Visitors and Guests

In May, our newly appointed leader of CMS, Dr. Don Berwick, gave the graduation address at Yale University Medical School where his daughter was entering the ranks of newly anointed physicians. The graduation address has all but gone viral, making its way to those of us in Chicago so interested to hear the heart-felt health care experiences Dr. Berwick shares whenever he speaks. While the entire address was quite moving, what struck me most was the humility with which he views his profession, and his place within the circle of doctor-patient involvement. Here is an excerpt that I found particularly moving and speaks to the importance of delivering health care in a way that puts the patient first:

…What is at stake here may seem a small thing in the face of the enormous health care world you have joined. It is as a nickel to the $2.6 trillion industry.… Continue reading

Patient-Centered Care Begins With Informed Consent

With a meeting of such high energy and exchange of ideas as described in Telluride less than two short weeks ago, there is much to digest. The key is to keep the momentum going along with the exchange of ideas here on the blog. For inspiration, it helps to read about those caregivers at the front lines who are successfully implementing unwavering patient centered care that begins with a patient-physician partnership, and true informed consent. Dr. Harlan Krumholz who recently penned an article published in a March 2010 issue of the Journal of the American Medical Association entitled “Informed Consent to Promote Patient-Centered Care” is adamant about putting patients first. He shares that many patients are going in for procedures, that if they truly understood all the related risks, benefits and alternatives, they may not be signing the consent forms at all.

And while there is continued discussion over the… Continue reading

Future Caregivers, Law Students and Patient Advocates Join Forces to Create Curricular Models For Open Honest Communication in Healthcare

The final day of our Telluride Roundtable on “Open and Honest Communication Skills in Healthcare” focused on reflection of the past weeks work and next steps in how best to disseminate the outcomes and products created from our work. One of the special highlights of the Roundtable was the interactions, conversations, sharing and bonding that occurred between our students and our patient advocates during the week. Students told us how they were so positively impacted by the advocate’s willingness to share their stories related to medical error, their passion to help educate, and their continued commitment to making care safer for all of us. Working with, and getting to know, patient safety advocate leaders Helen Haskell, Patty Skolnik, Dan Ford, Carole Hemmelgarn and Rosemary Gibson over the course of the week left lasting impressions on all the students. Both students and advocates identified a number of projects they will collaboratively… Continue reading

Mindfulness As A Foundation For Principled, Compassionate Actions

Telluride Patient Safety Roundtable Class of 2010

Topics tackled by the group on the fourth day of our Telluride Roundtable on “Open and Honest Communication Skills in Healthcare” included mindfulness and culture. The morning’s session on mindfulness, led by Bob Galbraith and Anne Gunderson, generated considerable discussion on the impact mindfulness plays in both open and honest communication skills and in high-reliability organizations (HRO’s). HRO’s are not satisfied with their successes. They have a preoccupation with failure and their culture is one where people feel safe to report incidents.

Mindfulness, as defined by Weick and Sutcliffe, is to become more aware of one’s own mental processes, listen more attentively, become flexible, and recognize bias and judgments, and thereby act with principles and compassion; it is one’s ability to uncover our own blind spots. Discussion also focused on the characteristics of curiosity, self-awareness and situational awareness in open and honest conversations.… Continue reading

Use of IT Improvements to Facilitate Open, Honest Communication Requires Education

At the Bear Creek waterfall on Wednesday

Today was the midpoint of our Telluride Roundtable on “Open and Honest Communication Skills in Healthcare”. After two full days of discussion, discovery and curriculum building, many participants shared a group hike up the mountain to Bear Creek waterfalls.  The scenery was magnificent and the two-hour climb provided hikers a great opportunity to reflect on the first two days of work while continuing discussions on open and honest communication issues before reconvening in our classroom for the afternoon working session. Participants were still feeling the excitement and energy generated from Tuesday’s sessions on shared decision-making and open disclosure education.

Our afternoon session focused on newer information technology (IT) platforms that could support open and honest communication skills in healthcare. After discussing the impact of informatics on patient safety (both positive and negative), discussion turned to how IT can support (and not replace)… Continue reading

Shared Decision-Making and Open, Honest Communication Change Outcomes

Rick Boothman sharing insights on open and honest communication related to adverse events.

What an amazing and invigorating second day of discovery and consensus building at our Telluride Roundtable on “Open and Honest Communication Skills in Healthcare”. The high altitude and beautiful mountain valley scenery have ways of opening up creative thought processes that lead to amazing new ideas. Some reflections from day two:

  1. Our second day focused on what patients and family expect related to open and honest communications in the domains of (a) informed consent and (b) when harm occurs from our care. Rosemary Gibson and Helen Haskell led the morning session which quickly evolved from the concept of informed consent to one of shared decision-making. David Longnecker talked about the “partnership” between patients and their caregivers when decisions on care need to be made and stressed that open and honest communication must go both ways in those… Continue reading

Open and Honest Communication Challenges the Status Quo

Helen Haskell, Rick Boothman and David Longnecker MD discuss emotional intelligence

The first day of our Telluride Roundtable on “Open and Honest Communication Skills in Healthcare” is now complete. After a full day of deliberative inquiry and exploration, some reflections come to mind:

  1. To start the day, students from medicine, nursing, public health, pharmacy and law attending the Roundtable watched the film “The Faces of Medical Error…From Tears to Transparency: The Story of Lewis Blackman” to start the day. After the film, Helen Haskell and Rosemary Gibson led an engaging and interactive discussion on the educational messages highlighted in the movie. The conversations were empowering and got us off to a great start.
  2. The students added an amazing dimension to our discussions on open and honest communication. Their excitement and passion was contagious; their ability to appreciate right from wrong without pre-existing cultural biases was refreshing.
  3. In the afternoon, Roundtable… Continue reading

Welcome to Telluride!

Welcome to the Sixth Annual Patient Safety Roundtable in Telluride, CO – an annual retreat for those of us working to help make healthcare safer through education.  This year’s work will focus on open and honest communication skills in healthcare, addressing the barriers surrounding transparency from informed consent through the continuum of care when unintentional harm occurs.  As we wait for this year’s Roundtable to begin, the sun has already begun to peek over the beautiful Telluride valley and the southern Colorado Mountains, signaling the start of another beautiful Rocky Mountain summer day.

Through the generous support of the Agency for Healthcare Research and Quality (AHRQ), eighteen students from medicine, nursing, public health, pharmacy and law will be joining us in our work this year. To kick off the Roundtable, we will share with attendees the award winning film, The Faces of Medical Error… From Tears to Transparency:… Continue reading

Welcome

Greetings! Welcome to our blog. So glad you found us.

Our hope is that this site generates important conversation among caregivers, administrators, patients, families, educators, policy makers and others on two very important issues in healthcare today: (1) the medical error crisis, and (2) while appreciating that medical errors will never be eliminated, how we respond to patients and family members when unintentional harm results from our care.

In an effort to stimulate this conversation and help lead change, our first educational film The Faces of Medical Error…From Tears to Transparency: The Story of Lewis Blackman addresses both of these important issues. The film premiered last September and in just five short months, The Story of Lewis Blackman has been used as a vehicle for change across the globe. In Chicago, Washington DC, Southern California, Australia, Japan and Europe, audiences have used the film to begin important discussions on medical… Continue reading

The Story of Lewis Blackman Awarded Highest Honor by Filmmaking Peers

In addition to providing an unforgettable learning experience for health care providers, Lewis Blackman continues to touch the hearts of all who hear his story. Most recently, The Faces of Medical Error…From Tears to Transparency: The Story of Lewis Blackman, was awarded a 2009 Aegis Award—a worldwide film industry honor given to the very best film and video productions of the year. Of the 2,109 entries, The Lewis Blackman Story received top honors, achieving the highest score awarded by a panel of peer judges.

Greg Vass, Executive Producer at SolidLine Media and partner to Transparent Health in the creation of the film said, “It always feels great to be recognized as the best in our field, but I think it feels even better to be part of such a special production project—one that is truly changing healthcare.”

For all of us at Transparent Health, the journey of making this educational… Continue reading