Progressive Hospitals are also the Transparent Ones

I found this article today and thought it was worth sharing for two reasons:

1. It talks about the most progressive hospitals being the ones that are also the most transparent concerning costs and medical records.

2. It highlights my ice breaker partner Luis’s hospital (Montefiore Medical Center in Bronx, NY) for their work in the community on social issues.

http://www.beckershospitalreview.com/hospital-management-administration/10-things-the-most-progressive-hospitals-do.html

“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!

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.

Trust and Safety in Medicine: Part 2 by Matthew Waitner M2 Georgetown

Perhaps, as Terry Fairbanks said yesterday, we should look not to our individual pursuits but the healthcare system that is in place.  Individually, we are each committed to the reason we put on the white coat – to cure, heal, and do our best to care for each of our patients.  And yet collectively as a system we are failing to provide that very goal.  How is it possible that such dedicated individuals are systemically failing – it would appear to be impossible, and the numbers certainly show that its more than just a few bad apples.  Perhaps our system needs to be overhauled.

I was struck at the insight that Dr. Fairbanks shared.  As a human factor engineer he explained that every other system in the world accounts for the natural errors in humanity.  There are fail-safes embedded in most systems to catch the errors before they cause undue harm.  Such fail-safes are not present in the culture of healthcare.  While every hospital is claiming to be patient-centered, we often fail to see the humanity within ourselves.  I am firmly convinced at this point that a systemic culture change is the only solution to our never-ending problem of patient safety.  Dr. Fairbanks made it clear that skill-based errors (or better put, automated errors) are the key to controlling our out of control safety issues.  In fact, as a first year medical student we learned in our neuroscience course about types of memory: short-term, declarative (semantic and episodic), procedural, priming, associative, and non-associative.  The last of these (non-associative learning) is when someone is habitually exposed to the same event over and over again that the event is done by rote.  This should sound familiar, as it’s the same as skill-based tasks that require automation or limited cognitive input in order to be achieved.

From my class example, this is when you live over a flight path (which I actually do), and you tune out the sound of the overhead planes because you hear them every few minutes.  Every once in a while a plane will fly lower causing a louder that normal event that triggers you to notice them again, and again with habituation it disappears from your thoughts.  So it is clear that our mind can become habituated by automated responses that require little cognition, and it is only when there is a difference that your routine is noted.  Hence is the case discussed today of the NICU heparin incident – habituation caused major medical errors.  I am fascinated by the idea that this system error could have been avoided if there had been a slight difference (a different shaped vial, a different drawer, any change from the expected norm).  Dr. Fairbanks would argue that this is how well-meaning, caring professionals make simple mistakes that cost lives – and it is not the individual practitioner, it is the system involved regardless of how mindful we may be.  That same error was noted in the book “Why hospitals should fly” when the flaps were not engaged yet 3 people confirmed a 15,15 green (indicating the flaps were extended) – it was the expected result and therefore it was what was seen.  These sorts of systemic errors are where the most margin for improvement can occur – because like any job, medicine becomes routine and we become habituated, and our brains are physiologically wired to become habituated.

To say this conference has been insightful would fall short of its true meaning in my eyes as a future medical professional.  These past two days have shown me that our profession is far from perfect (even though each of us strives for such), and requires some major safety overhaul before the public catches wind of our missteps.  In fact, I’m not sure how much longer we can pull the wool over their eyes before they catch us red-handed, and I’m not exactly sure how we have been fooling them for as long as we have.  The numbers are out there, the mistakes make headlines, and yet we are still more trustworthy than a stranger on the street, and we deserve no such pride.  As medical professionals, its time to put egos aside and start doing what we swore an oath to do: do no harm.

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!

Telluride “East” Kicks Off at Georgetown University in Washington DC

This week we transport the Telluride Patient Safety Educational Roundtable and Resident/Student Summer Camps to the heart of the nation’s capitol — Washington DC. Dave Mayer MD and Tim McDonald MD/JD along with faculty Paul Levy, Rosemary Gibson, Helen Haskell, Cliff Hughes, Kathy Pischke-Winn, Joe Halbach, Gwen Sherwood and more will educate the young of healthcare, sharing communication skills, patient stories and negotiation training in the spirit of keeping patients safe. The Telluride alumni numbers continue to grow, building that critical mass of voices who can share the wisdom of open, honest communication and transparency throughout medicine.

Student reflections on this year’s camps, as well as last year, are found throughout the Transparent Health blog, on Educate the Young and on faculty member Paul Levy’s blog, Not Running A Hospital. Look for additional reflections from this week’s class soon to come, and follow us on Twitter via #TPSER9. The goals of this week’s program follow.

TRANSFORMING MINDSETS III

“The Power of Change Agents: Teaching Caregivers Effective Communication Skills to Overcome the Multiple Barriers to Patient Safety and Transparency”

Patient Safety Student and Resident Summer Camp learning objectives:

By the end of the Patient Safety Summer Camp, students will be able to:

1.)   Describe in-depth at least three reasons why open, honest and effective communication between caregivers and patients is critical to the patient safety movement and reducing risk in healthcare.

2.)   Recognize and apply basic communication skills to improve effective communication among members of the healthcare team.

3.)   Utilize effective tools and strategies to lead change specific to reducing patient harm.

4.)   Implement, lead and successfully complete a Safety/QI project at their institution over the next twelve months.

%d bloggers like this: