician Summer Camps in Telluride, CO and Washington, DC

TPSSC_Logo_v3Resident physician leaders are now invited to apply to attend a week-long, immersive learning experience with leaders and educators in patient safety, along with patient and healthcare advocates at the 10th Annual Telluride Patient Safety Educational Roundtable and Resident Physician Summer Camps. Residency programs will be responsible for covering travel, lodging, and meeting registration fees for their attendees. MedStar Health, COPIC and CIR have been generous supporters of past Telluride Resident Summer Camps, and have sponsored many resident physician alumni, who are now change agents at their home institutions. We are again grateful for their support and participation in our 10th year!

The Telluride, CO and Washington, DC Patient Safety Resident Summer Camps are one-week, educational opportunities offering an in-depth exploration of current patient safety issues and risk reduction strategies for achieving optimal patient care. Two, one-week resident summer camps will be offered in 2014:

  • Monday, June 9th – Thursday June 13th, 2014 (to be held in Telluride, Colorado) — Arrive Sunday, June 8th for evening reception
  • Thursday, July 31st – Sunday August 3rd, 2014 (to be held in Washington, DC) — Arrive Wednesday, July 30th for evening reception

Over the last nine years, interprofessional leaders in patient safety, communication, informatics, human factors, patient advocacy and education have met in beautiful Telluride, CO to address patient safety issues. Because of the growing interest and number of resident applications, a second patient safety summer camp was added in Washington, DC in 2013.

The Telluride Roundtable Vision is to create an annual retreat where experts in patient safety come together with patients, residents and students in an informal setting to explore, develop and refine a culture of patient safety, transparency and optimal outcomes in patient care. The 2014 Patient Safety Summer Camps will again use an immersive, interactive format to examine ethical, professional, legal and economic issues around patient safety, transparency, disclosure and open and honest communication skills when medical errors and adverse events occur.

Applications and additional information can be found on the Telluride Patient Safety Summer Camp website (www.telluridesummercamp.com). Residency Programs interested in funding a resident to attend one of the patient safety summer camps will need to submit the following resident materials by March 1st, 2014:

  1. Two-page maximum CV
  2. Personal statement on your interest in patient safety and how attending the Patient Safety Summer Camp would benefit you
  3. Support letter from faculty or a mentor about your leadership and engagement in patient safety
  4. First and second choice for the summer camp weeks (Telluride CO or Washington DC)

Questions regarding the Patient Safety Resident Summer Camps can be directed to David Mayer, MD at: david.b.mayer@medstar.net

COPIC_registered_CMYK CIR PEI logoScreen Shot 2013-12-19 at 8.42.01 AM  


Who Wins When Medical Malpractice Claims Are Filed?

Screen Shot 2013-10-28 at 6.43.08 AMThe Doctors Company (TDC) and their Foundation (TDCF) have been committed to medical education for many years. They have been the major supporter of our annual Telluride Patient Safety Summer Camps for medical and nursing students the past four years, providing full scholarships to sixty medical and nursing students last year so they could attend this week-long immersion in safety, quality and transparency.

I have been honored the past two years to be invited to attend TDC Annual Advisory Board Retreat. The retreats have become a favorite meeting of mine, as well as one of the best educational meetings I have attended. One of the presentations I enjoy hearing most is given by Dr. Richard Anderson, the CEO of TDC, who opens the meeting with an update and discussion on the current medical malpractice environment. Dr. Anderson shares claims data along with insightful narrative so that a “novice” to the medical malpractice industry like I am can understand and appreciate the challenges healthcare really faces today.

A couple of numbers he shared this year really hit me:

  1. The average cost of a claim at TDC is $97,000
  2. 82% of all claims filed do not result in any payment to the patient and/or family

A couple of things came to mind as I reflected on those two facts. First, where is all that money going? If the $97,000 isn’t going to patients or families, who was it going to? Who was getting all that money? The second thing was the pioneering work done by Rick Boothman, Susan Anderson, Skip Campbell and others at the University of Michigan highlighted in the article entitled Liability Claims and Costs Before and After Implementation of a Medical Error Disclosure Program. After full implementation of a disclosure-with-offer program at the University of Michigan, Boothman and colleagues observed:

  1. Decreases in the monthly rate of new claims from 7.03 per 100 000 patient encounters to 4.52
  2. Declines from 232 lawsuits (38.7 per year) to 106 (17.0 per year)
  3. Declines in median time to claim resolution from 1.36 years to 0.95 year

They also appreciated decreases in monthly costs associated with total liability, patient compensation, and non–compensation-related legal costs. Through an open, honest, timely and effective communication approach to unanticipated outcomes, they were able to successfully start addressing the excessive costs Dr. Anderson referred to associated with liability claims.

Maybe there is a better approach to the “deny and defend” model we have seen used through the years.

One additional figure Dr. Anderson shared also hit me hard this year. The number of claims filed asking for compensation above $10,000,000 has tripled over the last year, with the total claim pool going from $400,000,000 to $1,200,000,000 in total costs in just twelve months. Even gas prices haven’t risen that fast. Has the severity of patient harm suddenly tripled over the past year or are there other factors contributing to this sudden escalation?

If interested, The Doctor’s Company website contains numerous healthcare, patient safety and risk reduction resources. Click here for more information.


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!


Living Mindfulness

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.

Dave_Cliff2For 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’…


Remembering Those Lost to Medical Harm at #TPSER9

Dave_Rosemary_Arlington_Cemetary

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.


Needed: A Greater Sense of Urgency Around Patient Safety & Culture Change in Healthcare

TSPRE9_Resident_Wk_2013_Grp_PhotoAfter spending a week with some amazing resident physicians at the Telluride Patient Safety Educational Roundtable & Student/Resident Summer Camp, I feel an even stronger need to create a greater sense of urgency around patient safety–as well as building patient centered care environments with a just culture as the foundation. The stories this passionate group carried with them to Telluride and shared with the group were the muse for this post.

For example, one physician, fighting back emotion, courageously told the group how she recently had to push a senior level care provider to finally acknowledge her concerns about an infant who later died. The physician sitting next to her, with emotional intelligence off the charts, not only acknowledged her pain, but that he also knew she had done everything she could in the best interest of her young patient. In a reflective blog piece, another Telluride alum expressed concerns about just how dangerous the academic medical environment is for patients. And more than one physician shared how coming together in Telluride, having an opportunity to compare similar experiences in an environment where open, honest communication was revered, was a reminder of why they went into medicine in the first place. But I wonder, how long can the Telluride influence last if the culture of our care environments these amazing, but human, care providers return to, does not change to embrace rather than ostracize those who truly put patient centered care before all other agendas?

Paul Levy, (Not Running A Hospital, and more), Telluride faculty for a second year, was equally as awed by the residents who attended. In a parting post on his blog, Not Like Too Many Hospitals, he also expressed the understanding that while this patient safety journey takes time, that time includes costs. Those costs are the lives and well-being of patients across the country. Here is an excerpt from his post:

As I have said before: Sometimes, I remind myself to be patient.  It is hard to change the medical system quickly.  But, more often,  I find myself agreeing with the words of Captain Sullenberger: “I wish we were less patient. We are choosing every day we go to work how many lives should be lost in this country. We have islands of excellence in a sea of systemic failures. We need to teach all practitioners the science of safety.”

I hope and trust that our attendees these last few days in Telluride will have the commitment and courage to make a difference during their careers.

I came across an old post on the Transparent Health blog, Stand Up-Stand Out, as I was reading resident and student reflections from this year and last. In this post, I had referenced Dr. Don Berwick’s essay in JAMA, To Isiah. Following is an excerpt I shared with Telluride 2012 alumni to carry with them as they returned to those who have yet to learn what they have, or worse, those who create barriers to progress. It remains true — even more so today.

…There is a way to get our bearings. When you’re in a fog, get a compass. I have one—and you do too. We got our compass the day we decided to be healers. Our compass is a question, and it will point us true north: How will it help the patient?

TPSER9_Residents_Jump_for_JoyThe faces of this year’s Telluride 2013 Class are reflective of all the good that the healing profession has to offer. Anyone reading this post who is in a position to Stand Up and Stand Out–to clear the way and allow their passion to expand and elevate, not only patients, but the spirit of colleagues as well, please help. Today —

Meanwhile, the Telluride alumni network continues to grow, building a critical mass of voices who believe patient centered care comes first, above all else. We are here for you–reach out, continue to share your stories — they can move mountains!