As healthcare providers, we are given a privilege to care for others, and must always remember that we treat complex individuals, making choices that affect their lives, families and personal well-being. At the same time, our patients must recognize that care providers are people too– always trying to do the best they can while juggling numerous responsibilities on a daily basis and working in a system that still has too many flaws. The clinician-patient relationship is most effective when both sides meet in the middle–a “safe space” where each is able to truly see one another and achieve the mutual understanding needed to succeed as a care team.
High Reliability science is one area we are looking to for answers to systems failures in healthcare. High reliability organizations stress the importance of “Stopping the Line” when a worker senses something doesn’t feel right. The concept has been shown to help reduce harm in many high risk environments. What if something similar existed for communication concerns in the healthcare environment?
The following short video, entitled Please See Me, created by patients and caregivers for patients and caregivers, offers a possible solution. Can “Please See Me” become that safe space, where patients and family members can stop the line and share those words if they feel their needs are not being heard or addressed? At the same time, can caregivers use the same phrase when they feel they are not being understood by patients and family members?
Many of us believe the phrase “Please See Me” can be the start of something special, creating that safe space and providing a phrase that helps improve communication and understanding in every healthcare environment leading to better outcomes.
Patients and Care Teams
Working as Partners
In the Spirit of Healing and Compassion
If you can make it to “When the Shark Bites…” you’ll have already seen what teamwork looks like in this talented quartet. A piano has just 88 keys, yet new music is created every day. How can we take what we have to work with in healthcare and see what has yet to be discovered or apply what has yet to be tried — especially when it comes to teamwork.
Please share creative examples of how your health system is applying teamwork!
Following is additional information from our team who helped share Annie’s Story, led by RJ (Terry) Fairbanks (@TerryFairbanks), MD MS, Director, National Center for Human Factors in Healthcare, MedStar Health, Tracy Granzyk (@tgranz), MS, Director, Patient Safety & Quality Innovation, MedStar Health, and Seth Krevat, MD, Assistant Vice President for Safety, MedStar Health.
We appreciate the tremendous interest in Annie’s story and wanted to respond to the numerous excellent comments that have come in over YouTube, blogs and email. The short five minute video sharing Annie’s story was intended to share just one piece of a much larger story–that is, the significant impact we can have on our caregivers and our safety culture when the traditional ‘shame and blame’ approach is used in the aftermath of an unintended patient harm event. At MedStar Health, we are undergoing a transformation in safety that embraces an all-encompassing systems science approach to all safety events. Our senior leaders across the system are all on board. But more importantly, we have nearly 30,000 associates we need to convince. Too often in the past, our Root Cause Analyses led to superficial conclusions that encouraged re-education, re-training, re-policy and remediation…efforts that have been shown to lack sustainability and will decay very shortly after implementation. We took the easy way out and our safety culture suffered for it.
Healthcare leaders like to believe we follow a systems approach, but in most cases we historically have not. We often fail to find the true contributing factors in adverse events and in hazards, but even when we do, we frequently employ solutions which, if viewed through a lens of safety science, are both ineffective or non-sustainable. Very often, events that are facilitated by numerous system hazards are classified as “nursing error” or “human error,” and closed with “counseling” or a staff inservice. By missing the opportunity to focus on the design of system and device factors, we may harm individuals personally and professionally, damage our safety cultures, and fail to find solutions that will prevent future harm. It was the wrongful damage to the individual healthcare provider that this video was intended to highlight.
In telling Annie’s story, we chose to focus on one main theme–the unnecessary and wrongful punishment of good caregivers when we fail to cultivate a systems inquiry approach to all unfortunate harm events. This is the true definition of a just culture…the balance between systems safety science and personal accountability of those that knowingly or recklessly violate safe policies or procedures for their own benefit. Blaming good caregivers without putting the competencies, time and resources into truly understanding all the issues in play that contributed to the outcome is taking the easy way out. We wanted our caregivers to know we are no longer taking the easy way out…
You will be happy to know that the patient fully recovered, that Annie is an amazing nurse and leader in our system, the hospital leaders apologized to her, and all glucometers within our system were changed to reflect clear messaging of blood glucose results. We believe we have eliminated the hazard that would have continued to exist if we had only focused on educating, counseling and discipline that centered around “be more careful” or “pay better attention”. We also communicated the issue directly to the manufacturer, and presented the full case in several venues, in an effort to ensure that this same event does not occur somewhere else.
This event, which occurred over three years ago, gave us the opportunity to improve care across all ten of our hospitals. It also highlighted the willingness of our healthcare providers to ask for help because they sensed something was not right and wanted to truly understand all the issues–they also wanted to find a true and sustaining solution to the problem using a different approach than what had been done in the past. Thanks to everyone for sharing your thoughts and for asking us to tell the rest of the story. We have updated the YouTube description as well.
And, thanks to Paul Levy for opening up this discussion on his blog, Not Running A Hospital, and to those of you who continue to share Annie’s story.
For those who have yet to see the video, here it is:
Each quarter, in the spirit of a learning culture inherent to high reliability organizations, MedStar Health Quality, Safety & Risk Management leadership, Dave Mayer MD and Larry Smith, host a retreat for quality and safety professionals, inviting outside speakers to share their expertise and discuss topics related to patient safety, risk management and improving healthcare quality. Those topics have included:
- Care for the Caregiver
- Human Factors Engineering
- High Reliability Organizations
- Patient & Family Stories
- Open, Honest Communication & Transparency
- Patient Engagement
- Baldrige Journey
MedStar Health has created a Video Learning Library on their website which includes a full recording of many of these sessions. The intention is to share the knowledge with all healthcare colleagues so that others can also benefit from the experience shared by these safety and quality thought leaders. The Library can be found on the MedStar Health website. Following is an example of the content, as Dr. Bill Neff, CEO & CMO, University of Colorado Health, shares the Baldrige Journey as experienced by Poudre Valley Hospital. Please share this resource with others!
So many of the healthcare stories shared in the mainstream are those that focus on patient harm, or egregious behavior by providers. It can make us forget that while these occurrences are still far too frequent, they are not the norm. For every patient harmed, there are roughly three success stories rarely shared. Stories of care teams, often operating in systems yet to be designed for optimal success, who manage to use the wonderful technology, knowledge and compassion at their disposal to send a patient home safely. While every patient story is of great value, so are the stories of those care providers whose voices are less frequently heard. When patients and providers work together throughout the course of a healthcare encounter real magic occurs. Human connection has power to heal, and will always complement any prescription or treatment. And it costs absolutely nothing…
Here is one of those success stories, recently shared by a colleague. Melissa, a patient in the Vidant Health system, was found to have an aortic dissection immediately after giving birth to her son. She shares with viewers a triumphant and tear-jerking healthcare experience, as well as what made her time with Vidant so positive and successful despite the odds. Following are a few of those highlights for those who don’t have time to view the entire video:
- Melissa felt she was listened to by the care team
- She needed someone to be human and care, and that is exactly what her healthcare team did
- Someone cared enough to push harder within the system when her survival depended on it
Here is Melissa’s story, in her own words. There is a wonderful tribute to the healthcare team that was part of her “family” during this challenging time in her life. If you have time, Melissa’s story is well worth a few moments of yours. It is also a story worth sharing–one that healthcare colleagues and consumers will equally appreciate.