Be hard on the problem & soft on the person

“Be hard on the problem & soft on the person.” – Paul Levy during small group break out on transparency today

These words stuck with me after our break out discussions early this morning. In acknowledging a systemic error, we acknowledge that the situation could of happened to anyone – they just happened to be in the wrong place, the wrong time. In accepting this culture where this would be the norm, we have to break away from our traditional deny & defend culture.

We have been discussing a lot about changing the culture from within, but it occurred to me that we are also facing a force from the external – the patients, their families & society’s perception. We must erase this idea that we are perfect & infallible. Although we acknowledge the difficulties we face within the system, I can’t help but think about my Grandmother (as well… Continue reading

House keys and the inevitability of human error

It always saddens me when a medical mistake is reported in the media, and the immediate reaction of so many people is: “Someone that careless and incompetent should be fired. There is absolutely no excuse for hurting a patient by omitting such a basic step as calculating the right dose / making sure you have the right patient / checking for allergies / etc… ”

My immediate response to this is always: “Have you ever locked yourself out of your house?” Human beings make mistakes. Human beings sometimes omit basic, crucial steps from tasks they supposedly have mastered. We make small, stupid, high-consequence mistakes so predictably, so inevitably that an entire industry (locksmithing) is dedicated to undoing the small, stupid, high-consequence mistake of not ensuring we have our keys when and where we need them.

The keys analogy is actually a great way to think about… Continue reading

Julia’s blog

Would you please help encourage one of our thoughtful and committed young doctors?  Julia Meade, one of the residents who attended last week’s Telluride Patient Safety Resident Physician Summer Camp, was inspired by the experience to start a blog called The Hospital Docent.  She’s posted a couple of entries in the last few days.

Would you please take a moment to welcome her to the blogosphere and comment on her posts? Perhaps you might want to suggest topics for future entries, too.

Also, please refer her blog to others who might be interested, ok?


What kind of clinician do you want to be?

This is very common question that I would get ask upon meeting new people, to which I would reply jokingly, “a good one of course!”

Kidding aside, I never fully understood the qualities that make up a “great physician” until the Telluride Patient Safety roundtable.

When I first entered medical school I thought that I knew what qualities made up a great physician. Some of the most important ones that I wanted to emulate were being compassionate, dedicated, hard-working, and a leader in my community. However, as first, second, and third year of medical school passed me by, my focus was geared towards getting top grades, doing as many USMLE questions to do well on the boards, and showing up early and staying late to impresses my residents and attendings so that I would get awesome clinical evaluations. Most of it, I am ashamed to admit it, was for a… Continue reading

Dreams from Telluride

20140609_081947Eleanor Roosevelt is quoted as saying:

“The future belongs to those who believe in the beauty of their dreams…”

With each passing hour I am reminded how blessed, humbled and fortunate I am to be a part of this year’s Telluride Patient Safety Summer Camp Roundtable. The setting up here in the mountains is surely beautiful, and so are the dreams, honesty, transparency and truthfulness of the students and their faculty.

With each presentation, discussion, break-out, game, meal, and conversation I am struck by the honesty and openness of the future of healthcare.

We cannot expect to envision and lead a truly safe healthcare culture unless we are willing to dream, and then share those dreams. For these are the dreams of transparent, trusting, patient and caregiver centered, and compassionate care.

I have already learned so much from the students and faculty here in this beautiful place, please keep telling… Continue reading

Fear, Forgiveness, and Father’s Day

Yesterday was Father’s Day, 2014. I woke up before everyone else in my room. Rolling out of bed, I padded down the stairs and brewed a cup of much-needed coffee. Pouring my face over the steaming cup, I looked out my window to the inspiring landscape of endless white-capped mountains. This year marks the ninth Father’s Day that I have spent without my dad, but the mountains and my purpose this week made me feel as though he were standing there with me, sharing our cup of morning coffee, just as we used to.

After taking the gondola ride into Telluride, the students and faculty plunged into our work of expanding our knowledge in the field of patient safety. We watched a documentary outlining the tragic case of Lewis Blackman, a 15-year-old boy who died due to medication error, miscommunication, and assumptions made by his medical team. The film explored… Continue reading

Negotiating in the Colorado Mountains

One of my roles as a faculty member to the Telluride Patient Safety Student and Resident Physician Summer Camps is to conduct a three-hour workshop on principles and strategies of negotiation.  The camps, after all, have a strong focus on the power of effective communication in reducing patient harm.  Negotiations occur all the time in clinical settings–between residents and nurses, between nurses and attendings, between clinical staff and patients and families–and our faculty leader Dave Mayer has asked me to provide some insights about negotiation to the students.
As I have noted on the Athenahealth Leadership Forum:
People who are likely to be the future leaders of health care institutions in America and abroad often come to me for career and training advice. My constant refrain is to learn the principles and framework of negotiation strategy. Negotiation can be defined as means of satisfying parties’ underlying interests… Continue reading

Unconventional Surprises

Day #1 of the Telluride Summer Camp was even better than I hoped. I expected to discuss patient safety; we did that. I expected to be taught by leaders and experts in the field; we did that. I expected small-group brainstorming sessions that let us come up with our own ideas to pitch to the group; we did that. I expected to hear troubling, yet informative patient stories; we did that. I expected team-building exercises (a workshop would never feel complete without them); we did that.

So, big deal, right? This sounds like every seminar ever, doesn’t it?

What surprised me about the first day was that we hit all of the bullet points of the camp’s agenda, but we did all this in the most unconventional of ways! I never expected to be bidding on an actual $10 bill. I never expected to be negotiating property value. I… Continue reading

How much is a $10 bill worth?

I really couldn’t have asked for a better start to our time in Telluride. The surroundings are beautiful, the accommodations are luxurious, and above all, the people are simply outstanding. Everyone from the students to our gracious hosts at TSRC to the organizing faculty have such a great energy. I’m so excited to get to spend 4 days away from all of our other obligations and just immersed in discussions and learning about patient safety.

There’s nothing to drive home a lesson like a poor financial decision and a little bit of embarrassment. I learned that well on day 1. When Paul said he was going to auction off a $10 bill, my immediate reaction was “I want nothing to do with that. If this is an activity that he’s doing in a session on negotiation, there’s just no way for me to win.” The auctioning began, and I intended… Continue reading

Keep the Faith

It’s difficult to believe that the Telluride Roundtable is celebrating its 10th year anniversary. For those of us who have been attending since the early years, the journey seems somewhat surreal. My first year on faculty at the University of Illinois College of Medicine was the second year of the roundtables’ existence. Little did I know that when I was introduced to Dr. Dave Mayer, founder of the Roundtable, I would be forever changed. In 2005, I attended the second year of the roundtable and found myself at a table with some of the most well known safety and quality leaders in the world. We shared one goal, to create safety and quality educational opportunities for medical students, residents, and ultimately, all health care providers.

In reflection, those first few years of the roundtable were a labor of love. The passion, the intensity of the discussions, is almost indescribable. Our… Continue reading