A New Generation of Physicians Matures into Patient Safety Leadership

Kerin Torpey Bashaw, MPH, RN, Senior Vice President, Department of Patient Safety and Risk Management, The Doctors Company

When New York University Langone Health radiology resident Luke Ginocchio, MD, returned to work after attending a renowned patient safety academy, he implemented a CT protocoling system for ED patients that reduced diagnosis delays and led to greater radiology resident satisfaction.

Dr. Ginnochio was one of several residents from New York hospitals who participated in this year's Academy for Emerging Leaders in Patient Safety in Napa, California. He was joined by Nicole Infurno, MD, a pediatric resident with Jacobi Medical Center in the Bronx, and Rajat Thawani, MD, an internal medicine resident at Maimonides Medical Center in Brooklyn, and nearly 100 other physicians from across the country.

Also known as the Telluride Experience, the academy offers a multiday immersive patient safety learning experience for healthcare professionals—all of whom make a commitment to complete at least one project to improve patient safety in the field.

For some participants, Telluride offers a first look at the clash between best patient safety practices and long-established medical cultural norms. Dr. Ginocchio said, “My biggest takeaway from the experience was learning how to best address avoidable medical errors by coming together with leaders, educators, and advocates in patient safety to discuss the challenges inherent in the culture of medicine and forming a community for the dissemination of ideas and potential collaborations.”

In addition to Dr. Ginocchio’s quality improvement project, some Telluride alumni return to their home institutions and create an in-house patient safety curriculum. Dr. Infurno was inspired by stories of patient harm to create patient safety training for her peers.

“By meeting the parents, spouses, and family of those who have suffered harm by the hands of medical professionals and hearing their stories, it became more and more clear that there are even greater issues in our medical system than I previously recognized,” she said. “I have learned that there are significant gaps in proper patient safety protocols and many systematic problems that can potentially lead to medical error. This has had a profound impact on the ways I wish to practice medicine.”

Dr. Infurno sees her growth as a patient safety professional as intrinsic to her medical career. “I hope to continue practicing medicine in a facility that sees patient safety just as important as I do.”

Noting the well-established influence of emotion on learning and memory, the Telluride Experience lets students hear directly from the family members of patients who have suffered harm through medical error. Then, using direct experience to help students retain what they have learned, the interactive program uses simulation to train future healthcare leaders in risk reduction and quality improvement.

Some Telluride students are both healthcare professionals and family members of patients harmed by medical error. These participants bring a unique perspective and sense of urgency. For instance, Chicago-area pharmacist Soojin Jun, PharmD, was a Telluride participant and said her father’s death was accelerated by poor care. “I became a pharmacist because of how my dad was treated—I wanted to be a part of change.”

Dr. Jun has taken her passion for patient safety to another level by accepting a position as a regional chair for the Patient Safety Movement Foundation. She is also involved with the Institute for Healthcare Improvement’s Quality Improvement Advocates Initiative.

For Dr. Thawani of Maimonides, these personal stories about adverse events “had a deep impact.” Knowing that gaps in communication can contribute to patient harm, after participating in the Telluride experience, he said, “I will definitely work on my practice to develop and ensure patient safety and effective communication.”

The Telluride Experience, approaching its tenth year, has grown into a multistate, multinational presence, offering courses in locations including Washington, DC; California; Australia; and Qatar. The Doctors Company Foundation, created by The Doctors Company, the nation’s largest physician-owned medical malpractice insurer, is among several sponsors. The foundation has committed to its tenth year of funding the Telluride Experience, totaling over $1 million. The program has graduated almost 1,000 students.

Some physicians who attended Telluride in its early years, when they were residents, are now in leadership positions at their home institutions, according to David Mayer, MD, a founder of the Academy. Dr. Mayer said that the healthcare environment has seen growth in patient safety awareness over time, as reflected in the decline of certain injuries and complications: Central line infection rates are down, for instance, as is sepsis mortality. Also, students now tend to arrive at the program with more baseline patient safety knowledge than before, so in response, Dr. Mayer said, “We’ve adjusted our curriculum.”

Dr. Mayer sees in practicing physicians today “a growing theme around patient-family partnership and collaboration.” He said, “You see the energy and passion of the next generation, and you think, ‘they really get it.’”

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