High Reliability Organizations

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

HRO’s- A Fitting End

This week we repeatedly discussed how hospital safety culture must learn from high reliability organizations (HRO’s) such as the airline industry, nuclear power plants, and aircraft carriers. Just before my 90 minute shuttle from Telluride arrived at Montrose airport, I received an email communication from United Airlines notifying me that my flight had been cancelled due to “aircraft maintenance.” Unfortunately, the next flight out of Montrose would not be until ~6am the following morning. In the past, I would have been rather disgruntled with the airline and likely would have projected my anger and frustration onto the check-in staff over the cancellation much like the two gentlemen at the counter next to me. However, after our discussions of HRO’s and reading John Nance’s Why Hospitals Should Fly, I was disheartened at first knowing it would be one more day until I got to see my fiance and dog… Continue reading

Post Telluride Reflection by Matt Starr #TPSER8

I finally was able to get my burrito, but not without trouble. We showed up to town after a long afternoon of biking down the mountain around 5 pm. The problem with that is the taco stand closes at 5 pm. So I raced over to the stand only to find it closed, but the back door, which also served as the entrance, was still open. I ran up to it and asked the man inside if he would make me anything that he hadn’t put away for the day or ran out of. He agreed and made me a burrito and I had no idea what was in it, but I loved every bite. I cannot wait until I get to come back to Telluride again, this place is by far one of my favorite places to visit in the world; the people, the food, the atmosphere, it is… 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

Telluride Experience 2020 Dates

BRECKENRIDGE, CO:
CMF Session One*: 6/8 – 6/11
Bennathan Session Two: 6/15 – 6/18
Session Three: 6/22 – 6/25

WASHINGTON, DC/MD:
Session Four: 7/22 – 7/25

*Session exclusive to the COPIC Medical Foundation Residents.