Change Starts At The Top at #TPSER8

#TPSER8Day 3 at the Telluride Patient Safety Educational Roundtable and Resident Summer Camp started with the annual hike up to Bear Creek Falls–an excellent team building exercise that always leads to relaxed and enlightened discussion about the work to be done and the knowledge gained from the week. It also provides yet another opportunity to get to know colleagues on a personal level, and build lasting relationships that will provide a support system for quality and safety efforts once everyone returns to their respective institutions.

Coincidence or not, we started the day near the top of the San Juan mountain range, and throughout the day it was reinforced that to achieve meaningful change in healthcare, it is imperative that hospital leadership not only supports, but leads the charge. Jill Prafke led a thought-provoking workshop on how to build effective teams with the ability to institute change during the afternoon session.… Continue reading

Patient-centered Care Education (Shared Decision Making)

Our second day in Telluride finished with the residents watching the award-winning film The Faces of Medical Error…From Tears to Transparency: The Story of Michael Skolnik”. The educational film addresses the importance of informed consent versus shared decision-making conversations – an important aspect of open and honest communication in healthcare that is still lacking in many health systems. The film asks the question – Can a conversation change an outcome? Can a conversation save a life?”

After the film, the residents engaged in a two-hour conversation with faculty and safety leaders on issues related to informed consent and shared decision making. When Paul Levy asked the residents how much training they get on this topic, every resident in the room acknowledged this three-hour session on informed consent/shared decision making was more education than they have received during… Continue reading

Conflict Resolution at #TPSER8

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Shelly Dierking is leading a workshop in conflict resolution today at the Telluride Patient Safety Educational Roundtable and Summer Camp. Residents are using role play of cases to highlight where conflict management breaks down and how best to build it back up.

What is coming to light is that there is variance that needs to be managed on a daily basis, and without teamwork and systems in place to manage and support those at the front lines, it’s only a matter of time before a tipping point is reached and the patient suffers. Not to mention the care providers who have the best of intentions, are human and who suffer along with their patients when an error occurs.

New friends, new tricks

Today was enlightening. Never before have I heard terms such as “early closure” and “normalization of deviance”, words that define the daily flaws of medical care. Narcissism and mindfullness are concepts that I’ve always associated with people I know but never thought of in relation to medicine

At the core of all the activities today was the concept of open and honest communication. The team caring for Louis Blackman had many opportunities to admit that they didn’t know the cause of his symptoms. However, they chose to downplay his symptoms and close the case wothout a clear diagnosis. Narcissism was at play with senior residents, who did not involve their attendings at critical moments.

In medical school we are expected to answer multiple choice questions to demonstrate our knowledge. However patients don’t come in with A through E on their forehead. Its critically important to know that you don’t know.… Continue reading

A light bulb goes off

Please check out this blog post over at Not Running a Hospital about how a new category of medical errors can arise as clinical innovations are introduced. In the cases discussed, use of robotic gynecological procedures created their own cottage industry of opportunities for patient harm.

Telluride Day 1 Reflections

Dave Mayer and Tim McDonald opened the 8th Annual Telluride Patient Safety Educational Roundtable and Summer Camp. This being the eighth year the pair have taken time away from busy academic appointments, clinical responsibilities and family to continue to push forward in educating new physicians along with faculty on the just culture they know will make healthcare safe for all of us.

The residents and faculty were introduced to one another, and then we quickly moved into the week’s agenda starting with all viewing From Tears to Transparency: The Story of Lewis Blackman — a striking example of why we are all here and why there is still so much work to be done.

The residents kicked off the week sharing how some of their current environments were aware of the need for open and honest communication, yet failed to provide the support when an opportunity to have that conversation… Continue reading

Close to Home

Ready for a week that will hopefully equip me with tools to make a difference back home. First day was great, including a pretty emotional video about a medical error with a devastating outcome, something I have unfortunately been able to see happen at a teaching hospital first hand early in my training. Growing as a physician and person includes accepting errors made and responding appropriately. Steering clear of human tendencies of avoidance, denial, and anger are negative responses.

Still tachypneic from this altitude but excited to learn!

Day #1 Transforming Mindsets Reflection – Todd Guth

We have just finished up the first day of the Resident Physician Transforming Mindsets Workshop in Telluride, CO. There has been much discussion on several issues in patient safety today. The issue that sticks with me most in the need for widespread cultural change within an institution if patient safety is to improve.

Cultural change within large institutions, such as hospitals, medical schools and medical specialities, can be a top-down or bottom-up phenomenon, but broad support across the entire institution must be in place for the cultural change to occur. My perception of the first day of our activities is that folks generally thought of being on the bottom can in fact be the agents of change. Grass roots efforts by residents, medical students, and other health care workers generally thought of being at the bottom of the power pyramid can make genuine differences in patient care through their individual… Continue reading

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