Lessons Learned — making the most of #CRICO14

I posted a blog earlier this week about the CRICO patient safety symposium that we hosted last month.

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”:


  1. You are your culture. What you say, how you model, how you behave and what you tolerate is culture. You are personally accountable.


  1. 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.


  1. 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.


  1. Hire and retain those that share your company values. Make the difficult decisions on those that don’t fit. Use data. Be brave.


  1. 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.


  1. Support, reward, recognize, celebrate, and listen to your employees. Period.


  1. Talk to people, not about them. Eliminate gossip—it is killing your culture.


  1. Tell stories. Invite everyone to share their narrative.


  1. 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.


A healthy dose of (workplace) culture

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…

The following is sample of the view from 2024.

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?

Re-learning the lessons of distraction and over confidence…

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.

Chopping Onions

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…