Day 0

Greetings everyone! I can’t wait to begin this week with all of you. I have been a registered nurse for the past 8 years and I am in the first year of my Doctor of Nursing Practice program focusing on Health Innovation and Leadership at the University of Minnesota. I have served patients at the bedside in both in-patient and out-patient settings, and I also have formal leadership experience managing a busy urban pediatric primary care practice.

In my nursing career so far, I have witnessed a wide spectrum of approaches to patient safety (the good, the bad, and the ugly). At an academic medical center where I worked on a pediatric med/surg and cardiology floor for five years, I got my first real experience with a grassroots approach to shifting toward a culture of safety. I feel fortune to have had the opportunity to participate in this quality improvement work as a bedside nurse; I know what a difference it made in my nursing practice and our hospital saw measurable improvement in the rates of preventable hospital acquired conditions. Fewer kiddos enduring unnecessary pain and struggle? A win for everyone!

In contrast to this, it was eye opening for me when I moved into clinic management at the end of 2016. I found that many of the basic tenants of patient safety that I had learned and benefited from in the hospital had not translated into the clinics belonging to the same organization. The best-practices were not common knowledge among staff in the clinics and there was no common language used for discussing concerns. Patient safety events which did not cause harm often went unreported and operational leaders did not seem to prioritize timely investigation of events. We also lacked capacity for root cause analysis in the ambulatory clinics. I realized that I had taken for granted the fortitude and wisdom of our leaders in the pediatric hospital who had made patient safety a top priority.

Out of inspiration, out of passion, and a little bit out of necessity, I have found myself gravitating back to Patient Safety and I recently accepted a position as an Ambulatory Quality & Patient Safety Specialist. While we take steps toward improvement as a system, we continue to have quite a lot of opportunity in the clinics as we consider ways to engineer safe patient experiences and build team cultures that foster safety. I have seen it work in the in-patient world, and it is going to require a lot of ingenuity to expand this work into the ambulatory clinics that I serve, but it is such important work to be doing. I am hopeful that my attendance at Telluride will equip and empower me with the knowledge, skills, and a new network of friends and future safety leaders so that I can be effective in helping to lead this change in my organization.

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