The Halo Effect

By now, many of you have started to read Why Hospitals Should Fly: The Ultimate Flight Plan to Patient Safety and Quality Care by John Nance. If not, you are in for an engaging read that starts by sharing the unfortunate story of the worst accident in commercial aviation which occurred at the Tenerife airport in 1977, killing 583 passengers aboard two different 747s and influencing cultural changes to aviation and other high reliability organizations around the world.

The author’s assessment of this event told through his character Dr. Jack Silverman, highlights the communication and cultural missteps that contributed to the unfortunate outcome–one of which being The Halo Effect. The Halo Effect, defined by psychologist Edward Thorndike’s empirical research, is the cognitive bias where people seen as knowledgeable or highly respected in a given area are given deference across the board. In the Tenerife example, neither the co-pilot nor… Continue reading

Teaching Transparency in Telluride

As transparency in health care begins to take root, remarkable and positive changes follow its adoption. Whether through the disclosure of medical error to patients and families or the public posting of hospital-acquired conditions, transparency is driving significant changes in behavior that improve the quality and safety of health care. In order for successful, transparent approaches to the prevention and response to patient harm to take root, education of our future health care providers and leaders becomes a critical imperative. To that end, the Eighth Annual 2012 Telluride Patient Safety Roundtable is training medical student and resident physician leaders from across the country in the identification and implementation of strategies, methods and tools  for the adoption and implementation of open, honest, and effective communication in the health care settings to which they will return.

This week will be emotionally and intellectually challenging for all participants as cases of patient… Continue reading

Welcome 2012 Telluride Scholars

Eighth Annual Telluride Patient Safety Roundtables and Summer Camps

June 11th – June 14th, 2012

June 18th – June 21st, 2012

June 25th – June 28th, 2012

Over the last seven years, interprofessional leaders from the AMA, ANA, Joint Commission, NBME, ACGME, Lucian Leape Institute, patient safety, informatics, simulation and health science education have come together with students, resident physicians and patient advocates in beautiful Telluride, Colorado to address current patient safety educational issues.

Through the generous support of The Doctors Company Foundation, COPIC, the Committee of Interns and Residents, MedStar Health and the UIC Institute for Patient Safety Excellence, we will have three separate weeks of patient safety summer camps for residents and students. These organizations have provided funding that allows us to bring twenty resident physicians and forty-five medical students to Telluride in 2012,… Continue reading

2012 Social Media Contest Starts Today

If you have made it to this blog post, you may or may not have found the contest question on Twitter. If you have found the question, post your answer in the comment section below. If not, see the contest rules below and Good Luck!

The first person to find the contest question on Twitter, and then post the correct answer in the comment section of the “2012 Social Media Contest Starts Today” post on the Transparent Health blog will be crowned the Pre-Telluride Social Media Scholar.

With that prestigious title also comes your choice of one of the educational documentary films we will discuss during the week in Telluride.

Hashtags are an excellent resource to find information on a specific topic on Twitter! Our meeting hashtag is #TPSER8

2012 Telluride Patient Safety Educational Roundtable Gearing Up

The first of three weeks of Patient Safety Education for medical students and residents kicks off in Telluride, CO with the Resident Patient Safety Summer Camp, Monday, June 11th at the Telluride Science Research Center (TSRC). If you are a speaker or student and have not yet registered, use this link to take you to the TSRC home page.

In its 8th year, the Summer Camp has expanded its reach and will train 60 future patient safety leaders in 2012 thanks to the generous support of The Doctors Company. And this year’s cast of patient safety leaders once again promises to provide top notch leadership from those creating meaningful change in health care ! Paul Levy, former President and CEO of Beth Israel Deaconess, patient advocate, health care social media leader and blogger at Not Running A Hospital, will open the week along with David Mayer MD,… Continue reading

2011 Telluride Patient Safety Roundtable Thank You

Telluride 2011 Alumni

Telluride Patient Safety Roundtable Attendees June 2011

A tremendous thank you to the faculty who shared their time, wisdom and experience during this year’s 7th Annual Telluride Patient Safety Roundtable. An equal thank you to the student scholars who shared their own experiences, enthusiasm to learn more about patient safety and willingness to step up as leaders related to this very important aspect of delivering care to patients.

I feel privileged to have been included in this meeting, and look forward to hearing more about the projects students and faculty will contribute to both patient care and medical education as a result of this year’s roundtable.

Please comment on your experiences in Telluride, as well as on how your projects are progressing!

Climbing Mountains Related to Improving Patient Care

Patient Safety Roundtable Hike Destination

Bear Creek Falls, Telluride, CO Final Destination Telluride Patient Safety Roundtable Hike June 2011

 As we were making the five-hour drive from Telluride back to Denver, Tim McDonald likened the movement toward transparent, patient-centered care to climbing the same mountains that surrounded us that week. A team building 2.5 mile hike up to Bear Creek Falls at an ending elevation of ~10K feet on our third day at the Telluride Patient Safety Educational Roundtable provided plenty of opportunity to get to know our fellow attendees on both a more personal and professional level. It also served as a wonderful analogy, as Tim suggested, to the challenges inherent in delivering patient-centered care by teams of individuals who bring a variety of strengths, weaknesses and skill to each encounter.
As we climbed the mountain, sharing stories of our families and our work lives, we all grappled with the demands of the… Continue reading

Bullying in Hospitals: What’s the Solution?

The focus of this year’s Telluride Patient Safety Educational Roundtable is to develop solutions for disruptive behavior in medicine. Some of the required reading for the week examined how other health systems are confronting issues such as bullying in the workplace. Our patient safety and quality experts from Australia, Kim Oates and Cliff Hughes, have shared information on the New South Wales health policy statement on how to combat bullying in the workplace. A second reading, an article by A Lazare & R Levy in Chest (Chest 2011;139;746-751), discusses how humiliation in medicine leads to less than optimal care, and offers strategies on how to apologize for inflicting such an offense so that healing follows.

A post on the physician led blog, KevinMD entitled “Hospital bullying requires everyone to share in the blame and solution” written by Kevin Pho himself, addresses the need discussed this past… Continue reading

Will You Stay With Me?

Cliff Hughes, CEO at New South Wales, Australia Clinical Excellence Commission shared a story Wednesday afternoon that exemplified what patient-centered care is all about. When Cliff’s patient, a 52-year-old truck driver named Neville was not going to live through the night, Neville asked Cliff if he would stay with him. Without hesitation, Cliff agreed and not only stayed to share prayer and poetry, but was also able to reunite Neville with his estranged daughter and 6-week old granddaughter before dying.

Cliff then posed two questions to the student scholars and patient safety leaders in the room.

“Is it unusual for you to cry?”

“Do you forget about the individual in the technology of care?”

“This is the way I want you to treat me, and how I will treat you. It’s no different in Australia than in the United States,” he said.

The final assignment for the day was for… Continue reading

Award winning film “The Story of Michael Skolnik” closes Day #2 at Telluride Patient Safety Roundtable

Dr. Lucian Leape opened day #2 at the Seventh Annual Telluride Patient Safety Educational Roundtable with a call for the return of “Joy and Meaning in Healthcare Work”. After Dr. Leape’s motivating address, Roundtable attendees spent considerable time in small group breakouts building consensus on ways to address dispruptive caregivers, humiliation, bullying and harassment in healthcare – all critical issues that significantly contirbute to increased patient risk and medical errors. Patient safety experts attending the Roundtable all agreed that efforts to solve the patient safery crisis will not occur until unprofessional behaviors by some caregivers is rectified.

The second day closed with all Roundtable attendees and medical students watching the award-winning film The Faces of Medical Error…From Tears to Transparency: The Story of Michael Skolnik”. The educational film discusses the importance of shared decision-making – an important aspect of open nd honest communication… Continue reading