Learning from Adversity

Dear Friends,
I want to share with you an adverse event that I experienced almost nine years ago, which resulted in a major re-direct in my career and that served to define my approach to change.
On November 18, 1999 I was providing anesthetic care for a 37-year-old woman undergoing a total ankle replacement. I placed a popliteal fossa nerve block preoperatively with Bupivicaine and there was no deviation from the standard of care.
Within moments, the patient experienced a grand mal seizure and progressed to cardiac arrest. After approximately ten minutes of resuscitation the patient remained unresponsive. A fully prepped cardiac operating room was fortuitously available and our patient was rushed into the room, where she underwent a sternotomy for emergent cardiopulmonary bypass. The patient’s cardiac rhythm was restored and after being weaned off of the bypass machine she was taken intubated to the cardiac intensive care unit (ICU).
As is typical during medical emergencies, we were focused on the resuscitation with our emotions on hold. Only after the patient had been stabilized on bypass did the impact of what I had just done begin to sink in. I felt personally responsible for what had happened and compelled to communicate with the family. I thought I would be able to provide a factual account of the event to the husband but to my shock, the husband came at me with full emotional and physical force; fortunately the orthopedic surgeon intercepted him. I was now forced to confront my own emotional distress and I realized my complete lack of training in how to manage this situation. In an instant, the years of clinical training, my board certification and the respect of my colleagues as a competent anesthesiologist had become irrelevant and meaningless. I felt lost and alone.
The following day I was doing cases as though nothing had happened. No one mentioned the event as I performed my clinical duties with numb detachment.
In spite of multiple attempts to speak with the patient, there were three communication barriers: 1.) Risk management’s request that I leave communication with the patient to them; 2.) The ICU team’s desire not to be pulled into the aftermath; and 3.) The husband’s request that I keep my distance. When the patient was discharged home ten days after the event without any opportunity for me to communicate directly, a profound sense of responsibility broke through my fear and compelled me to write the patient a letter of apology with an invitation to open communication if and when she was ready.
Six months after the event, Linda Kenney called me in Seattle. This was Linda’s first opportunity to hear a factual account of the event and when Linda surprisingly offered me forgiveness, I felt an incredible emotional release. I had my life back and I could talk openly about what had happened. We met in person two years after the event, and as Linda described her frustration and anger at my institution’s refusal to communicate with her about the event, two things stood out for me: 1). That healthcare had strayed from compassionate care in a profound way; and 2). That the wall of silence that was there to protect against lawsuits was in fact a major contributor to them. I began to recognize that in addition to a gaping hole in the emotional support for patient’s and families that there was also very little support available for caregivers following adverse events. It was time to do something about this.
What followed was my commitment to be a voice for doing the right thing and to take courageous action in transforming healthcare, however remote the odds of success might appear. I supported Linda with the founding of Medically Induced Trauma Support Services (MITSS, see www.mitss.org), an organization whose mission is to support healing and to restore hope to patients, families and clinicians impacted by adverse medical events. At the same time, I took action within my hospital to create the Peer Support Service, a service that utilizes trains caregivers to provide emotional “first-aid” to colleagues involved in adverse medical events. Initially the climate was anything but receptive to these ideas, however, with commitment and perseverance what resulted was a gradual and steady recognition that the patient safety movement had to incorporate support into its improvement initiatives if it was to achieve sustainable change.

“They didn’t know it was impossible so they went ahead and did it” – Mark Twain

I have had the fortunate opportunity to do presentations on Peer Support at a national and international level over the past several years. These presentations have provided me with continued exposure to the latest developments in patient safety and quality. I have observed the increasing complexity with which the challenges are being addressed and the myriads of methodologies that now exist to solve our safety and quality woes. While there have been successes, what is now becoming apparent is a frustrating absence of sustained change and improvement. Things really aren’t getting a whole lot better and I started to become acutely aware that much of what hospitals are advertising as major improvements in presentations and publications is not visible at the level of patient care. Why?
I started to develop an interest in systems and process improvement and scrutinized improvement initiatives that were ongoing at my institution as well as others. I knew that there was some important connection between the work that I was doing with MITSS and in Peer Support and systems improvement but the link remained elusive for quite some time. Out of synchronous circumstances I happened to take a 10-day training offered by David Dibble titled “The New Agreements in the Workplace.” The core concepts for achieving sustainable change were simple and comprised of four things:
1. Find your purpose
2. Love, grow and serve your people
3. Be a systems-thinker, and
4. Practice a little every day.
I progressed through the initial few days of the training thinking that I already knew the curriculum, and I was happily validating my foundation of expertise. However, it started to dawn on me that I was anything but expert and that a lot of what I thought I knew was based on a wonderful set of incorrect assumptions. To my great surprise, I discovered that I was systems illiterate! What I was viewing as systems (IT systems, pharmacy, infection control, medical records etc.) were in fact macro systems far beyond the level at which change initiatives had to occur. I chose to participate in the remainder of the training with an open mind and as I continued to learn I suddenly saw the connection between peer support and systems thinking as critical elements to the transformation of healthcare.
We spend an enormous amount of time and effort in healthcare training our people in a fragmented manner about team building or process improvement. On the team training side, methodologies such as Good to Great or Crucial Conversations are sold as the magic bullets to safety or quality improvement. On the process side, we are introduced with great zeal and zest to complex methodologies such as Six Sigma, Lean Sigma, Kaizen and TQM. While all of these approaches are wonderful toolsets in the abstract, they produce very little sustained success, much to the frustration of their creators, to the consultants and to the client organizations. When we look at how they’re being implemented and by whom, it becomes very apparent why this is so.
There exists a universal systems principle that states that everything is connected. We have become so good at fragmenting healthcare into sub-subspecialties that we have in large part forgotten this key principle when we take care of patients. Everyone thinks that his or her focus is most important and the result is that nobody sees any connection in what they do to anything else, least of all the patient. This attitude transfers to the majority of improvement initiatives currently underway. It’s either team building and communication or process improvement. Then we take quality improvement away from the people doing the work at the frontline and relegate quality improvement to the “experts,” our quality departments and our patient safety offices. The simple reality is that it takes a compassionate and supportive work environment to create a foundation for teamwork, a methodology for applying systems improvement that is simple and accessible, and quality improvement has to be returned to the frontline people with the support of leadership. This is my purpose.
Chances are that most hospitals, consultants and process improvement gurus will posit that they incorporate all of these elements into their programs. What I believe will become uncomfortably clear as this blog develops is that the vast majority of quality improvement is top-down driven, largely disregarding the importance of frontline input, and that we are skimming the surface of the quality and safety challenge rather than going down into the infrastructure that is unglamorous and dysfunctional to the core. Healthcare is held together by the everyday heroic work arounds of the caregivers, who do everything in their creative power to see that patients get the care that they deserve. Everything is connected folks and until we start addressing the broken platform that supports the shiny, high tech side of care, we are going to continue on our stagnant path.
This blog is going to educate with stories from the frontline of care. This will not be a gripe site but rather one that shares the truth with compassion and with the intent of improving healthcare. This is not about finger pointing or about making any institution right or wrong – every hospital in America has the same challenges and what we need is the courage and the commitment to recognize this and to step up to do the right thing. Off we go!
With love and respect,
Rick