Yesterday morning while waiting in line at breakfast, I encountered a man by the toaster who was toasting 3 slices of bread. He was reaching to grab in one piece of bread and accidentally dropped the toasted piece onto the floor; he quickly bent over to grab it and looked at me and said “10 second rule, right?” and put it back in the toaster. Well, clearly I didn’t say anything (to be fair I was just having my first sip or two of coffee) and then he put the piece of toast back into the toaster. So now everyone after him who used the toaster has unknowingly accepted that same decision, and that will be true at least until the machine gets washed.
While this seems like a trivial incident, I think it’s almost a metaphor for complacency sort of like the story that David was telling about his friend Darrel. When is it the right time to speak up? When is it “worth” the hassle? After attending Telluride, it feels empowering to be reminded that it is always the time to speak up and make the right decision when it comes to patient safety. Knowing that there are others who are fighting the same fight and knowing that you will help create a culture change by advocating for your patient makes it feel easier to make the right call.
But how do we hold ourselves accountable to translate all that we learned into actions when we get back? Back to the task-centric environment, long shifts, and overworked team. In thinking about my own strengths and weaknesses, I think the way to continue moving forward on this journey for me is to will focus on being a consistent and clear communicator. By laying the groundwork for the team dynamic, establishing an open and honest environment, and encouraging everyone to use their voice and question their concerns, I hope that I will lay a framework for others to follow. As I move into the role of team leader as the senior resident in the upcoming weeks, I expect that the results will be imperfect, but my hope is that each person after me improves on this foundation. What it comes down to is that when we don’t all have the same principles underlying our actions and goals, then every little decision matters. Definitely this is true in healthcare, certainly feels true in the above installment of the hotel toaster saga. In all aspects of healthcare, so much of what we learn—both in terms of what to do and sometimes more importantly what not to do—we can eliminate inconsistencies and potential errors at least by working to establish a shared foundation of principles, ideas, and goals that will ideally guide all of the countless decisions that each member of the team makes. Imagine all the decisions that goes into caring for each patient for a single day, think of all the caregivers from dietary to janitorial staff to nurses/pharmacists/physicians and learners of every level. We all have countless decisions that affect our patients, and while I can’t immediately make institutional change, I can start by instituting what I think are positive changes for my own team.