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
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
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
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!
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?
The patient safety film “The Faces of Medical Error from Tears to Transparency…The Story of Lewis Blackman” was shown this morning to international patient safety leaders, patient advocates, medical educators and 20 medical student leaders from across the US. The award winning film kicked off the Seventh Annual Telluride Patient Safety Educaitonal Roundtable. This years Roundtable continues the discussions and consensus building from the previous two years on the need for Open, Honest and Professional Communication between caregivers and patients/families related to unanticipated patient care outcomes. Helen Haskell, the mother of Lewis Blackman, along with Tim McDonald and Dave Mayer led interactive discussions with attendees after the film on (1) why honest communication in healthcare has been lacking and (2) the positive changes that have been observed by health sytems who have adopted a… Continue reading
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 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