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  Residents will understand the reasons why open, honest and effective communication between caregivers and patients is critical to the patient safety movement.

  
  
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  Residents learn to utilize tools and strategies to drive positive change towards reducing patient harm.

  
  
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  Residents will implement, lead and successfully complete a quality improvement project at their institution within 12 months of taking the Telluride patient safety training course

In 2013, a study was published in the Journal of Patient Safety estimating deaths due to medical error were not improving, but in fact, were now thought to be 4 times the number revealed in the Institute of Medicine (IOM) report of 2000.¹ To date, a formal systematic patient safety and quality care curriculum remains a gap within healthcare education across the country. Innovative healthcare educators, however, are creating ways to protect and empower learners as well as keep patients safe, through novel patient safety education opportunities. The Academy for Emerging Leaders in Patient Safety, formerly the Telluride Roundtable and Patient Safety Summer Camp, is one such entity.

In 2000, the IOM shocked the medical world when it declared that medical errors accounted for 98,000 deaths annually in the United States.² This made medical errors the eighth leading cause of death in the United States; more prevalent than deaths from breast cancer, AIDS, or motor vehicle accidents. Medical errors were also costing the nation approximately $37.6 billion annually, with between $17 billion and $29 billion of those costs associated with preventable errors. The United States had clearly entered an era in medical care where understanding the physiology and treatment of disease was not enough.

Quality health care and patient safety were, and still are, central public concerns in the United States. Secondary to the IOM report, modification of health sciences education dominated discussion in both the public and private sectors. Systematic safety and quality education for healthcare professionals was lacking, the available literature was scarce and inconclusive, and interprofessional training was just beginning to attract attention. Dr. Jordan Cohen, then president of the Association of American Medical Colleges, back in 1999, stated there needed to be a “collaborative effort to ensure that the next generation of physicians is adequately prepared to recognize the sources of error in medical practice, to acknowledge their own vulnerability to error, and to engage fully in the process of continuous quality improvement.”³

Reforming medical education to adequately address safety and quality issues, however, presents a major challenge to educators because the shortcomings that must be addressed are deeply entrenched in the tradition and culture of the institutions and organizations that compose the medical education system. While patient safety is now undoubtedly recognized as a key dimension of quality care, systematic safety education remains lacking in all healthcare disciplines. Medical educators needed to find ways to align medical school and resident learning competencies with ongoing quality care and patient safety initiatives in an effort to help initiate a cultural shift towards an ethos of safe patient care.

Inaugural Patient Safety Roundtable

Contemplating the vast need to join forces with other patient safety and curricular experts with similar interests, Dave Mayer identified and invited select leaders to an inaugural patient safety educational roundtable. Included in this inaugural group were a number of patient and family “advocates” who were personal victims of medical harm. In 2004, these experts made their way to a remote intermediate school in Telluride, Colorado, to begin these discussions. Over 5 long days and nights, each member of the group shared his or her knowledge and experience at the Telluride Roundtable. As the attendees engaged in open conversation and consensus building, the initial plans for building a patient safety curricular framework became a reality. Each participant embraced the challenge and agreed to meet again the following year… the Telluride Patient Safety Educational Roundtable Experience had begun. (see Figure 25.1)

Over the next few years, additional experts were added to the Roundtable team. Each summer, the multidisciplinary group would meet in Telluride (see Figure 25.2) to eventually design and create 11 specific elements essential for an effective patient safety education curriculum. All members took the information back to their institutions and began working to create a new order in very traditional medical school and graduate medical education settings. Although some small gains were made, it still wasn’t enough and most medical school curricular maps continued to lack any substance related to the science of errors and how to reduce them.

In 2008, 2 medical students and 2 medical residents with strong interest in safety and quality were invited to the roundtable. The young learners added their voices to the discussions while learning from the experts. The success of this model provided the inspiration for the creation of a new patient safety “training academy” for health science learners. To make the plans a reality, Telluride Roundtable leadership sought funding through an Agency for Healthcare Research and Quality (AHRQ) small conference grant. With this support, the new Patient Safety Academy was officially launched when 20 interprofessional students were added as Roundtable attendees and learners. In 2010, with continued funding from The Doctors Company Foundation, COPIC, and the Committee of Interns and Residents (CIR), the Patient Safety Academy expanded to 60 young learners.

For more than a decade, reports of the IOM focused attention on a persistent set of problems within the American healthcare system, including poor quality, lax safety, high cost, and questionable value. If unaddressed, the current shortfalls in the performance of the nation’s healthcare system would deepen on both quality and cost dimensions, challenging the well-being of Americans now and potentially far into the future. By 2010, medical errors had become the third leading cause of death and accounted for more than 400,000 deaths per year. It became apparent that contemporary health care required a systems-oriented, multidisciplinary team-driven, patient-centered approach for optimal patient outcomes. The traditional systems for dissemination of new knowledge could no longer keep pace with scientific and quality improvement advances.

An Interdisciplinary Education Program

Telluride faculty determined that a constantly expanding interdisciplinary educational program was needed to better prepare health science students and medical residents to understand, appreciate, demonstrate proficiency, and assume a leadership role in patient safety and quality outcomes initiatives that have positive impact on patient care. The vision was to design, create, and provide exceptional training for medical and nursing learners committed to becoming future leaders in helping reduce medical error and preventable harm. The mission was to identify patient safety health science learners and future leaders committed to developing patient safety knowledge, skills, and behaviors in an immersive and reflective educational environment. The learning opportunities would provide novice learners with the knowledge, skills, and experiences that promote discipline, competence, and a sense of personal and societal responsibility for the delivery of safe, high-quality patient care.

Training of the learners required knowledge, skills, and competency in critical disciplines not traditionally taught in health science education. To be successful, the curriculum required a qualitative culture shift in the way learners, even experts, think about healthcare education. The need for a new culture of care is common to all types of healthcare organizations; all need to build their capabilities to continuously learn and improve. Healthcare education, as it currently exists, is focused on an individual’s performance and assessment of that performance. Education, like hospital care, is traditionally organized around specific functions; medical students learn to write prescriptions, pharmacy students learn to issue the medication, and nursing students learn to deliver it to patients. Not much attention, however, is paid to the systems needed to link these functions, and the healthcare students, into a coherent, integrated, and safe system. In addition, the recognition of the system as a source of error is generally not addressed in the training of students. Instead, students are trained to individually meet their patients’ immediate needs while working around recurrent system problems, ambiguities, and inefficiencies.

Continuous improvement requires systematic problem solving, the application of systems engineering techniques, operational models that encourage and reward sustained quality and improved patient outcomes, transparency on cost and outcomes, and strong leadership with a vision devoted to improving healthcare processes. Healthcare professionals have a tremendous need to develop expertise in the fields of healthcare quality and patient safety. These relatively new disciplines have emerged as central to the development of safe, patient-focused care and require knowledge and skills not currently included in standard curricula.

Unfortunately, traditional teaching methods are inadequate. The ultimate goal of the Telluride Experience (TTE) curriculum was to change the current culture of error and create continuously learning organizations capable of generating and transferring knowledge from every patient interaction to yield greater performance, predictability, and reliability. To make this happen, educational strategies needed to involve both content and effective learning methods. Although instructional methodologies in health science schools have somewhat shifted from a teacher-centered pedagogical approach to a more student-centered approach, there is still something missing. In an ideal teaching and learning situation, the student becomes an active learner and constructor of knowledge instead of a passive knowledge receptacle, and the teacher becomes a facilitator and guide rather than someone responsible for simply relating facts.

One of the most striking areas of curricular reform applicable to the patient safety education challenge has been labeled the soft sciences of medicine. Eddy noted, “Approximately 19% of what is practiced in medicine is based on science, and the rest is based on soft-science.”⁴ The soft science of medical practice can include communication, leadership, collaboration, personal clinical experience, and patient relationships and any other non-basic-science knowledge or skill. Loeb (2004) suggested, “Not all decision making in medicine is grounded in scientific fact and clinical evidence; opinion plays a significant role in medical decision making.”⁵ From the beginning of TTE, stories provided a foundation for learning. Inviting patient advocates to share their stories on film and in person was an obvious next step.

Inviting Patient Advocates as Faculty

The Telluride “Aha” moments relate to open and honest communication and transparency. Young learners through the years have had the opportunity to work 1:1 with patients and families who have experienced medical error. In addition to improving the traditional communication between caregivers (eg, reporting, shared decision making, just culture, respect), Telluride provided an unheard-of opportunity to discuss medical errors with real patients and families, so they better understand the multiple breakdowns in care that led to that preventable harm. During these learning sessions, fears and barriers were brought to the forefront for open discussion. Having patients and advocates become an important part of the learning team enhanced the discussions and ultimately transformed the Telluride learning experience.

Each year, the demand for a seat at the Telluride Experience has grown, and as a result, training sessions have expanded to additional locations in Napa, CA; Ellicott City, MD; Doha, Qatar and Sydney, Australia. See Table 25.1. The learners who attend the sessions complete an application and are chosen based on a history of leadership in their young careers. The curricular topics discussed at TTE are designed and developed specifically for this program. Multiple individuals from various health science disciplines, patient advocates, and safety and quality experts participate in the development of the educational platform (see Figure 25.3). This method of development was chosen to ensure that the educational content is representative of all health science disciplines and includes multiple expert perspectives on the educational experience and student learning. Additionally, this curriculum development technique ensures that content is not recycled from existing programs; rather, the content represents the most up-to-date patient safety and quality knowledge and practices.

The curriculum includes training in the following arenas:

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  Patient safety and error science

  
  
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  Interdisciplinary teamwork and peer-peer communication skills

  
  
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  Effective communication skills related to unanticipated patient care outcomes, patient harm, transparency, disclosure, apology, and early resolution models

  
  
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  Leadership, mindfulness, and professionalism

  
  
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  Informed consent/shared decision making

  
  
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  Resilience science

  
  
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  System error and human factors engineering

  
  
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  Creating a just culture within the concept of personal accountability

  
  
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  Quality improvement tools and techniques.

Armed with this new knowledge, learners go back into their home environments to “infect” others on patient safety, risk reduction, and quality improvement strategies for better patient care outcomes.

There has been a movement in healthcare toward the honoring of stories within the process of delivering care. The intent varies, depending on the hospital or health system, but the outcome of connecting the heart with the head serves as a reminder to healthcare professionals as to why they chose to dedicate their lives to the caring of others. For example, stories can serve as vehicles for culture change—introducing difficult topics up for conversation that healthcare professionals can experience from a safe distance. Stories of patient and provider harm, like that of Lewis, Michael, Josie, and Annie that follow, allow readers and viewers to live vicariously through the actions and experience of others. Newer to the healthcare story scene are the stories told by practicing healthcare professionals of their own experiences. While Atul Gawande and others have eloquently set the stage for this genre of storytelling, healthcare colleagues are growing in rank as valued storytellers, blogging, tweeting, and serving as contributing authors across the country. Stories can also be shared within health systems in the form of good catches, near misses, unsafe conditions, or harm events as a tool for recognition, while at the same time allowing for learning around the strengths and weaknesses lying deep within a health system before a patient or caregiver is harmed. These stories can not only offer insight to faulty systems processes, but also a route to healing for all involved when care does not go as planned.