It was a great first day at Patient Safety Camp! It is a privilege to learn from leaders in quality and safety from around the country and internationally (thanks for coming back, Kim!!). The bigger privilege, and the one I didn’t anticipate prior to arriving, was the privilege of meeting fellow residents from around the country. At first it was a little intimidating to be surrounded by residents who had accomplished so much as leaders in the IHI, leaders in CIR, radio talk show hosts, and pharmacists… the list went on and on. But as the day progressed I realized that I was lucky to be surrounded by such great people that I can hopefully learn from for years to come. We have already learned so much from each other by discussing ways to improve transparency and communication with patients, how to increase physician reporting… Continue reading
By Barbara C. Nzegwu, M3
The University of Toledo College of Medicine
The first day of the telluride roundtable was filled with great introduction into the great discussions that we would be having the rest of the week. We started with the story of 15 year old Lewis Blackman and how he lost his life due to a costly mistake and inattentiveness made by his medical team. This was a powerful story to me not only because his mother, Helen Haskell, was among us sitting just two rows ahead of me, but also because as the story was being told, I was able to pick up on what the diagnosis of a perforation with the symptoms of an acute abdomen as the movie told his story. And I only have a third year medical student education. I felt the injustice and the less than standard of… Continue reading
LEAN in a nutshell–Dave LaHote’s masterful diagram
The theme of our second day at Telluride was about reporting, risk management and quality improvement. We learned about the great examples that UIC and the University of Michigan Health System have set in adopting a policy of transparency and timely open and honest communication with patients when it comes to medical errors. The systems not only have resulted in improving direct communication between providers and patients, but have also led to significant cost savings (click here to learn more). The most important aspect of the system is that it allows a health system to engage in continuous quality improvement and learn from its mistakes.
However, as the discussion continued, we realized that while events at these health systems will trigger a process of error analysis and patient communication, many systems are severely lacking in a mechanism for medical students and residents to… Continue reading
Student scholars and medical education leaders joined in a group discussion after watching the film that shed light on areas of opportunity in healthcare across the country. Comments touched on the over-arching failure of leadership that led to the communication breakdown in Lewis’ case and the national need to empower students, interns and nurses to ask the necessary questions to keep patients safe today. When no one is willing to say “I don’t know” the patient is at risk. Lewis and his mom, Helen Haskell, whose life’s work has become keeping all of us safe in the hospital, paid the ultimate price for the inability to exchange three simple words.
What can be done to create a culture starting in medical school that welcomes these questions, allows providers to maintain belief in their abilities while still doubting an initial diagnosis and communicate with one another openly, transparently and with respectful professionalism?
On June 10th of this year, Colorado Governor Bill Ritter signed Senate Bill 124, better known as the Michael Skolnik Medical Transparency Expansion Bill, enlarging the circle of healthcare professionals in the state of Colorado that must make available all information related to their training, qualifications, criminal, disciplinary and malpractice history to healthcare consumers.
In 2007, Senator Morgan Carroll of Colorado, along with Patty and David Skolnik, championed the original Michael Skolnik Medical Transparency Act (HB 07-1331). This bill requires physicians in Colorado to report education, certain business relationships, malpractice involvement, and any disciplinary action or crimes. The bill is named after Patty and David’s son Michael, whose needless death at twenty-five years-old was the result of a surgery where related information was not disclosed to the family. Since Michael’s death in 2004, his mother, Patty Skolnik, has fought for greater transparency in healthcare. The expansion bill, passed earlier this… Continue reading
On June 11, the Department of Health and Human Services’ (HHS) Agency for Healthcare Research and Quality (AHRQ) awarded a number of grants to support State and health systems in their efforts to implement and evaluate patient safety approaches and medical liability reform. Transparent Health Co-Founders, Tim McDonald MD and Dave Mayer MD, along with the University of Illinois at Chicago, are the Principal, and Co-Investigator respectively, on one of the largest remunerated demonstration and planning grants recently awarded by AHRQ, a part of President Barack Obama’s patient safety and medical liability initiative announced last year. See press release for additional details.
“As Co-Executive Directors of the University of Illinois at Chicago Institute for Patient Safety Excellence [UIC IPSE], Dave Mayer and I feel highly honored that our grant proposal: The Seven Pillars: Bridging the Patient Safety – Medical Liability Chasm received notice of $3M in funding from AHRQ,”… Continue reading
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
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:
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