My wife and I recently watched as our eldest child headed off to college for the first time, as he read this letter the night before he left he commented that these were good “life” reminders, I agreed, and so share the letter here:
August 28, 2015
My dear sweet Harrison,
I’ve noticed that the mornings stay darker a little later and that the evenings are drawing in, and I am reminded that this is nature’s nod to the fact that everything has a season, and that everything must end and begin again. Just as I know that the seasons change, I’ve known since the day we brought you home from the hospital, that this season of you being a daily constant in our home and our lives would end and that your new beginning, in college, would start.
The time has come my love – the freedom that has excited you and that you are so ready for is here, and yet this same freedom is one that I have very mixed emotions about.
I have both dreaded this moment and been incredibly excited for it.
I think I’ve privately dreaded this day since I first held you almost nineteen years ago. As a parent you learn the difficult lesson that raising children is in fact to embrace a love that is built on the reality of constantly having to let go of things, of constantly having to let go of you. Letting go of you as your learned to crawl, saying goodbye to your little clothes, dropping you off at pre-school, waving the bus goodbye, watching you go out with your friends, and watching you drive away from the house with your brand new license.
Your mom and I have also learned that the deep love that we have for you has changed us as people. You have added an indescribable richness to who we are as you have grown, challenged, tried, failed, argued, agreed, laughed, cried and blossomed as our “beautiful boy”
And so here we are, on the verge of this next chapter of your life, and as the page turns we are as excited to watch you embrace it, as you are likely to go grab it.
And yet I have this mix of stuff going on… I know you won’t be very far away, but emotionally I’m going to miss having my “little man” around. It’s going to hurt because I know we have to say goodbye to a chapter of our lives that is closing; leaving us with the memories, the mementos, the pictures and the stories; but it is over, it is done, it is closed, it is time.
While I will work hard not to cry tomorrow Harrison, you know me as well as anyone and you know that I’m proud of my emotions and share them unconditionally with you. I will work hard not to cry because this is an exciting happy time (the mix of stuff…) and yet as I write this I have become overwhelmed with tears and the desire to hold you so tightly, to remember all that we did together, the adventures we had, the plans we made and even the things that we never quite got to…
I remember you in the hospital in Beverly, hiding in the dryer in Manchester, building walls in Rockport, sailing up to Maine, treehouses in Amherst, snakes in the kitchen, tongues on lamp-posts, your bravery leaving Amherst, a wooden boat project in the backyard, running in Chicago, and fishing in Ipswich, and I remember laughing, crying, running, playing, learning and living with you as you grew up to be the college bound adult that stands before us, and I miss you Harrison. I miss you so very much.
Watching you learn and grow continues to be one of the greatest blessings and experiences of my life, so as I reflect back on all that you have given us, the lessons you have taught us and the example you will continue to be for all those blessed to be a part of your life, I wanted to share with you some guidance as you navigate this next chapter, some choices and some reminders…
Some choices – remember they’re exactly that, choices:
- Smiling OVER scowling
- Working for it OVER wishing for it
- Optimism OVER pessimism
- Owning it OVER making excuses, blaming others, complaining or gossiping
- Being kind OVER being unkind or rude
- Believing in your abilities OVER believing in your insecurities
- Hugs OVER handshakes
- Loving yourself OVER beating yourself up
- Being your own hero OVER waiting for a hero
- Doing what’s necessary OVER doing what’s easy
- Living for today OVER living for someday
- Being vulnerable OVER being perfect
- Living with purpose OVER sleepwalking through life
- Talking to people OVER talking about people
- Being happy OVER being right
- Have goals and review them
- Use logic and reason AND listen to your gut and your heart
- Admit when you’re wrong
- Praise others – privately and publicly
- Be appreciative – say “thank you”, even better, write “thank you”
- Ask for help, remember that you are a work in progress
- Love life and let it show – be honest with your emotions and bring them with you
- There are no limits to what you can do – remember: “if it is to be it is up to me”
- You are empowered – take a risk, speak up, be brave. It’s OK if your hands shake and your voice quivers. Be brave, speak your heart.
- Take time for you – rest, relax, restore, and exercise
- People and relationships are everything – stay in touch, reach out, lift others up, help people succeed, pick people up
- Be mindful and take action – if you see something, say or do something.
- Strive for purpose, find your passion. Do what you do with love, energy, audacity and proof
- Remember that the small things are the big things
- Above all, remember that you are a work in progress, you are blessed and you are forgiven.
Harrison – you will find your own guides, reflect on your own words of wisdom, and learn your own lessons (you already have many of them under your belt…) and I know you’ll be searching for your own answers along the way at Emmanuel, but please also know that if you ever need help, advice, a shoulder to cry on, or an ear to listen, that I am always, always, always here for you.
What I have shared with you is what guides me. I work hard to live up to it every day, and every day I fall short, but that’s OK. Reaching out for advice, help and inspiration is not a sign of weakness my love, it is a sign of strength.
Time will slip by, the next chapter will end I suspect more quickly than the last.
This time is yours, you’ve earned it, give it as much as it will give you. And remember, as a wiser person than me once shared, “There is no grand prize at the end of your life, no all-expense paid trip to utopia. This is your final destination, this is your life. The prize is here, now, in every breath you take, every new friend you make, every kiss, every hug, every challenge, and every exciting piece of information you discover.”
Godspeed little man! Breathe it in, savor every sip, enjoy every moment! Oh the places you’ll go!
I love you,
Reflecting on our first day of the Academy for Emerging Leaders in Patient Safety and I am feeling blessed for the insights, the lessons and for the reminders.
Yesterday morning we watched the Lewis Blackman Story – we were fortunate to have Helen Haskell with us, Lewis’ mother, who graciously and bravely answered our questions, provided more insights and shared the reminder that this November marks the fifteen-year anniversary of the death of Lewis.
I’ve seen this video more than a few times and to be honest was thinking to myself that there was not much more to “learn”. How wrong was I?
Re-watching this emotional story I was abruptly reminded that the stories of communication failure, mis-diagnosis and poor communication are as real and relevant today as they were fifteen years ago, and that being reminded of the work ahead is critical to this effort of making patient care safer, more just, and more transparent.
I watched the video again, took new notes, re-read those notes, and listened to the story and the discussion. I heard things I hadn’t heard before, heard perspectives that I hadn’t paid attention to in the past, learned new lessons, and was left with a re-galvanized commitment to this difficult, rewarding, and necessary work.
In the work that I do with healthcare leaders to change culture, I hear and see a lot of conversations, interactions and exchanges. Having the ability to reflect on what I have heard or seen, either from reading my own notes, re-remembering my experiences, or having the story interpreted by someone with a different perspective, provides me renewed energy, fresh insights and ideas about alternate solutions.
Day 1 reminded me that re-visiting the stories, notes, videos, conversations and perspectives are some of the most powerful reminders of the work still ahead to change the world of patient safety.
Thank you Helen for the reminder.
Last speaker of the day
Several years ago I found myself in the audience of a quality and safety conference at Harvard University. The last speaker of the day took the podium with little fanfare and no slides. What a welcome change…
With his very generous permission I’d like to share my memories and notes from that day, the lessons and leadership “keys” he shared then, ring true now, and continue to resonate with me.
And now for something completely different…
Mike Dowling is the President and CEO of the North Shore-Long Island Jewish Health System (NSLIJHS). Prior to becoming president and CEO on January 1, 2002, Dowling was the health system’s executive vice president and chief operating officer.
Mike served in New York State government for 12 years, including seven years as state director of Health, Education and Human Services and deputy secretary to former governor Mario Cuomo. He was also commissioner of the New York State Department of Social Services. Before his public service career, Dowling was a professor of social policy and assistant dean at the Fordham University Graduate School of Social Services and director of the Fordham campus in Westchester County.
Mike presented at the Eleventh Quality and Safety Colloquium (Cambridge MA – August 14-16, 2012) – my notes summarize his comments. Without any slides, Mike shared “7 Keys” to creating a “Premiere Healthcare Organization” by stating, “NSLIJ is not there yet, but we are on a journey toward this, and I’d like to share it with you…
Have a coherent idea of where you want to end up – a clear VISION
- Not just the “what” but the “why”
- You must be able to engage EVERYONE’S head and heart in the VISION – in the “why…”
Have a positive attitude
- Be optimistic and believe that it is possible – a “can do” attitude
- Be responsible for outcomes and model personal accountability – “if it is to be it is up to me”
Have a complete commitment to transformation
- Be ready to think differently – we CANNOT be risk averse
- Be open minded – healthcare is NOT unique – exceptional, high-quality organizations are NOT industry specific
Engage and develop EVERYONE
- Lead a continuous culture of learning
- Be mindful of who you hire, who you promote, who you let go
- Remember: People + Values + Behaviors = SUCCESS
- Use simulation
- Make a core part of your curriculum mandatory
- Break down silos and train people across disciplines
- Manage your board and medical staff
- Change how we do medical school training
Become deeply consumer focused
- Everyone you serve is more educated and informed than ever
- Expectations are constantly changing
- Constant communication of the “why” from #1
- Top down, bottom up, side to side
- Face to face, electronic, multi-media, print, etc. etc.
- You CANNOT over-communicate
Most of all – remember that:
- we do great work every day in healthcare!
- we have much to be proud of!
- we do make a difference!
Mike closed his remarks with the words of Sir Winston Churchill, “Success is going from failure to failure without losing enthusiasm…”
Thank you Mike, you continue to inspire and encourage!
A conversation with Chuck Lauer
Last year I had the wonderful opportunity to be introduced to Chuck Lauer, the former publisher of Modern Healthcare, by my good friend and colleague Kristi Peterson. Chuck and I spent considerable time talking and emailing about a subject of mutual interest and something we are both passionate about, accountability, specifically about the idea and concept of ‘personal accountability’.
This concept of personal accountability, and the choice to change the words I use when I think about accountability, are in part lessons from the leadership, writings, and friendship of Linda Galindo.
Chuck went on to pen a piece that appeared in Beckers Hospital Review on August 17th 2013. I just re-read it, and thought I’d share it here again. Enjoy…
We hear a lot about “accountability” in healthcare — from the boardroom, to the workplace, to new payment methodologies like “accountable care organizations” — but most people don’t have a clue about what the word really means.
Everyone knows the basic definition: Accountability is a kind of answerability. The word derives from having to give an account — to clearly explain what you are doing. But the actual definition goes much deeper than that.
Richard Corder, assistant vice president of CRICO, a Harvard-affiliated malpractice and patient safety organization, has thought a lot about what accountability is — including what it is not. It is not, he told me recently in an email, about saying “yes” whenever your approval is sought. “In healthcare, we have fallen for the belief that good service means saying yes to everything,” he said to me. “Saying no — and being clear about why, and when you may be able to meet, chat, review, discuss — is a liberating, time-saving, accountable action.”
One of the things often missing in today’s workplace, he said, is a lack of clarity about what accountability really means. “Treating everyone the same is disrespectful to our high performers and excuses (rewards) our middle and low performers,” he said. Fairness is not about treating everyone the same. As leaders, we understand that we have to treat, manage, coach and lead people differently — based upon performance and needs.
“In healthcare, we are currently spending a lot of time (and money) talking about and pondering the ‘accountable entity,'” he told me. “We wax and wane poetically about the who, what, why, when and where, when all the time it’s staring back from the mirror. We are the accountable entities.”
That gets us to the heart of the matter: Accountability has to start with you! If you are ever going to be successful and fulfilled in your life, you have to be accountable to yourself. Sure, you can kid yourself about how good you are, and you can even fool other people by what you say and how you behave. But do not forget that the hardest person to satisfy is you! You have to judge yourself and live with it every day!
Each of us is an accountable entity. That’s why, when leaders lead with clarity and conviction, honesty and transparency, they bring with them inspiration and determination. They have become accountable to themselves! It’s a contagious enthusiasm that permeates their organizations. Talented people are attracted to institutions where leaders are dedicated to innovation, creativity and risk-taking. They fully accept that answering to oneself is the key to success.
I have had the honor of meeting a lot of great people — people who have made a difference and achieved unparalleled success in sports, business and other pursuits. None of them really caught fire until they took stock of themselves and became accountable. Some did this when they were young. Others didn’t face up to themselves until they were older. But in all cases they look back and say that being accountable to themselves is what changed their lives.
Richard Corder said personal accountability means always trying to be clear. When confronted with a problem, you can say, “I tried, but they wouldn’t let me,” he said, or you can say, “Can you help me figure this out? I need to get some clarity.”
It’s important to put some effort into establishing clarity, he said, offering me a quote from the inspirational speaker, Mark Victor Hansen: “By recording your dreams and goals on paper, you set in motion the process of becoming the person you most want to be.”
Listening to yourself can help you put your plan into action. I don’t know about you, but I have conversations with myself all the time, and from what I can gather from colleagues and friends, they do the same thing. This enables us to begin to develop a sense of our own accountability.
With accountability comes additional responsibility. For instance, in your job, do you speak up when you feel something could be improved? Or are you so concerned about the risk of falling out of favor that you don’t say anything?
In healthcare, we too often delude ourselves into accepting the status quo and are unwilling to try new things that just may be more efficient and guarantee a better experience for the patient. Accountability has to start with people who are willing to hold themselves to a higher standard and be answerable to themselves at all times. The goal is to never deviate from your dedication to excellence.
The road ahead is paved with uncertainty, and you will probably have to drive over many potholes along the way. The whole industry needs leaders who have the courage to look into the future with clear eyes and to inspire their people to do the same. We need to be willing to bring about the changes that healthcare so critically needs. It isn’t going to be easy. Those who hold themselves personally accountable to mission and vision and to themselves will be the stars that inspire all of us with their courage.
Richard Corder gave me a kind of motto for personal accountability. It’s all simple, two-letter words that go like this: “If it is to be, it is up to me.”
I have already put them up on my office wall.
Thanks again Chuck for the friendship, mentorship, interest, and support.
Leadership lessons from the New England Patriots
On the way home tonight I listened to a recording of last week’s post-game press conference with Tom Brady, Quarterback for the New England Patriots football team. In the spirit of full disclosure; I am a Patriots fan, and Brady and colleagues had just come off a victory that many a pundit predicted they had no hope of pulling off, a win against the favored Denver Bronco’s…
I am a happy fan of the winning team, feeling additionally buoyed by the fact that my team had just beat the team that denied us a berth in last year’s Super Bowl, a good result by anyone’s measure. All this aside, what I heard in the press conference from the captain leader of this team, made me realize that what made this football team successful last Sunday afternoon are the same tenets that make any team successful, regardless of the game being played…
A clear vision
During the comments made about the winning game, it became obvious that the vision for this team was broader and longer term than the afternoon’s victory. The vision of the organization (New England Patriots), is to ultimately win the Super Bowl each year. They are competing every week to win enough games to get to the post season, and ultimately get to the final game of the season, and win. Clarity and single-minded committment to a vision is critical.
Clear, executable goals
Tom Brady reiterated that winning football games is the reason the team goes out on the field every week. There are clear goals related to the execution of everyone’s job, there is clarity about each and everyone’s role, the expectations of each player, and their purpose when they’re out on the field. Role and goal clarity is often glossed over as a nice to have, not for this team, not for the Patriots.
Relationships built on trust
When asked about several remarkable plays, from a one-handed catch, to a stunning interception resulting in a touch-down; Brady spoke to the fact that he and his team mates take time to get to know each other, developing deeply rooted bonds of friendship and building trust with each and every one. Over time they learn how to build on and support each other’s strengths, accommodate each others shortcomings, and provide honest (for anyone who has been naked in a locker room with another team mate you know what this feels like), timely, and candid feedback.
A dose of reality
In the locker room, following the win, the Patriots’ coach Bill Belichick congratulated the team for a well-played game, allowing those that had worked hard for the victory a moment of celebration and appreciation. He then reminded the team that seven wins does not make for a winning season and does not guarantee entry into the post season and will certainly not win a Super Bowl. I was struck by this gracious dose of reality; a little time to enjoy the moment, to savor the win, and then remember why you are here. To achieve the goals and reach the vision. Do not stop working toward your goal.
Hire and retain the right people
It was clear listening to Brady during the press conference that this team was made up of people that really love the game of football. They enjoy working hard to get better through practice every single day of the season. He also spoke to the fact that if this wasn’t how a player was “wired”, then they wouldn’t last very long in the program.
Clear vision, communicated expectations and goals, the trust of those you work with, against a back-drop of reality, and a culture of “player fit”, are tenets of any high performing organization and successful team.
How does your organization or team perform? What would your “post-game press conference” sound like?
Leadership lessons from training to run a marathon with my teenager.
I just finished read Richard Branson’s recent blog – Leadership Lessons Begin at Home. #thevirginway
Richard talks about watching and learning from the tenacious spirit, and limitless energy, of his mother Eve. I have a leadership lesson that I am currently learning at home, not from my mum, but from (and with) my seventeen-year-old son.
After running what I thought was my first and last marathon in 2004, my then seven-year old asked if we could run a marathon before he heads off for college. At the time I quickly agreed, and secretly hoped that he’d forget…
In the pre-dawn hours of a New England winter, the thought of running 26.2 miles was daunting, distant and in my opinion; impossible. So we crafted a plan and the lessons began…
Establish the goal
Run a marathon in seven months’ time… this was a stretch to say the least. After some discussion and research we got clear about our goal, and then both committed to it. Get to the start line injury free on October 12, 2014. We figured that if we could do that with all the necessary preparation and training, the running of the race, would be the icing on the cake. Clarity of expectations, getting on the same page, and clearly articulating the goal (with a date) was critical.
Change is personal
I hadn’t run for several years and I was carrying what my doctor referred to as “too much weight for my height”. Early efforts were small, and required changes to diet and a commitment to exercising at least four days a week. The lesson was that the changes necessary to achieve this goal were a personal choice, and not an easy one. If I was serious about achieving the goal I needed to stick to the plan and learn some new habits. We chose a different mind-set from the past to achieve the desired outcome in the future.
Break the plan down
Thinking about running for over four hours to finish a marathon, was incomprehensible at some level. The lesson here is that the biggest, most intimidating goal required a plan, an approach, and a way to eat the proverbial ‘elephant’. We used a spreadsheet to set out the miles that we would run for every single day until October 12, 2014. It became easy to understand, realistic to imagine, and allowed us to take every day one at a time.
We had a plan, we also had lives, and reality happens. The plan had us committed to specific miles that we needed to run every day, “long runs” on the weekends, cross-training days, and rest days.
My son is a senior in high school and I travel quite frequently for work. So we’ve had to get really good about communicating changes to the schedule, adjustments to the miles, and really good about sharing how each of us was feeling in any given week. We also found that communicating during the run was incredibly valuable. Asking for help, sharing what hurts and when, and being clear about our own needs made it easy to learn from each other and adjust the plan in real-time.
Achieving a different outcome (losing weight, running a marathon) has required different habits and choices. Early morning runs have had an impact on family, work, and school, and have required choices that have meant giving some things up. Fewer carbohydrates and fewer late nights are relatively easy sacrifices. The burden that training places on family has been a lesson in open communication, clarity of expectations and forgiveness…
Having a passion or a sense of purpose
Early in our commitment and decision, we decided to do the race in honor of my late mother, the grandmother that my son never met. We joined the team for the American Cancer Society. Knowing that our effort directly related to something that was bigger than us, that we have a passion for, and that we had a belief in, has buoyed us along the way.
Through five months of training we have learned that rest, relaxation and cross training (exercise that is not running) have been as important as the running. While the “work” has required discipline and a plan, so to have the activities that have kept us “whole” as people. This focus on our resiliency has ensured that we have enjoyed this experience, and has set us up to be the best that we can be. Taking care of ourselves and those we work with as whole human beings is something that I am now, more than ever, astutely aware of.
There are other lessons that I continue to learn from my running partner and my all too soon “off to college” son. The lessons of tenacity, perseverance, hard work, sacrifice, good humor at all times, listening, laughing, tradition, and family, to name a few.
Rudyard Kipling’s final sentence of “If” captures some of this sentiment for me:
“If you can fill the unforgiving minute with 60 seconds worth of distance, run, yours is the earth and everything that’s in it, and — which is more — you’ll be a man, my son”
Every time we lace up, stretch out, and get ready to run, I realize that we are also creating special memories that will stay with us both for many years to come. Thanks for the lessons my son, I’ve loved every mile of them. I love you!
24 days; 20 hours and 31 minutes to the start line! We’ve got this!
Yesterday afternoon the faculty and students at the “Telluride-East” Patient Safety Summer Camp visited Arlington National Cemetery.
As we paused for some reflections from our leaders Paul Levy and Dave Mayer I was overcome by the scale of what presented itself in the form of field upon field of white grave markers.
Poignant words reminded those gathered that we were indeed standing on hallowed ground and that many have given, and continue to give, the ultimate sacrifice. A sobering reality is that there are between 25 and 30 new burials every day at the cemetery.
Following our time of reflection I took a walk to reflect on the sacrifice, loss, and scale of what lay beneath me. 400,000 markers of lives once lived, now at rest.
In a recent piece of research published in the Journal of Patient Safety it is estimated that more than 400,000 hospital deaths are attributed to preventable harm. Put another way, since August 2013 more than 400,000 mothers, fathers, brothers, sisters, sons and daughters are no longer alive as a result of harm that could have been prevented with better designed systems, more situational awareness, and other proven human factors and safety science approaches in health care.
I think these numbers are becoming “noise” for many leaders in healthcare, we have heard the numbers and yet still choose not to make the different decisions and the difficult choices. We disassociate from the difficult reality because we don’t “see” the totality of what we are doing.
The grave markers stopped me in my tracks, a visual reminder of what we are doing every year in healthcare by tolerating variation, blaming people, doing the same things over and over and expecting different outcomes.
My walk took me to the Kennedy family grave site. Off to the side of the eternal flame is a Robert F. Kennedy quote that really resonated with the work we are doing with the faculty and students at Telluride-East:
It is from numberless diverse acts of courage and belief that human history is shaped. Each time a man stands up for an ideal, or acts to improve the lot of others, or strikes out against injustice, he sends forth a tiny ripple of hope, and crossing each other from a million different centers of energy and daring, those ripples build a current that can sweep down the mightiest walls of oppression and resistance.
Robert F. Kennedy, South Africa, 1966
This quote captures what I will leave this time of learning and sharing with, and what I urge the students, residents and faculty to find the courage to continue doing…
- Lean in and keep speaking up to improve safety; these are the “numberless diverse acts of courage”
- Believe in yourself and the difference you can make
- Stand up for what you know is right and stand up for those less brave and courageous than yourself
- Speak up, even when your voice quivers and your hands shake. Speak up for patients, the ones you care for, know and for the one’s you dont…
- Most of all, send forth a “tiny ripple of hope”. These ripples will build to a current. These ripples will make care safer
- By thinking and acting differently, by bravely speaking up and taking a stand we will sweep down what often feels like a mighty wall
I commit to making ripples and I urge my new found colleagues and friends to do the same.
Make ripples. Ripples save lives, ripples make care safer.
As we closed the daylong exchange from some of the country’s leading minds on safety culture, I wanted to recap the themes that we heard and that seemed universal across the day’s conversations. Here’s what we learned and how we captured the “lessons”:
- You are your culture. What you say, how you model, how you behave and what you tolerate is culture. You are personally accountable.
- Open up to the fact that there is only one kind of empowerment. Self-empowerment. No one can “give you” empowerment. You can be given authority. Self-empowerment—take the risks, “lean in”, and get the results that you desire.
- Assess your current reality. Where are you at? Where is the company at? Where is your team at? Are you where you want to be? Look in the mirror, under the covers, and be honest with what you see.
- Hire and retain those that share your company values. Make the difficult decisions on those that don’t fit. Use data. Be brave.
- If you’re about to say “no” to an idea, an approach, an alternate, or a different way of doing things. Stop! Consider what “yes” would look like. You do have a choice.
- Support, reward, recognize, celebrate, and listen to your employees. Period.
- Talk to people, not about them. Eliminate gossip—it is killing your culture.
- Tell stories. Invite everyone to share their narrative.
- Keep doing the difficult, heavy, awkward, challenging, rewarding work that is changing the culture of healthcare. Your patients, their families, your colleagues, and the children in your lives are relying on you.
Thank you for all you do every day to improve.
Last month, at CRICO, we hosted healthcare leaders from around the country at our annual patient safety symposium “Walk This Way”. My talented colleague and dear friend, Dana Siegal, RN, CPHRM, opened up the meeting with a theatrically inspired look back over her career as a registered nurse, and patient safety expert. Reflecting through narrative and performance that we (healthcare) have come a long way with regard to our tolerance/acceptance of smoking in the workplace…
Now, if that’s all you were left with, you missed her point! She deftly wove the analogy of smoking in with many other “journeys” of change, from seat-belts to car seats, from drunk driving to exposure to sunshine safety. Up to and including our current journey of patient safety; from pre-IOM report, through “Crossing the Quality Chasm”, up to and including the most recent Lucian Leape white papers.
With this as a back drop, Dana challenged us with a hopeful message, that indeed journey’s such as these take time, require leadership and demand that we stay focused. We explored how attitudes, policies, and behaviors—that is, the workplace culture— related to smoking changes over time. We looked back in amazement to a time when physicians, nurses, and patients openly smoked cigarettes in hospitals and other health care settings…
Then we asked our Walk This Way attendees to place themselves 10 years into the future, and make a prediction about changes related to patient safety in their workplace that would make the look back in amazement…
It’s hard to believe that back in 2014 we:
- Worried that all clinicians were not reporting adverse events or near misses or good catches
- Took over a year to build a patient portal while arguing about what to “allow” patients to see
- Shouted at colleagues while treating patients when something went wrong
- Sequestered doctors and nurses from other health care workers
- Kept adverse events a secret from staff
- Expected patients to make their own appointments for consults and follow-ups
- Blamed people working in bad systems versus looking at the process and making that better
It’s hard to believe that back in 2014 we didn’t:
- Allow patients full access to all parts of their medical record so that they can truly partner with us in their care
- Always wash our hands when seeing patients
- Feel comfortable stopping the line when something doesn’t seem right
- Have a standardized handoff process
- Have efficient systems for formally tracking/following up on abnormal test results
- Respond effectively to every instance of disrespectful behavior
- Round on patients as an interdisciplinary team
By definition, this is our “current state”…
What will you look back on in 2024 and be “amazed” that we did or didn’t do?
Does it need to take us ten years?
My wife and eldest child are out of town; my youngest child is at a sleepover. I decide that this “free” evening is an ideal time to get some things accomplished around the kitchen.
Its 8pm and I decide that while catching up on televised network news, I will also check emails while cooking some meals for the week (following a recipe on the iPad), and prepare myself some dinner.
By means of background, the task I am about to undertake is one for which I am well-trained, and have a plethora experience with, after all it is the simple task of chopping an onion.
I learned to cook in the kitchen of the Savoy Hotel in London, where I was extensively reminded of the importance of knife safety, and repetitively trained and retrained on the appropriate technique for dicing, slicing and chopping of said onion.
With the first slice of the knife I removed the tip of my left pinkie finger…
What followed was a relatively calm elevation and compression exercise, while putting away all the dinner and meal ingredients, turning off the TV, laptop and iPad, and then determining what to do…
Over the next twenty-four hours, I heard from my OT, RN and MD friends that this was a reminder of some of the basic tenets of distraction, safety science and human factors. This was, after they cared for my injury, treated me exceptionally well, and suppressed the giggles and smirks of “funny that the guy that talks about reducing distractions and putting error prone humans into safe systems doesn’t seem to heed his own advice…”, a somewhat painful and rather bloody example of to err is human.
The loop was especially well closed by my friend and colleague, David Ring MD at Massachusetts General Hospital (MGH). David is the Chief of the MGH Orthopedic Hand and Upper Extremity Service, someone I have known for several years, and someone whose willingness to talk openly about his own humanness and natural tendency for error has been an inspiration. Check out his mea culpa:
David took a look at my finger within 24-hours of the accident, and recalled the fact that there is a human tendency to take the routine, habitual, oft repeated task, and stop paying attention to the risks associated with it. He shared that when driving long distances his wife will take the wheel; for him driving has become routine and habitual. He, and most likely she too, are aware of the fact that he is not paying attention to the small variations that could ultimately lead to a harm event.
I had undertaken my routine task so many times that I believed I could simultaneously safely perform other tasks at the same time, while taking in the noise of the digital world along with TV images. This over-confidence resulted in a missing fingertip. This over-confidence in healthcare environments can result in care providers putting themselves, and their patients, in unsafe and potentially deadly situations. While still dealing with the discomfort (and embarrassment), I am kind of grateful for the reminder.
Now – how to break this news to my wife…