Jeff Anderson — Reflecting on a Wonderful Week — #TPSER8

Sitting in the airport after a successful week in Telluride, it is difficult not to reflect on where to go from here with regard to taking what we learned during the Roundtable and applying it to our home institutions.  So many wonderful and innovative ideas for moving forward were shared on the last day, including ways to grow IHI chapters, methods of addressing patient safety and quality improvement with attending physicians, and developing student reporting tools, only to name a few.  It was great to see so many students excited about returning home to spread the word and improve their systems, and I certainly share in that enthusiasm.
A few things that especially struck me most during the week were students’ lack of knowledge about the role of their nursing counterparts in the care of patients as well as the lack of “just” reporting tools for medical students nationwide.  It would be great to see an effort to expand the education of medical students to include inter-disciplinary seminars, modules, and simulations in order to help medical, nursing, pharmacy, physical therapy, and social work students understand everyone’s role in the patient driven model of care.  Additionally, I particularly appreciated Dr. Mayer’s idea of forcing a culture change around medical students’ ability to report incidents that jeopardize patients’ safety.  As he put it, it would be great to see the culture change from “how/should I report” to “where do I report” a violation.

Thanks so much to everyone for a wonderful week and I look forward to hearing about changes that everyone helps bring about in the year to come!

Collusion

Collusion: When a person perpetuates the system of oppression by action, inaction or silence because she/he internalizes the false belief that the system is correct or fears repercussions or chooses to stay unaware, or refuses to take action.  [Definition from National Conference for Community and Justice’s Anytown Institute , Glossary of Terms]

Today at the Telluride Roundtable we discussed (among many things!) who should report and whose responsibility it is to take action when patient safety and effective communication are at risk.  This term “collusion” kept popping into my head.  I first came to know the term when challenged to think about oppression surrounding identities such as race, class, gender, sex and sexual orientation.  For example, collusion with racism is “[t]hinking and acting in ways that support the system of racism.  White people can actively collude by joining groups that advocate white supremacy.  All people collude by telling racist jokes, discriminating against a person of color, or remaining silent when observing a racist incident or remark.  Both Whites and People of Color can collude with racism through their attitudes, beliefs, and actions.”  [Again, quote from Anytown glossary of terms, italics mine.]

One of the cases we worked through in small group today involved a disruptive surgical attending who was verbally abusive to the nursing staff and threw instruments across the room.  As we were thinking it through we wondered if it is the nurses who should bring the first complaint forward since the attack was directed against them.  Dr. David Mayer then provided an insightful description of the reporting system at UIC which is anonymous and expects every member of the team witnessing the incident to make a report.  This takes the pressure off the victim because the offender will not know who made the report.  Additionally it is a powerful way to support those affected by disruptive behavior and appalling communication.

To witness a threat to patient safety and not report the incident even if I am not directly involved in the incident is to collude with the system that has normalized this behavior.  Even if I am not the egregious offender putting Foleys in without sterile technique or operating when it is not indicated or fabricating vital signs in the chart to reflect the patient I want to believe is lying in that bed or yelling at nurses–even if I am not the one doing these things or the one directly affected by these things–if I see someone else threatening patient safety in this way and I do nothing I am just as guilty.  I return to Emory at the weeks conclusion with a pledge: my collusion ends now.

Only when our collective collusion has ended will the system of miscommunication and error currently ramped in America’s hospital become a lesson for the history books .

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