High Reliability Series: The Need For Transparency

At 0:43 in the YouTube clip above, Bob Galbraith, MD, and Executive Director, Center for Innovation at the National Board of Medical Examiners says:

“If we don’t talk about our mistakes, we’re doomed to repeat them. Over and over and over again. So we have to have transparency and admit that we’ve made a mistake in order to prevent that mistake from ever happening again. And if we don’t do that, shame upon us.

Transparency is a core characteristic of high reliability organizations. How can an organization improve if those leading the way do not expect and set the course for a culture that embraces honest assessment of operations and open, honest communication around the good, the bad and the ugly? The first step to change is admitting there is a problem–it’s Psychology 101. If organizations fail to admit, or even see, there is a problem the journey to high reliability never gets off the ground.

AHRQ has put out an excellent set of guidelines for the HRO journey, “Becoming A High Reliability Organization: Operational Advice For Hospital Leaders”In it, Exempla CEO Jeff Selberg says that transparency is the key to culture change, and that an “unwillingness to face and share the hard facts is an indicator of denial, and denial is not compatible with a safe environment.”

Transparency sets the foundation and tone within an organization for every aspect of daily operations. Reporting of outcomes, reporting of near misses and unsafe conditions, management of medical error, interprofessional communication, patient-centered care–all of these operating procedures are limited, or reach new heights, in direct relationship to the level of transparency within an organization.

The challenge to create a truly transparent culture is a “must have” for any HRO–and as Paul Levy wrote in yesterday’s post, An Interest In Remaining Alive, a challange to hospital systems around the world. A healthcare culture that remains opaque will continue to harm patients–it’s occurring far too frequently in every corner of the globe. In the end, this is what we all swore to do when we received our MD–to first do no harm. Honing the characteristics of a HRO, starting with transparency, will help move healthcare to a state of being that will make patients feel they are as safe as they are on airplane when they enter a hospital.

More on transparency tomorrow…

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Resident Physician & Health Science Student Summer Camp in Telluride, CO: What’s It All About?

Many have asked about the Telluride Patient Safety Educational Roundtable and Resident Physician/Health Science Student Summer Camps mentioned in previous posts. In short summary, interprofessional leaders in patient safety, patient advocacy, and health science education have come together in Telluride, CO for the last eight years to address educational challenges around patient safety. The original Telluride Vision–still true today–was to create an annual retreat where stakeholders in patient safety, patient advocacy and health science education can come together in a relaxed and informal setting to discuss, develop and refine curricula that support a culture of patient safety, transparency and optimal outcomes in health care.

The theme the last few years has focused on The Power of Change Agents: Teaching Caregivers Open, Honest and Professional Communication Skills to Overcome the Multiple Barriers to Patient Safety and Transparency. Through the generous support of AHRQ, COPIC, the Committee of Interns and Residents, and in particular The Doctors Company Foundation (TDCF) and MedStar Health, we have been able to add Patient Safety Summer Camps for health science students and resident physicians. This year, funding from these organizations is allowing us to sponsor 70 students and residents each to attend one of three week-long Summer Camps, where our focus truly is educating the young.

Paul Levy teaches Medical Residents the Art of Negotiation

For more information on the recent Resident Patient Safety Summer Camp activities, I encourage you to visit Paul Levy’s blog Not Running A Hospital. Paul spent last week at our resident physician summer camp, and posted a number of stories about his experience with the residents while in Telluride.

Student and faculty daily reflections and comments can also be found on the Transparent Health blog.

Learning objectives for 2012 Summer Camps will enable the residents and students to:
1. Describe at least three reasons why open, honest and professional communication between caregivers, patients and family members is critical to patient safety, transparency and reducing harm in healthcare.
2. Utilize tools and strategies to lead change specific to improving communication and reducing patient harm.
3. Implement, lead and successfully complete a Safety/QI project at their institution over the next twelve months.
The passion and excitement exhibited by these young caregivers is contagious. Over the course of the week, they engage in both structured and informal discussions, addressing a wide range of issues related to transparency and patient safety. When the week is finished, they reflect and share their thoughts with all attendees.

Every one of the student reflections is powerful, providing insight into the front lines of medical education. I wanted to share one reflection from the residents’ week that captures the essence of the Telluride Summer Camps:
“If I had spent the last four days locked in a library researching the patient safety literature non-stop, I would not have walked away with as much knowledge, enthusiasm, and support as I acquired participating in the Transforming Mindsets: Patient Safety Summer School for Resident Physicians in Telluride, Colorado.  The collective efforts, shared experience, and mutual support of everyone involved made for a special atmosphere (in the already special atmosphere of nine thousand feet) that allowed each of us to rise above our prior potentials.  Within an hour of resuming clinical duties today, I was already championing our collective cause, walking a fourth year medical student through an incident report about a delayed dose of nevirapine in a newborn; her initial grimace at the optional “name of reporter” question eventually morphing into an enthusiastic smile as she entered her name following our discussion about the benefits of reporting and transparency. I couldn’t be more excited right now to motivate these types of small shifts towards a safety mindset while also pursuing large-scale systems shifts that ensure safety as well.  Thank you to the faculty and especially to the other residents!”

For information on next year’s Telluride Patient Safety Roundtable and Summer Camps, email: david.b.mayer@MedStar.net and have a look at the following short film from last year’s summer camp which captures student and faculty comments about their experience.


We Are All Students

The educational value of narrative and reflective learning is well documented in the literature. These educational powers are especially true in healthcare when teaching health science students and resident physicians risk reduction strategies in the provision of safe, high quality patient care. Wall of Silence, written by Rosemary Gibson, demonstrates this educational power extremely well. The book shares numerous cases where medical error caused significant, many times fatal, patient harm. Unlike traditional medical case reviews discussed in M&M’s or written for journal publication, the book takes a different approach to these cases and shares through interviews what patients and family members expected from caregivers after good intentioned care caused harm. The take-away from these patient and family interviews highlight five areas of need:

1.       The truth

2.       Accountability

3.       An apology when appropriate

4.       Remedy

5.       Commitment (and action) to change the system to protect others from similar harm.

Patients and family members are great teachers and educators. Lessons learned from these stories through the patient’s voice are powerful teaching tools that survive the educational decay commonly seen with traditional teaching methodologies. While these are all tragic stories, there is much to be learned when we as caregivers are willing to hear what our patients tell us and engage in truthful and transparent discussion. As Rosemary told me many years ago, the best teachers find ways to connect the brain to the heart and leave a lasting educational imprint on their students.