Why are we afraid to admit we are human?

By Betsy Mramor, M2 MUSC

It seems like common sense for us to realize that we will all make mistakes at some point in our careers. So why are we so afraid of admitting this when it happens? Are our own egos so big that we can’t admit we are human? Why is it that this same humanity that our patients and society expect of us disappears in a mistake. By not talking about these mistakes we continue to allow society to form these unrealistic perceptions that the healthcare field is perfect. I believe that in order for the culture to change; this perception needs to be broken.  There is no other way for this perception to change unless mistakes are brought to the table, discussed, and proactive measures are taken to correct them. Sweeping them under the carpet will only end up reinforcing this perception of the perfect healthcare system. Not only will this perception be reinforced, but also the unacceptable behavior of hiding or covering up mistakes.

I was so happy to hear confirmation of my thoughts from Cliff. Earlier in the week, Cliff had told us a story about how he lost his first heart transplant patient. He told us how shaken he was afterward. So shaken that he came home and told his wife that he had a 100% mortality rate. The next day he was asked what he told his next heart transplant patient. He told us how he was completely honest. He told the patient it was his second time doing the surgery and he lost the first patient. I keep trying to place myself in this patient’s shoes. Would I let this physician do my own heart transplant? Even with odds not in his favor;  I would have let him. For myself, there is a feeling of comfort and safety that comes from someone willing to admit that he is just as human (imperfect) as me.

By Molham Abdulsamad

I would like to start by saying thank you to everyone who made any single effort to make this amazing work about patient safety. I actually had a great experience this first session. I was really touched by Lewis Blackman’s story, as it made me look deeper into how easily a human life can be lost due to our mistakes. I think I learned a lot about how to be a better negotiator and I will absolutely use what I learned on a daily basis to get the best and safest care to my patients. Thank you again! I am so excited to get more out of this camp.

Telluride Roundtable: Week Three, Day One–Some Powerful Reflections

Introductions at Telluride Student Summer CampThe day began with introduction ice-breakers as student took turn introducing each other to the bigger group. From the introductions, it was clear that the Telluride Patient Safety Roundtable is hosting an extraordinary group of students this week – Medical Students, Pharmacy Students, and one student obtaining her Masters of Jurisprudence in Health Law. In addition, the Roundtable is blessed with faculty from Colorado, Illinois, Ohio, North Carolina, Maryland, Florida, and California.

Following introductions, the entire group attentively watched the film The Faces of Medical Error – From Tears to Transparency: The Story of Lewis Blackman. Unlike the two prior Roundtables this year, Helen Haskell, Lewis’ mom, was part of the faculty. She offered her own reflections on the events which occurred related to Lewis’ case, and answered questions from students and faculty. At one point Helen made the poignant observation that Lewis would have been the age of many of our students asking the questions. Had he lived, Lewis would have been 27 years old this year. He certainly was gifted enough to attend medical, nursing, or pharmacy school and could very well have attended such a Roundtable.  These observations were not lost on the students today.

In the afternoon, Deb Klamen from the Southern Illinois College of Medicine led the group in a discussion on leadership and the challenges students face in their day-to-day studies, and early clinical rotations. Small group discussions allowed the students to share their own leadership styles, as well as the leadership qualities of those they admire. Over and over a common, yet essential, leadership trait was described by students and faculty – COURAGE – the courage to confront those engaged in unprofessional and unsafe behaviors in a way that could avert future harm to others.

For the last exercise of the day, the students broke into two groups to engage in the now famous [infamous?] teeter-totter egg game. In an ironic twist the first group actually completed the task in the allotted time without breaking the egg while the second group suffered from a last-minute hesitation and injury to the eggs precariously placed below the ends of the teeter-totter. In almost all prior exercises, the first group most commonly fails while the second group learns from the debriefing and missteps of the prior group.

Most importantly, Dave Mayer led the two groups in reflections following the exercise and gave them an opportunity to understand the power of effective, clear, concise and goal-oriented communication tested through this “gaming” situations. The applicability to healthcare was clear to all.

Students Jump for Safety and Social Media #TPSER #hcsm

This has been the most successful social media start to the Student Summer Camps yet!

Thanks to everyone’s participation on the blog, facebook and Twitter, the Transparent Health blog hit an all-time high number of page views today with 241 hits to the blog. Thanks so much for sharing your wonderfully creative insights and thoughts on how healthcare can become safer for all of us.

Let’s keep the conversation going–and not let up. As you all learned today, a conversation can change an outcome. The more noise out in the Twitterverse, the blogosphere and whatever “they” call Facebook-land–the more likely the Telluride Summer Camp messages of: transparency, open/honest communication, patient-centered care, creation of a just culture in medicine, respect and joy in the workplace and building of high reliability organizations that drive preventable medical error to zero will catch fire–in a good way. Keep the momentum going even after heading home and we will nurture this community that continues to build strength. The Tipping Point is well within reach.

Telluride Patient Safety Summer Camp: Week Two Begins! #TPSER8

Under gorgeous blue skies and immersed in the cool crisp summer air, the Telluride Patient Safety Summer Camp: Week Two begins! With students from New York to California and everywhere in between, the Patient Safety Summer Camp opens for its 8th consecutive year. As with prior Summer Camps, the week will focus on the application and implementation of methods for engaging in open, honest, and effective communication with patients and families throughout the therapeutic relationship.

This week the students will enjoy learning alongside faculty who also hail from a multitude of near and far away places. From nearby Colorado communities all the way to Sydney, Australia, California, New York, and Illinois—all have traveled to Telluride to share their own experience and learn from the students as well. As always, the faculty also includes patient advocates – an essential component to all prior Telluride Patient Safety Roundtables.

Throughout the week, this diverse group will tackle some of the tough issues and barriers associated with providing honest communication to patients and families, such as dealing with disruptive behavior in the workplace. Through a series of large and small group discussions, role play, and “games” the group will become fully immersed in identifying solutions to the problems of ineffective or dysfunctional communication in the healthcare environment. As the week unfolds, it will become clear that all of the participants will leave with an entirely new and positive perspective on ways to improve patient safety and quality outcomes.

The Heart Part of Transparency

On my trip home from Telluride, I kept asking myself what would have been different if the session on respect and humiliation was covered earlier in the conference? These two concepts and processes are so central to the work we do and the work we want to achieve.

Throughout the week we saw, heard and felt what stories can do for the way we think, act and make decisions. But telling stories demands trust and it also demands humiliation because it exposes our natural limits as human beings which can be incredibly uncomfortable. However, these moments of discomfort are often some of our most powerful learning tools because we open ourselves up temporarily to the possibility of change and transformation, whether we are the story teller or the listener.

During the negotiation session, for instance, what would have been different if we underscored the importance of respect and humiliation during any and all negotiations?

What it is like to be in a negotiation? What does it look like? What does it sound like? And what does it feel like to have to let go of some of your own values and goals for the benefit of the collective, in this case, the patient and family? I think it would have been interesting to role-play during the negotiation session to take this concept from theory to practice in order to “try on” some of these skills in order to feel and talk about how difficult and uncomfortable this process can be, yet how important and empowering it can be.

This move requires a lot of respect and a lot humiliation in recognizing the heart part of this type of work, and even the heart part of talking about it with colleagues in the same room. But in doing so, it allows communication to be productive, meaning it allows us to achieve something new and different together that we normally couldn’t have done on our own. And this begins to shift away from a more reproductive model of communication that essentially reproduces old and outdated skills, patterns and habits that simply aren’t conducive to our current health care situation.

Last week was without a doubt the most stimulating and enlightening learning experience I have ever had, so many thanks to all!!

Telluride Day 1 Reflections

Dave Mayer and Tim McDonald opened the 8th Annual Telluride Patient Safety Educational Roundtable and Summer Camp. This being the eighth year the pair have taken time away from busy academic appointments, clinical responsibilities and family to continue to push forward in educating new physicians along with faculty on the just culture they know will make healthcare safe for all of us.

The residents and faculty were introduced to one another, and then we quickly moved into the week’s agenda starting with all viewing From Tears to Transparency: The Story of Lewis Blackman — a striking example of why we are all here and why there is still so much work to be done.

The residents kicked off the week sharing how some of their current environments were aware of the need for open and honest communication, yet failed to provide the support when an opportunity to have that conversation with a patient actually arose. Another mentioned the mainstay Morbidity & Mortality (M &M) conferences failing to address the real story, or even address the cases that could have been true teaching moments. In response, another resident shared that their institution had moved from the traditional M & M to a Quality Improvement conference. This is just touching the surface of the type of conversations Telluride engenders in a roomful of people intent on changing the medical culture for the good of the patient and those who work within in it.

The afternoon was filled with an excellent workshop on Negotiation, led by special guest faculty, Paul Levy, who broke new ground in transparency in healthcare while CEO at Beth Israel Deaconess Medical Center when he started a blog, Running A Hospital, and posted quality metrics online for the world to see. A wonderful summary of Day One in Telluride can be found on his blog as well.

Key take aways on negotiation from Paul’s workshop include:

  1. Understand your BATNA (Best Alternative To A Negotiated Agreement).
  2. Both parties can be made better through effective negotiation.
  3. Solving their problem is part of your problem.
  4. Create value in negotiation.
  5. Never threaten in negotiation but degrading the other side’s BATNA is fair game.
  6. Invent options–Learn about the other side’s interests.
  7. There are commodities, things, decisions with different value to parties in a negotiation–you can trade on those differences.

And finally, the day ended with a team building game that required new colleagues to work together through communication and system design in the best interest of our egg-headed patient.

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