Systems Approach and Just Culture Resonate at Doha Telluride Experience

TE_DOHA_SethOn day three of our Academy for Emerging Leaders in Patient Safety…the Doha Experience, Dr. Seth Krevat, AVP for Patient Safety at MedStar Health, led discussions on the importance of in-depth Event Reviews, Care for the Caregiver, and Fair and Just Culture approaches to preventable harm events. Seth shared the event review process used at MedStar Health which was designed by experts in patient safety, human factors engineering and non-healthcare industry resilience leaders. This event review process has been adopted by AHRQ and AHA/HRET, and has been incorporated into the upcoming CandOR Toolkit being released shortly to US hospitals.

The young learners engaged in deep discussions around Fair and Just Culture – the balance between safety science and personal accountability. This topic followed interactive learning the previous day on human factors and system/process breakdowns. Similar to challenges we have in the US, the culture in the Middle East blames the individual first without a thorough understanding of all the causal factors leading up to an unanticipated event. After Seth showed the video, Annie’s Story: How A Systems Approach Can Change Safety Culture, and shared other case examples demonstrating how a good event review can disclose system breakdowns versus individual culpability, the young leaders gained a new appreciation of effective error reduction strategies. In the short clip that follows one of our young leaders, so empowered by the short three days with us, explains how she used what she learned to try to change her parents point of view on patient harm:

The passion and commitment of these future leaders to patient safety was inspiring for our US faculty, as well as for the leaders from the numerous Qatar healthcare institutions that participated in our sessions. I have no doubt this next generation of caregivers will be the change agents needed to achieve zero preventable harm across the world. We have seen many examples of their work already.

It was exciting to be in Qatar working collaboratively with others who are committed to “Educating the Young” as a powerful vehicle for change. Next stop for the Academy for Emerging Leaders in Patient SafetyThe Sydney Australia Experience!

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Call for Quality Training Abstracts via Telluride Alum

If you are looking for something to do over the holiday weekend, why not submit an abstract to the American Journal of Medical Quality? The following opportunity was shared by Telluride Alumni (2013), Martin Wegman, and offers another outlet for the excellent work we know Telluride Alum are leading across the country!

Quality Training to Improve Performance (QTIP)
American Journal of Medical Quality
Call for Abstracts

AJMQ_Pub_ETYPostThe American Journal of Medical Quality (AJMQ) recognizes that opportunities to learn about the perspectives of professionals in training are limited. To expand learning opportunities for its readership, AJMQ launched a column dedicated to publishing student work on the topic of performance improvement in 2013. Through collaboration with the American College of Medical Quality, articles will be solicited for the column, “Quality Training to Improve Performance (Q-TIP),” which will be published in the 2016 issues of AJMQ.

Abstracts of no more than 150 words, written by health professions students, describing improvement work and interdisciplinary collaborations should be sent to the faculty advisor, James Pelegano, MD, MS (james.pelegano@jefferson.edu) by September 15, 2015. Eight abstracts will be selected by the faculty advisor and an Editorial Advisory Board for full article submissions and up to six articles will be published in AJMQ during each publication cycle (one article per issue). Questions regarding “Quality Training to Improve Performance (Q-TIP)” or submissions may be directed to Dr. Pelegano at james.pelegano@jefferson.edu.

The American Journal of Medical Quality (AJMQ) is a peer-reviewed bi-monthly journal for those practicing, conducting research, and teaching in the field of clinical quality improvement. AJMQ publishes research studies, evaluations of the delivery and management of health care, and reports on changes in the field of medical quality, utilization, and risk management. Each issue provides information on the latest innovations in quality, editorial commentary on issues of importance in the field, and pragmatic suggestions to improve practice.

Please visit the AJMQ website, http://ajm.sagepub.com/, for more information about the journal, or to view an issue free of charge.


A Young Nurse and Telluride Alumni Shares Inspiring Words on Keeping Patients Safe

Today’s post is from guest author Brennan Killeen, RN, BSN, Clinical Nurse at MedStar Georgetown University Hospital (MGUH) and Telluride Scholar June 2015. Brennan was asked to give a speech to this year’s MGUH Nurse Residency graduating class. Her focus was patient safety and her experience at the Telluride Patient Safety Summer Camps. We are so happy to see the premise “Educate the Young” continues to build momentum in a new generation of healthcare leaders.

Hello everyone and congratulations on your graduation. I’m Brennan Killeen. I graduated from the Nurse Residency Program here at Georgetown this past March. I work on C4-1, the Cardiovascular and Thoracic Intermediate Care Unit and I’m coming up on my 2-year mark as a nurse in February. I was a second-degree nursing student here at Georgetown before starting my career as a nurse on C4-1. I remember feeling all of the same emotions you all felt after graduation: the anxiety of finding a job, picking a city, finding the right hospital, the right manager, deciding whether or not being part of a residency program was the right fit… I want you to take a moment and reflect on all of your accomplishments thus far. Graduating from nursing school, passing your boards, landing a job at such a well-respected place like Georgetown and completing your first year as a nurse are big deals!

2015-06-08 15.16.19I’ve actually been to this ceremony 3 times now. The first time was when I was still a baby nurse and had barely gotten on the floor yet. I remember sitting here and feeling slightly panicked that I’d never be able to complete an NRP poster or that I’d make a make a med error, I wouldn’t know how to hang blood, or I’d never get over being intimidated by doctors and senior nurses – there were so many emotions that flooded my mind that first ceremony. I did feel very overwhelmed but I never felt alone. I felt calm knowing that if I didn’t feel confident about my poster presentation I had Kristine and Kim, or if I was scared about making a med error or performing a procedure incorrectly I had my coworkers and policies to turn to, or if I felt intimidated I had my manager, Elly, or educator, Alisa to ask for guidance. This is the beauty in a place like Georgetown. The support that is provided to you as a new nurse is incredible. There are systems in place so that it’s hard for us as new nurses to fail and there are people around you who truly care about your success. There’s a palpable sense of pride at Georgetown. We honor our spirit values, we support one another and we always put the patient first by practicing as safely as possible.

The second ceremony this past March was my graduation. It was a day when everything really came full circle. I felt proud of myself and my NRP partner for completing a project that we felt passionate about. I felt so excited my classmates and I had survived our first year as nurses. I remember walking around and observing the posters and feeling giddy. It was such a big moment for all of us. We’d become comfortable in our practice and it was hard to believe that we were no longer the new nurses. By this time, I’d become involved in Georgetown’s falls task force because of my interest in patient safety and I knew that my second year of nursing would give me the opportunity to take on more responsibility.

Today is my third ceremony and I felt so much confidence in Georgetown when I walked around the room earlier and looked at your presentations. You all should be so proud of yourselves! You’ve survived your first year. But with that comes a new set of challenges and goals. It’s time to push yourself to really dive into this wonderful community. You’re veterans now and it’s you who’s going to be guiding the new nurses. The opportunities that Georgetown provides for us are countless. During my second year as a nurse I felt a strong sense of obligation to get involved. Georgetown invests so much time and energy in creating a safe environment for us as new nurses and in turn a safe environment for the patient. I can’t tell you how many times I felt thankful over the last year and a half for all of the safety measures that were in place for me at Georgetown: policies, MC75s, double checks, bed alarms, daily rounding and the list goes. All of these measures promoted safe practice for me and influenced my passion for patient safety.

Students_Reception_Mtn_BackgroundThis summer I had the amazing opportunity to attend a safety camp in Telluride, Colorado sponsored by The Doctors Company Foundation and MedStar Health. It was the first year that Georgetown nurses were included in the camp in large part due to Eileen’s Ferrell’s efforts. Med students, nursing students, doctors and nurses from around the country were able to gather together in Telluride to expand our knowledge on patient safety. We spent the week discussing patient safety improvement, techniques, philosophy and approaches for reducing patient injury and adverse outcomes. Family members of victims devastated by medical errors also attended the camp to collaborate with us on ways to make system changes to avoid such errors. It was an eye-opening week for me and I learned so much. The sense of empowerment I felt after the conference was incredible. Knowing that we’re at a place like Georgetown where we can make a change after just a year and a half of being a nurse is an amazing feeling. One of the risk reduction strategies we discussed during the week was education. In our residency program Georgetown specifically carves out time during our classes to educate us on such strategies. This community encourages us to call for help and demands that this is a sign of excellence and not a sign of weakness. We belong to an organization with a just culture that applauds transparency and shared-decision making. As nurses we are encouraged to promote a culture of compassion, empathy and trust and in doing so we stand by our mission to provide safe, high quality care, excellent service and education to improve the health of our community.

Telluride truly has been the highlight of my nursing career thus far and I have Georgetown to thank for that. I didn’t think that back in March I’d be standing up here speaking to you all about my Telluride safety experience but Georgetown challenged me to be better, to do more and to get involved.

I want to leave you with a story from Telluride that really resonated with me and inspired me to prioritize patient safety during my nursing career. Lewis Blackman was a 15-year-old boy who died from a medical error following elective routine surgery in November of 2000. He suffered due to deficiencies in the system. He’d been prescribed Toradol post operatively. He was on an inadequate amount of IV fluids and it was a 2-day struggle to get the IV fluids increased but by then it seemed like the damage had been done. After 30 hours of alarming clinical decline, 24 hours of no urine output and 4 hours of an undetectable BP, Lewis died on post op day 4 from an NSAID induced duodenal ulcer. During the morning of Lewis’s death, doctors and nurses scoured the hospital to find a cuff or a machine that worked so that they could detect Lewis’s undetectable BP. They took his BP 12 times using 7 different machines and cuffs, dismissing the undetectable BP as an equipment error. Lewis eventually went into cardiac arrest. Could his death been averted by an assertive nurse? Could open and honest communication have prevented this error? If the doctors and nurses had practiced mindfulness and considered the family as part of the healthcare team would Lewis still be alive today?

This story speaks directly to safety. It’s an example of why nurse empowerment in reference to patient safety is so critical and why you all are so valuable to the lives of our patients. We belong to an institution that empowers us to speak up, to be accountable, to communicate and above all to practice as safely as possible. I ask you all to remember this every day and to teach our new nurses that it’s okay to speak up, it’s okay to say you’re unsure of something, it’s okay to ask questions. By doing so, you could save a Lewis Blackman or a family from tragedy like this.

Now that you are official graduates of your residency program, I challenge you to lead by example and continue to foster a safe environment here at Georgetown. You are now leaders and it’s your job to take our new nurses under your wing and show them the way. Dave Mayer, our VP for Quality and Safety here at MedStar told our Telluride group this: “leadership is like tennis, it’s a skill that you always have to work on.” I’m proud to have you all as leaders and I have confidence in each and every one of you that we will be a safer institution because of you. Congratulations!


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.


Patient Safety Lessons All Around Us

20140729_153721As 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:

Mise-en-place: patient safety lessons from the kitchen

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.


A Story of Frustration and Despair…and then a Flicker of Hope

IMG_20140802_093257We just concluded another great week of learning and inspiration at the Telluride East Patient Safety Summer Camp held at Turf Valley Resort in Ellicott City, MD. Educational discussions led by Anne Gunderson, Rosemary Gibson, Paul Levy, Wendy Madigosky, Patty and David Skolnik, Richard Corder, Rick Boothman, Tracy Granzyk, Kathy Pischke-Winn, Gwen Sherwood, Lisa Freeman – some of our wonderful faculty who gave their time to “Educate the Young” on the importance of Patient Safety, Transparency and Patient Partnership. There were so many great student and resident reflections during the week but one written by Mona Beier captured both the frustration – how the current educational system is “beating down” and desensitizing our next generation of caregivers – and a flicker of hope that they still may be able to salvage the caring spirit they entered their training with…that same caring spirit that will guide them to deliver safe, high quality, patient-centered care.

Realizations

First published August 3, 2014 on Telluride Summer Camp blog | By Mona Beier

First of all, I have to say this will be my first ever blog about anything….so here goes nothing….I have to say these past few days have been eye opening, and dare I say, life changing. I went into the conference not knowing exactly what to expect, but at least thinking that I knew something about patient safety and quality improvement. What I have realized is that my idea of PSQI was so unbelievably superficial. Everyone at the conference has opened my eyes to see that through everything we do in PSQI, it is ultimately for the better of our patients. Maybe because we are all required to do PSQI projects at my institution, I feel that it was always presented to us as how to make YOUR life easier and less frustrating, instead of the patient. Maybe they felt we would only be motivated if we felt we were helping ourselves in some way. These talks, stories, reflections have all made me take a step back and realize what it is all about: our patients. It makes me really sad that in the very little time I have been in training that I have completely lost sight of that.  There is really no excuse for that. I could blame exhaustion, long hours, too many patients in too little time….but at the end of the day, there is no excuse for not putting our patients as our number one priority.

I have had some really negative realizations of myself during these past few days. I hate to admit this, but during a lot of the talks and the videos, I saw things that I had done, and I have seen my colleagues do time and time again. It is almost a daily occurrence that I hear people labeling patients as “high maintenance” if they ask questions about their healthcare or if they “challenge” our decisions and our actions. Instead, we should be celebrating this and saying thank you to them for taking an interest in their own health care. I have replayed imagery in my mind about how many times I have rushed through explaining informed consents, or felt hurried to get histories and physicals because I have 48392 other things to do (seemingly). Or, how many times I have interrupted and not listened. Instead, I should be finding other ways to make my day more efficient so that I will have more time with my patients. Or, maybe I stay an extra 30 minutes a day so that I have that extra 5-10 minutes with patients. Sometimes, a few more minutes can make all the difference. I have thought about times when I have anchored, or had premature closure of patients I was taking care of—and it wasn’t until they were not getting better or something was going wrong that I ever stopped and thought that, hmm I could be wrong or that I was missing something. The talks at the conference have made me realize that I should be doing this every day–stopping, taking time to think–and say, is this what’s going on? what would be the worst thing that I could miss? should I go back and get more history? does this make sense? Moreover, I thought about times when something actually did go wrong–when patients on my team have gone to the ICU or have died. I tried to replay in my mind,  and again, I saw myself saying “oh, they were very sick”–almost trying to justify it to make myself feel better. Being here these past few days is going to make me view this completely differently. I am going to take the time to think about what happened when things went wrong. Was it preventable? Was there something else we could have done? Why did this happen in the first place? What were the series of events that led up to this? Did I call the family? And more importantly, was my conversation meaningful with the family? Did I address their needs and reassure them? Was I there for them like I would want someone to be there for my family member?

Anyway, I could go on and on. There are a lot of other lessons I have learned. All I really know is that I am walking out of here a better person than when I came in. This conference has inspired me to take a deeper look into who I am—what kind of physician I want to be—and what kind of person and role model I want to be to my peers, my patients, and really everyone in my life.  I am inspired to try and break the mold of the culture we have grown so accustomed to—the culture where everything seems to be about me–and remind both myself and others that is not why we are here.


Like Grilled Cheese, Patient Safety Can Be Contagious

20140617_113839Confession… I am hooked on three foods – Peanut Butter, Chocolate Chip Cookies and Grilled Cheese Sandwiches. I keep a spoon next to the peanut butter jar in the cabinet and always zero in on the Mrs. Field’s when I get to the mall. Grilled cheese sandwiches, like mom used to make, have been more challenging to find until this year’s Telluride Patient Safety Roundtable and Summer Camp.

While walking through town this year, I came across a grilled cheese cart right on Main Street. It was set up across the street but like Pavlov’s dog, I crossed quickly while beginning to salivate. Dickie, the wonderful woman who owned the cart, offered several different types of grilled cheese sandwiches, and these were not your average grilled cheese either. Dilemma time – what should I pick? Habanero cheese, cheddar and bacon, apricot and brie…I had a big decision to make. I finally settled on the more traditional cheddar and bacon, and with one bite I was hooked.

During the next two weeks, I found myself sneaking out during lunches, skipping the traditional Summer Camp faire, and quickly walking the three blocks to Dickie’s stand to get my fix. By the fourth day, Dickie was letting me sample some of the newer offerings she was considering before adding them to the menu, including a Brie and Tart Cherry sandwich, which quickly became my favorite. I was in heaven.

telluride grilled cheese3My noon habit was soon discovered however, and after a couple of days, students and faculty alike started to notice my quick, back door exit as soon as the group broke for lunch. They started to question the grin on my face as I sat in the back of room, eating something out of a paper wrapper. To my surprise, but not before weathering a number of creative cheese jokes, people began to ask if they could join me on this grilled cheese pilgrimage. By the last two days of the Roundtable, we were like lemmings…a line of committed people walking to the grilled cheese cart. We became a “village” with a mission.

So why am I sharing this? Be it grilled cheese or patient safety, it only takes one passionate person to start a village. The mission of the Telluride Patient Safety Summer Camps has been to take passionate and caring young healthcare leaders and show them how to create their own village of like-minded colleagues at their institutions. These young leaders have been creating their own patient safety villages back home, and it is clear this movement is becoming contagious. I am reminded of Margaret Meade’s mantra, a thought I have often returned to on the journey to make care safer throughout my career:

“Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it’s the only thing that ever has.”