20 Lessons Learned in Telluride by Heidi Charvet MD

I just returned from an amazing week in Telluride where I not only learned a lot but was also inspired and reinvigorated by the group of colleagues and faculty I met.  One of the most surprising things about the week was that despite our varied backgrounds and geography, we all came together with a common set of interests and experiences (sometimes bad ones) determined to make changes moving forward in our practice.  Thank you to everyone I met this week.

Here are the main lessons I learned during the week as well as some fantastic quotes from the group…

1.) Start every meeting with a story (it’s all about the patient!)

2.) The way we treat nurses when they bring a concern to us that ends up being wrong, is often more important than when they bring a concern that ends up being right (respect and appreciation are key or else you may not hear about the next concern that ends up harming a patient)

3.) The art of negotiation is about “letting them have your way.”

4.) Culture eats strategy for breakfast.

5.) Patients who end up in the “wrong ward” are often the most vulnerable.

6.) Your greatest enemy is complacency.

7.) Informed consent is a process, not an event.  An even better term for it is “shared-decision making”

8.) Doctor language can be disrespectful to patients (whoa!)

9.) Knowledge is power.  Your job is to transfer this power to the patient.

10.) Once you have made your point, shut up and listen.

11.) Seek first to understand and then be understood.

12.) Holding “patient safety event reviews” focused on resident education rather than RCAs, may be a better way to achieve buy-in.

13.) If you want to report something, but the other person involved is resisting, write it together so there will be no misunderstandings or division of blame.

14.) Reporting a patient safety concern is about the INCIDENT (and the harm or potential to harm) not the individuals involved.

15.) There is a role for situational leadership in healthcare.  You lead differently on a sinking ship vs. when making changes about parking at the hospital.

16.) Leaders do not make excuses, they build solutions.

17.) Some is not a number, soon is not a time.

18.) As physicians, sometimes we take steps to treat ourselves and not the patients.

19.) Build trust by saying what you are going to do, and then doing it.

20.) Problem-solving is one of the main barriers to listening among doctors.  We need to be cognizant of this when we find ourselves tuning out.

Stand Up–Stand Out! #TPSER8

Wednesdays, or the third day in Telluride, has become my favorite day of the weeks spent here at the Patient Safety Educational Roundtable and Student Summer Camps. It is because on Wednesday mornings, the group gathers unofficially at Baked In Telluride for coffee, a burrito or sweet treat before heading to the foot of Bear Creek Trail, our official meeting place, to start the annual (this year three-time) trek up to the waterfall. It has proven to be a great team-building experience over and over again–as we gasp through our excitement, sharing new ideas and unfailing awe of the mountains surrounding us.

What struck me in particular on yesterday’s hike, in addition to the inspiring conversation with my hiking partner Stephanie, was though I have been on this same trail three times in the last year, it is never the same. This year, the mountainside has been left dry and thirsty by a year of low snowpack, and even less spring rain. But despite the lack of water, jutting strong from the side of the waterfall was the beautiful, bright pink flower you see above in the photo captured by Tim McDonald at the pinnacle of our hike. To me, that flower stood for each one of the students here in Telluride, willing to do whatever it takes in order to stand up strong to protect their patients from harm.

It is clear you, and all your Telluride Alumni, are the future leaders of medicine. You have a solid network of support through your fellow classmates and the faculty who believe so strongly that the patient belongs at the center of every decision you will make as a caregiver. Remember this if you feel like you are standing alone, or standing out, when you return to your home institutions. You are all in very good company, even if that company is an email, or phone call away. Dr. Don Berwick wrote yet another heartwarming article, this one published in JAMA, To Isiah, and the following is an excerpt to carry with you as you return to those who have yet to learn what you have this week:

There is a way to get our bearings. When you’re in a fog, get a compass. I have one—and you do too. We got our compass the day we decided to be healers. Our compass is a question, and it will point us true north: How will it help the patient?

Delayed Gratification–#TPSER8

By Stephanie Christians

Having been a part of the group hike both years I’d been a participant at Telluride, I know how powerful this ritual can be.  Once again, I made room in my suitcase for a dusty pair of Garmin hiking boots, in preparation for the hike.  Earlier in the week, when people brought up the Wednesday morning agenda, I enthusiastically shared that I planned on going on the hike, even trying to convert those who had other plans.  So it seemed strange that this morning – a gorgeous morning for a hike – I found myself manufacturing excuses to bow out.

Thankfully, I’m becoming more skilled at parenting my inner four-year-old.  First, I began with gentle pleading: “All your friends will be there!  You don’t want to miss out on that, do you?!”  Next came bargaining, “If you climb with the group, you can get ice cream after dinner.”  After those attempts failed, my inner mom rolled up her sleeves and got a little salty: “Stop hitting snooze and get your @$# in the shower.  Now.”  The internal tug of war continued until I joined my peers just as they finished up breakfast.

Within a few minutes of joining the group, my internal whining subsided.  Thanks to the honesty of my fellow travelers, I knew I wasn’t the only one feeling less than enthusiastic about the work ahead.  Yet, in between shortened breaths, we all expressed our belief that in the end it would be worth it.  Before I went up the mountain today, I would have said this was the perfect metaphor for what it’s like to push for improvements in patient safety: Difficult work that’s worth it in the end.  For good measure, I would have included the observation that some days you just need to get out of bed, lace up your boots, and put one foot in front of the other until the rest of your body (or your colleagues) decide to follow suit.

Yet, today was different.  For the first time, the journey was just as rewarding as reaching our destination.  Tracy and I started out on the trail together, and in less than five minutes of sharing our current work projects, I got goose bumps – the same response that normally accompanies the sense of accomplishment and awe I feel once we reach the base of the waterfall.   Sharing honestly from our personal experiences not only made the time pass by more quickly, it helped us make creative connections that we may never have made on our own.

It’s tempting to withhold gratification for the end – once we reach the patient safety summit.  While creating a perfectly safe environment is a noble goal, postponing satisfaction until we reach our destination likely guarantees we never will.  All week we’ve discussed the myriad obstacles to creating and sustaining culture change.  If we can’t learn to find the value and joy in the journey, it’s doubtful we’ll be able to maintain the passion and enthusiasm necessary to accomplish our goal.

As we get ready to leave the patient safety incubator here in Telluride, I can’t help but think about the reality that’s about to come rolling back in on us: deadlines, obstacles, and pockets of toxic culture.  It’s normal to feel overwhelmed: We’d be naïve to think otherwise.  However, if we stay focused on taking small, steady steps and continue to reach out to our fellow change agents, we will not only achieve more than we could have on our own, but hopefully we’ll find that with each patient safety victory, the journey was just as important as the destination.

Student Reflections — Take Home Messages From #TPSER8

Michael Coplin, Emory University, MD/MBA 2016 says:

As we wrap up day 3 of the Patient Safety Roundtable, I am amazed by how quickly this week has gone by.  It has been a wonderful week of exploring critical questions during sessions guided by patient safety experts, engaging with and learning from students with a common interest, and enjoying the beauty of Telluride.  It has also been enlightening to learn from both American and Australian healthcare professionals and to recognize that we share common challenges despite being a world apart.  The days have been incredibly thought provoking, and I am certain that I will leave here with more questions than I had coming in.  I feel empowered and motivated to return to my home institution, Emory University School of Medicine, with the goal of sharing the lessons I have learned with fellow medical students, IHI Open School members, as well as faculty members.  Importantly, I will know how to proceed if I observe lapses in patient safety.

One of the most memorable activities of the week was the teeter totter game.  We worked as a team to balance 6 people on a wood plank for 10 seconds without falling.  Upon stepping off of the wood, our team unfortunately could not maintain balance, and the egg/”patient” was crushed.  Following this incident, we debriefed to learn from the experience and to understand what we could do differently in the future.  We understood that clear and consistent messages by team leaders combined with critical thinking and mutual support among team members are the necessary components of success.  We were also able to improve our strategy by observing subsequent teams.  The valuable lessons from this experience will remain with me in the years ahead as I begin to interact with and play a role in health care teams.

A Burning Platform

While I am spending a week surrounded by some of the most gorgeous mountains, the Hide Park wildfires continue to ravage northern Colorado. Despite some of the best efforts of firefighters, the wildfires have consumed more than 58,7000 acres, have forced thousands to evacuate, and have destroyed more than 180 homes in nine days. With continued hot weather and winds, the goal is to contain the fire and minimize as much damage as possible.

With news about the fire on a nearly continuous feed on local news channels, I am reminded of Dr. Don Berwick’s famous 1999 National Forum Speech, “Escape Fire.” In the speech, he describes the 1949 wildfire that broke out on a Montana hillside and how it changed the way firefighting was managed in the United States through the use of an “escape fire.” Dr. Berwick draws the powerful analogy that our health care system is in a similar state of impending fiery disaster in great need of innovative solutions like an “escape fire.”

On our first day of programming at Telluride, we spent little time discussing the obvious that our health care system is sitting on a burning platform. After watching a video about the tragedy of Lewis Blackman, we jumped right into a presentation by Dr. Kim Oates (Fun Fact: Dr. Oates was Dr. Berwick’s Senior Resident at Children’s in Boston) on the qualities of the new clinical leader. Here are some essential tasks of a new clinical leader outlined in Dr. Oates’ presentation:

  • Lead reform in putting the patient first
  • Be a motivator, mentor, and facilitator
  • Be a communicator
  • Be a team leader and team player
  • Demonstrate high level clinical skills and research
  • Manage finances
  • Think critically
  • Monitor one’s own performance
  • Behave in an honest, open and ethical manner
  • Display integrity
  • See the big picture
  • Be able to learn from experience
  • MOST IMPORTANT: put the patient rather than one’s self at center stageThe task that resonated most with me was a reminder to keep the patient at the center. While not a tangible innovative solution, like an “escape fire,” perhaps the concept of patient-centeredness will be the compass towards those solutions.

    I look forward to continuing our discussions as we explore innovative communication strategies tomorrow that we can not only employ, but also share with our fellow students to work together and extinguish our burning platform.

Fight the fight

A soldier cannot run from battle because there are guns trained on his back in both directions.

This is not so in other occupations. As medical students and professionals, we constantly have to choose how to react to new information and whether to take action or to sit on the sidelines. Soldiers don’t have the luxury of these options. So in a way, because we must make difficult choices, we also need to muster more courage to perform in the battlefield.

Patient safety improvement takes a lot of guts. It means challenging the status quo, confronting established traditions, risking your job or grades, and most of all, dealing with recalcitrant people….who may be your seniors.

Today I was confronted about my experience shadowing a preceptor who does not wash his hands before he sees patients. I have commented on this directly to the physician by saying, “I notice that you don’t wash your hands between patients, this is different from what we learned in school.” This did not change his behavior, but I did notice that he would wash his hands after he saw me do it first. I have been rather passive about confronting my preceptor again, but I think that I have renewed determination after these eye-opening conversations at Telluride. The strategies of CUS and DESC will certainly be helpful.

Good leaders set priorities and make decisions. The Telluride patient safety camp is doing more than informing us, it is training us to be leaders – those will not turn back in the face of adversity, those will fight against apathy, and those who will be soldiers who cannot turn back because they see no choice but to push on.

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.

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