“Some is not a number and soon is not a time”

By Fiona Campbell (Medical Student at the University of Calgary)

It was refreshing to hear all of the insightful closing comments from all of the Telluride East participants today, and exciting to hear what we all plan to work towards as we return to our schools. It’s easy to see why we would all come away with such momentum and inspiration. This week was full of eye-opening discussions and thought-provoking workshops. It’s easy to feel empowered by everyone with a shared passion, and to think that we really can make healthcare better around the world.

But it’s also easy to succumb to real life and let that momentum fizzle away. It’s easy to forget how important patient safety is when you’re once again surrounded by leaders who don’t value it. It’s easy to get caught up in all of the knowledge we are expected to learn at school and forget about pursuing initiatives that will improve the system.

I’m still in the newlywed zone and every day I am reminded of the vows that I spoke one short week ago. They weren’t ground breaking, but by speaking them out loud in front of so many loved ones, it helps me hold myself accountable to following them. Today, we all vowed to each other to take what we’ve learned here, bring it back to our institutions and create something from it. Let’s not let life get in the way of accomplishing what we promised to do, and let’s hold each other accountable for making change. But as Dr. Mayer pointed out, some is not a number and soon is not a time – we need to think in realistic milestones in order to hope to accomplish anything. So let’s create more specific goals for ourselves and share our successes and shortcomings along the way.

My first step will be to do a patient safety project with the Human Factors group at the University of Calgary. I will start by defining the scope of the project this month and come up with a manageable deliverable to be completed before I start Clerkship in March. I’ll come back to this blog at least twice along the way to share my progress and get inspiration. Thank you to all of the Telluride East participants and faculty for the knowledge, motivation, and support to work on making healthcare safer one project at a time.

Hope everyone has a safe drive home from the airport!

Advertisements

Telluride Day 3 Reflection

The morning was spent in the trip to Arlington Cemetery. Going on trip with colleagues is a very different feeling from going on trip with families or usual friends. The trip actually provided a chance for us to talk over things that we would not cover in the conference room, such as a bit more personal life about ourselves. I appreciate that the conference has brought together people with so much diverse background, which could be inspirational to the others.

The afternoon started in the discussion of SBAR style communication. I had no experience watching professionals in my university hospital exactly using this, neither was this mentioned frequently in our courses, at least not in our pharmacy courses. From people’s discussion I realized that this “technique” has been much more emphasized than what I thought. This can be a good point to note and observe when I get back to school.

The highlight of today was root cause analysis workshop. I was designated by our facilitator Dr. Roger to play the role of risk manager to lead the discussion. Oh my god… I totally lacked the experience to play the role. I even had not comb my thinking flow well within such short time after reading the case, let alone to lead the conversation for others… There were teammates demonstrating much more experience than me, from which I learned that there is a long way to go before I can really play a good leadership role in this area. This is critical to know. Before the Telluride meeting, I thought everyone would be at the similar level, at least I would not imagine myself that far behind since I was on our school’s Enhanced Medical Training Track on Patient Safety and Clinical Quality. The first time I realized the reality is not like this was in the first day’s ice-breaker—-some people has already got years of practice experience to back up their knowledge in safety and quality issue while I am still kind of green…… now the impression strikes me the second time, reminding and stimulating myself to keep moving forward.

The most thought-provoking part of the day was Dr. Mayer’s lecture on transparency. What the elements of transparency are, what the barriers and benefits are, what actual outcomes of those stories are. I am particularly interested in and admired their story on this issue at early stage, when transparency was quite not yet advocated as a trend, when culture change was more difficult. It takes vision, belief and courage to be a pioneer, it also takes strategy, patience, and supports from friends. How “rich” the person should be before he/she deserves the reputation of “pioneer”! Facing these pioneers these days, one more thing I have learned is humility.

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.

Reflections on Telluride East: Day Three by Lynne Karanfil, RN, CIC

Loved the discussions on high reliability. Healthcare can learn a lot of lessons from the US Navy as Dave Mayer pointed out. If you want to see our Navy in action, you only need to go to Facebook. Each vessel has a Facebook page that they post how they do some of their operations. Below is a link to the carrier USS John Stennis. They also share their thoughts on leadership as well. We don’t have to go to far on seeing how to do things safer! Sometimes the answers are in our own backyard.

https://www.facebook.com/#!/photo.php?v=10152313797947334&set=vb.110454772346710&type=2&theater

Telluride Day 2 Reflection by Yimei Huang Pharm.D Candidate 2015

The day started with Dr. Cliff’s “railmen story”–Listen to the Rhythm. I was deeply impressed by Dr. Cliff’s kindness to, and caring for others, whom he does not know and may never know. Not only did he give extra notice to the things easily overlooked as a passerby, but he also carried out his caring despite the inconvenience to himself. I was thinking to myself what in the world could stop this devoted man from becoming extraordinary? He is so caring to the world outside of his expertise, then what level of caring does he pay to his field? I was also reflecting on myself on how far I am behind him as for the caring heart—-how often I overlook what’s going on outside because I am already quite full with my own business?

A fun thing for today was Teeter Totter Game. This was my first time playing the game personally, and I really enjoyed the moments when our team worked so closely for a common end. At those moments, I felt so supported, accompanied and comfortable to come up with and share ideas with my teammates to work out a better plan. We were successful, but it was not the outcome itself that is dearest to me. It was the process before, during and after that 10 minutes. I would say every team has achieved this process and experienced the similar feeling as ours.

The most emotional and thought-provoking activity of the day was discussing the film “The Story of Michael Skolnik”. As I said in the meeting, I am curious to know what measures have been taken in the past ten years to improve. What has been done to cut off the unnecessary incentives that make surgeons desire to do procedures and even induce patients to agree? What has been done to guarantee a second-point checker for the clinical decision even when patients themselves do not have the second resource accessible? What has been done to ensure that risks are thoroughly informed rather than partially? How well is the fact of surgeon’s expertise and experience honestly communicated to patients? How often does it still exist that assuring patient of one senior surgeon to win their signature but actually carrying out the procedure by his/her student? Maybe taping or video taping the informed consent conversation would help? Maybe a consultant meeting with everyone involved in the case would help? Maybe a written form of patient’s teach-back document files to the supervision level would help? Where are we getting right now?

The day ended with a recap on Dr. Cliff’s Listen to the Rhythm. What an inspiring day!

Trust and Safety in Medicine: Part One by Matthew Waitner M2

George_WashingtonI have been participating in the Telluride East conference taking place in Washington, DC since August 1. In the whirlwind two days I have been barraged by information, struggled through leadership, boggled by safety concerns, and simply overwhelmed by my own emotions.  To put it bluntly, this is the most interesting two days I have spent all summer, and even though I am exhausted, I am beyond stimulated by the experience of this conference.  One minute we are hearing from Paul Levy on negotiations and the next we are working on teamwork and leadership in a teeter totter game with 9 teammates, a 2×8, a cinder block and 2 eggs.  Suffice to say this is truly a hands on and experiential learning experience like none other.

In reflecting on the past two days I have stumbled upon many thought trains (thanks Cliff), but one that my psyche continues to grapple with is the following conundrum: How can the medical community as a whole commit so many errors as to kill nearly 100,000 patients yearly (for at least 13 years according to the IOM), and still be considered one of the most trustworthy professions in the country?

All I have to say is, whatever PR firm is handling healthcare’s interest deserves some large bonuses for pulling off this feat.  Nurses, Pharmacists, and Doctors all top the list here in the US according to the most recent Gallup poll in November (http://www.gallup.com/poll/1654/honesty-ethics-professions.aspx), nurses rank #4 and physicians #6 in Australia (http://www.readersdigest.com.au/most-trusted-professions-2013) and doctors rank #1 in the UK (http://www.gponline.com/News/article/1171314/Poll-reveals-doctors-trusted-profession/).  Seriously – this PR firm not only succeeded here in the US, but internationally as well.  I am stunned because on average (in the US) we kill 272 people per day due to medical errors which is the equivalent of two Boeing 737 crashing each and every day (total capacity per 737 = 137).

According to today’s presentation by Terry Fairbanks, we have a 1:616 adverse incident rate as a field – akin to bungee jumping in safety, while other professions soar in safety comparatively.  How could we possibly still believe then that healthcare professionals are still worthy of the patient’s trust? My only conclusion is that we as a profession do not deserve such accolades until we get our house in order and focus on patient safety.

What continues to be mind-boggling about this conundrum is that the population polled must have had some interaction at one point or another with the medical field.  Healthcare touches nearly every life in the country either directly or indirectly, and yet we are still given the distinct honor of being one of the most trustworthy professions.  This is even after Press Ganey scores (indicating mediocre treatment in the hospital, as any front-line employee will indicate), after outrageous hospital acquired infection rates (about 1.7 million yearly according to the CDC), and our dismal rate of iatrogenic death previously discussed.  Why are people not more outraged at these numbers?  As a future physician, these numbers are staggering and show that truly patients should not trust our professions.  So, truly, whatever PR firm is handling medicine must be doing one hell of a job and be making a killing in the process.  Seriously though, these numbers and our perception are at complete odds with one another and deserve to be honestly considered.

The only conclusion I have been able to draw from this analysis is that the healthcare profession has been given nearly implicit trust by our patients, by simply putting on a white coat, and we have done a horrible and dismal job of accepting that trust and caring for our patients safely.  Again I ask, where is the outrage?  Are people not doing the math? Where is the expose on 60 minutes or 20/20?  Frankly I’m surprised anyone trusts us at all, and if we are going to continue to receive such trust, we best make some changes fast to ensure that this trust is correctly placed.   From my perspective, somewhere in our profession, we have determined that while patients are the reason we exist, they are not to be treated as having such power.  Instead of being patient centered and safety conscious, we have turned healing into a business focused on doing more and caring less.  I am appalled as a future professional that this has been allowed to occur.  I, as many others reading this blog, came to this profession in order to diagnose, heal, and comfort people in their most dire need.  How could our profession have lost sight of our reasons for entering the profession in the first place?

Stay tuned for Part 2…

Slowing down to Speed Up

Day one reflection–Telluride East

by Scott Emory Moore

“We don’t run in the ER.”  

Early in my career as a new graduate nurse in a Level 1 Trauma Center, I remember hearing these words.  I do not remember why the nurse said this to me at the time, may not quite be the same reason as it comes to mind now, but it is a valuable lesson none-the-less.  In reflecting on my first day at Telluride East, it is evident to me that one person’s hasty actions can have tremendous impacts on outcomes and patient experiences.

Often in the healthcare industry we are quick to focus on speed and time rather than diligent and deliberate precision in the execution of the interventions.  Getting caught up in the fervor of the emergent situation does no good for us, rather it is when we slow down and take a full account of the situation that we are able to serve our patient’s best interests.

Slow down in order to speed up…

The Lewis Blackman story is a great example of the need to really take our time to ensure strong work and safe outcomes for patients.  Intentional focus on safety must be at the center of our work as healthcare professionals.  The stories of patient loss like Lewis Blackman must pave the way for improved hindsight, insight, and foresight surrounding patient safety.

%d bloggers like this: