Healthcare Quality

I Am a Doctor

I am a doctor. I save lives. Sometimes, by accident, I take them. I fight off bad infections. I spread worse. I do no harm. I do no good. I order the right tests and the wrong ones. I do only what is necessary, then do more. Maybe I do less. I care for the individual. I care for their lab values. My care is evidence based and defensive.

I am a physician. I am the new guard and the old. I am bright eyed, optimistic, jaded and bitter. I have integrity and prescribe the drug rep’s newest candies. My patient’s autonomy knows no bounds, nor has my paternalism found its limit. I admire. I condescend. My patients are wise fools. I welcome their questions and scorn inquisitiveness. I listen to them. I don’t. I have the utmost respect for nurses when I dismiss their assessments. My patience is exemplary,… Continue reading

The Task: Write a reflection. The goal: Mindfulness.

Academy for Emerging Leaders in Patient Safety – Day 1, June 8, 2015

Sentences that stuck:

  • “People don’t remember powerpoints, they remember stories.”
  • “I need a little clarity.”
  • “Telluride has more dogs per person (1.8/person) than any other town in the U.S.”
  • “The most important question: ‘What’s the worst it could be?'”
  • “Why do we have a Monday-through-Friday culture when illness happens every day of the week?”
  • “The best way to starve a dog is to tell two people to feed it.”
  • “Make a plan to persuade; People are motivated by data, structure, and emotions.”
  • “Why are you here? What do you want to take with you? What are you willing to invest?”

After only one day of the “Telluride Experience”, I’ve got 6 pages of handwritten notes and an unending stream of questions and ideas buzzing around my head. Today Dr. Wendy Madigosky asked us to list situations… Continue reading

Mise-en-place: patient safety lessons from the kitchen

On the way to the hospital this morning, I heard a report from NPR’s Dan Charnas about mise-en-place, the chef’s philosophy and discipline for organizing and managing a hectic commercial kitchen.  The piece was a great reminder that many of the challenges we face in healthcare are shared by others.  Chefs standardize their procedures, prepare meticulously for each workday, and read back instructions from their colleagues to keep orders straight in the hectic kitchen.  They also “work clean” and practice “clean as you go” to keep their workspaces organized and their food safe.  When something’s not right, the chef “slows down to speed up” by taking time to correct any problems before a dish reaches a customer.  A few weeks after Telluride it was a great reminder that we can get inspiration and motivation for patient safety practices anywhere!

Reflections from Telluride East

First and foremost, I’d like to thank all the leadership, instructors, and patient families for having me and taking the time out of thier busy schedules to share with us their valuable information and experiences.  I will echo what Rick said yesterday in that this conference definitely re-ignited that fire in me to change our culture in Medicine and put the focus back on patients and their safety and well-being.  When I go back to my slightly younger self to think of how I expected to be as a physician, I never thought of the negative effects I could have on patients, I only thought of myself as a healer.  Then I said to myself, “OK, I can change my ways and improve myself so that I am better aware of errors around me or because of me, and correct them before they do real harm to… Continue reading

Chick Fil A and Healthcare Quality

By Christine Galligan

My friend is allergic to gluten and can only eat the grilled chicken nuggets. One time on the way home from our internship, we stopped at Chick-fil-A and she ordered grilled chicken nuggets. However, when we pulled out of the drive-thru, she realized that she had been given fried chicken nuggets. This was a near miss as she could have had an extremely allergic reaction. We pulled around and parked, and she ran inside to report the mistake. We could have driven away and she could have gone hungry, but we decided to let the management know. At the very least, the cashier or the person wearing a headset at the drive-thru should be made aware. Human error exists. It is not a crime and it is typically not intentional. Chick-Fil-A is quite efficient at standardization. However, no one is perfect. Work one day in the food… Continue reading

Impact through metaphors

An incredibly strong, sobering metaphor was made today at Arlington National Cemetery.  The notion that 400,000 lives lost over the course of several wars in the pursuit to protect the freedom of citizens to pursue meaningful goals matches the loss of those citizen life every year due to medical error is disheartening and baffling.  It hits home because just as each member in this cemetery belongs to a family…leaves behind loved ones… each patient who loses his or her life does too.  So it is sobering, but Arlington holds another impactful metaphor that offers hope to the medical discipline.  That is a metaphor that can be found in the ritual of the Changing of the Guard.

The Changing of the Guard has a long, rich history which each sentinel imbues and lives through his duty.  The process by which a… Continue reading

Communication and the Optimism Bias

Communication, teamwork, team-coordination – all buzzwords of patient safety and improved healthcare system performance. But does everyone truly know the meaning of these terms? We were presented a case study today in which an experienced and revered surgeon encouraged his surgical team to break protocol by closing a patient when the sponge count was off by one sponge. The surgeon cited, with amiability, the length of time under anesthesia as the urgency for ending the procedure before the missing sponge was accounted for – and rightly so, as longer times under anesthesia are associated with decreased patient outcomes.  However, so are surgical materials left in patients. The concerned team deferred to the surgeon’s congenial and persistent request for the sutures to close the patient.

At first glance, this team could be considered to have some of the above qualities: they communicated about the missing sponge, they coordinated a course… Continue reading

When to Wake Up the Doctor – CCIRs for Medicine

At Telluride East today we were all touched by the story of Lewis Blackman.  The care he received suffered during night and weekend hours when coverage was limited to housestaff.  We discussed how making the decision to call an attending about a patient can be a difficult one, especially if the hour is late.  I  was delighted to learn today that at some hospitals, attendings and residents have come together to agree upon a list of ten patient situations that will always always generate a phone call from the resident to the attending, regardless of day or time.  Further, at the end of the call, the attendings have agreed to thank the resident for reporting the situation.

This practice parallels a concept from military doctrine.  In order to succeed in his or her mission, every commander requires up-to-the-minute information about the status… Continue reading

Changing the culture is like herding cats

Pic retrieved from http://brickandtree.files.wordpress.com/2013/05/herding-cats.jpg

The clip with the cowboys herding cats really got me thinking.  I love cats and I have 3 of them.  They each have their own personality.  We adopted our first cat about 6 years ago.  She was a kitten, and I had brought her home for my daughter as a Christmas present.  One day, before leaving for work, I heard the kitten meowing and began to look all over the house for her.  I finally found her about 20 minutes later, when I went to reach for a drink in the refridgerator, where she was sitting on the middle shelf.  She had jumped in when I went to get milk out for my cereal.  I went to work telling all my friends my crazy cat story.

About a week later I came home from work and I… Continue reading

Proud, Humbled, and Somewhere in-between!

To say today was educational, informative, and life-changing would be an understatement.

Before the conference we were instructed that we would be introducing a fellow conference attendee at an icebreaking event. We were encouraged to email and get to know one another in order to provide a concise yet effective introduction. My partner and I had many interests and motivations in common- we are both from Oklahoma, we both are interested in mastering the skills necessary to become patient safety advocates, and, perhaps most importantly (or most movingly), both of us have lost a grandfather to an avoidable medical error. In our introduction we both shared this information with the group which I felt made the group more tight-knit because of the personal connections that echoed throughout the room- it seems everyone in some way has been directly affected by an adverse medical outcome. The camaraderie I felt after sharing… Continue reading

Telluride Experience 2021 Dates

BRECKENRIDGE, CO:
CMF Session 1*: 8/23 - 8/26
TDCF Scholars Session 2: 8/30 – 9/2

*Session exclusive to the COPIC Medical Foundation Residents.
 
ELLICOTT CITY, MD:
Bennathan Scholars Session 3: 9/9 - 9/12
 
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