Creating A Culture of Safety? Start with A Patient Story!

Screen Shot 2013-07-10 at 8.38.41 AMEvery three months, Dave Mayer MD, Larry Smith and MedStar Health host a quarterly Quality, Patient Safety & Risk Management Retreat, inviting leaders and innovators across the health system to spend a morning discussing topics such as high reliability organizations, transparency and patient centered care. For the last year, two speakers–also healthcare thought leaders from across the country–have been invited to share their expertise with MedStar associates during the retreat. (An archive of retreat videos can be found on the MedStar Patient Safety & Quality website here).

Today’s retreat included:

  • Denise Murphy: A Carole DeMille Lifetime Achievement Award winner for infection prevention and now Vice President of Quality & Safety at Main Line Health in Philadelphia. She is leading her health system on the journey to becoming a high reliability organization.
  • Helen Haskell: Mother, patient advocate, healthcare policy driver and founder of Mothers Against Medical Error (MAME).

Those who follow our blogs (ETY & Telluride) might already be familiar with the story of Lewis Blackman, Helen’s 15-year-old son of great promise who was taken far too soon by medical error. Helen and her family have gifted healthcare communities around the world by sharing their loss so that others can learn with the hope that similar harm can be prevented. Both speakers emphasized the need to personalize every healthcare encounter, keeping patient stories at the front lines of care. Both Denise and Helen’s presentations also have been made available on the MedStar Health website. Following are useful takeaways from this quarter’s retreat for use in your own health system.

Denise referenced John P. Kotter’s Harvard Business Review article, Leading Change: Why Transformation Efforts Fail,  as a resource, and shared the following tips for successful creation of a culture of safety:

  1. Patient safety trumps all else
  2. Keep leadership uncomfortable
  3. Keep patient stories up front — put a face on all harm
  4. Leaders lead from the front versus push from behind
  5. Provide tools for the critical conversations patient centered care requires
  6. Engage all care providers in the journey
  7. Flatten authority gradient and reduce power distance (i.e. Everyone’s voice matters, title irrelevant)
  8. Include daily “Safety Huddles” to assess progress, update colleagues on patients at risk, share stories and any concerns.

And finally, here is the trailer for The Story of Lewis Blackman. If interested, there is a YouTube version of the entire film available in the creative commons, and a DVD copy available for a nominal fee that includes learning materials. If interested in acquiring a copy of the educational film please reach out.


Follow Telluride 2013 Resident Summer Camp Reflections at Transparent Health Blog

IMG_0188Please join us in Telluride this week!

We are well into day two with our resident scholars in Telluride, where the topic for 2013 is Change Agents: Teaching Caregivers Effective Communication Skills to Overcome Patient Safety Barriers in Healthcare.

This amazing group is engaging in some truly moving conversations around patient centered care, shared decision-making, personal experiences with near misses and the dangers that exist within medical education. Their bravery, knowledge and commitment to their patient is so very evident — it is inspiring, and gives hope of a very bright future for healthcare.

We will be posting summaries of the days events for the next two weeks here on ETY, but please also join us this week at our Transparent Health blog, (found here). Today’s post on the TH blog shares a number of resident reflections and can be linked to here.

Paul Levy, Not Running A Hospital, has joined us in Telluride to teach negotiation skills to our resident physicians and is also blogging about the experience. You can find his reflections here.