Culture Change? Which One?

By Garrett Coyan, University of Kansas Medical School

The last week I spent at Telluride was very eye-opening for me. I was glad to be surrounded by so many other healthcare professionals that had the same desire to provide the safe and high-quality patient care experiences as I do. Reinvigorated with ideas for improving communication and decreasing risk to my patients, I couldn’t wait to get back to my institution and start implementing change. However, as I returned to the hospital today, I was quickly reminded of the main reason why this goal will be so difficult. Not only does cultural change need to occur in the hospital, but I would argue that even more importantly, cultural change needs to occur in the education of health professions students. This was made evidently clear by a conversation I had with one of my recently graduated colleagues who is staring his internship in a week. At our school, we take a one month class in our fourth year about public health, health policy, and healthcare practice. A few days of this class are slated to discuss patient safety and quality improvement. When I asked my friend about the content of this lesson, he told me frankly he couldn’t remember, because he and most of his classmates thought the information was either common sense or not really applicable. He related that most of this lesson was simply going over “bundles” of different types, and maybe 15 minutes was spent on communication between providers. The material was never really tested, and apparently didn’t stick with this particular colleague of mine. This, of course, was rather startling to me after the experience I had just had in Telluride!
In order to change the safety culture of the hospitals and health systems we work in, we need to create providers who are trained, knowledgeable, and willing to implement the changes needed to provide quality, compassionate, and safe care to our patients. It is for this reason that I will be speaking with my dean, director of quality improvement, all of my mentors, and as many of my classmates that will listen about making this information a mandatory and testable portion of our curriculum. It is only then that we can hope for young medical students, residents, and physicians to be competent and comfortable enough to speak up when medical errors are made, and confront them head on and honestly with our number one partner in healthcare: our patient.

I suppose the hardest part of the Telluride experience was not being involved in the intense and productive discussions that took place, but coming down from the mountain (literally and figuratively). It’s time to get to work. Culture change will not occur until we start demanding it!

Change Starts At The Top at #TPSER8

#TPSER8Day 3 at the Telluride Patient Safety Educational Roundtable and Resident Summer Camp started with the annual hike up to Bear Creek Falls–an excellent team building exercise that always leads to relaxed and enlightened discussion about the work to be done and the knowledge gained from the week. It also provides yet another opportunity to get to know colleagues on a personal level, and build lasting relationships that will provide a support system for quality and safety efforts once everyone returns to their respective institutions.

Coincidence or not, we started the day near the top of the San Juan mountain range, and throughout the day it was reinforced that to achieve meaningful change in healthcare, it is imperative that hospital leadership not only supports, but leads the charge. Jill Prafke led a thought-provoking workshop on how to build effective teams with the ability to institute change during the afternoon session. Resulting discussion among residents and faculty reinforced these initiatives are most effective when those at the top set expectations for a culture of respect and transparency, and then follow through with support as bumps in the road to change arise.

The diversity in the cultures and, as a result, the work environments the residents come from, ranged from the very functional to those that still had much room for improvement. One of the residents shared a story of how his chairman instituted “The Disney Way” at the hospital, and how the required self-introductions, complete with Disney character representation to patients and other staff members was resulting not only in deeper connections among colleagues, but efficiencies in workflow. His upbeat attitude and apparent “joy at work” that Lucian Leape references as a must in the transformation of healthcare was evident.

In contrast, another resident shared how the strained inter-professional relationships at her institution was a result of ineffective management. While she remained positive and upbeat, she also knew the work environment was less than optimal. With a 20-1 patient to resident/intern ratio, this system seems stretched to its limits, and unless a stronger attempt at culture change occurs soon, it will be hard to retain the well-intentioned.

In Maureen Bisignano and Charles Kenney’s book, Pursuing the Triple Aim: Seven Innovators Show the Way to Better Care, Better Health, and Lower Costs the authors reference seven characteristics of the hospitals highlighted who were successful in transforming to centers of excellence. Having hospital leadership on board with those efforts was one of those characteristics. A discussion with the authors can be heard by clicking this link to the IHI Website.

Please share examples of what your organization is doing to support a culture change that is transparent and focused on patient-centered care, as well as the challenges that have been encountered along the way and how they were overcome.

Day #1 Transforming Mindsets Reflection – Todd Guth

We have just finished up the first day of the Resident Physician Transforming Mindsets Workshop in Telluride, CO. There has been much discussion on several issues in patient safety today. The issue that sticks with me most in the need for widespread cultural change within an institution if patient safety is to improve.

Cultural change within large institutions, such as hospitals, medical schools and medical specialities, can be a top-down or bottom-up phenomenon, but broad support across the entire institution must be in place for the cultural change to occur. My perception of the first day of our activities is that folks generally thought of being on the bottom can in fact be the agents of change. Grass roots efforts by residents, medical students, and other health care workers generally thought of being at the bottom of the power pyramid can make genuine differences in patient care through their individual and collective efforts. Residents and students trained with the proper knowledge, skills, and attitudes early in their training can not only advocate for their patients during their schooling and residencies but also champion broad based cultural changes throughout their medical careers.

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