Knowing it’s The System and Not The Human

Podcast Transcript

Adrienne Boissy: Welcome to another episode of Studies in Empathy, a Cleveland Clinic podcast exploring empathy in patient experience. I'm your host, Adrienne Boissy, Chief Experience Officer here at the Cleveland Clinic in Cleveland, Ohio. I'm very pleased to have my good friend and colleague Dr. Leslie Jurecko, Chief Quality and Safety Officer. Welcome. I'm so excited to have you.

Leslie Jurecko: Thank you.

Adrienne Boissy: All right, Leslie. You are relatively new to the Cleveland Clinic. Talk to me about your background and how did you get into health care.

Leslie Jurecko: Thanks, Adrienne, for having me. Very excited to be your partner in this work we do. So, I'm a pediatric hospitalist by background and so I see kids that are treated in the hospital. And, I got into quality and safety years ago. It actually started in my childhood. When I was 10 years old, my father was in a significant accident and was a quadriplegic, so he couldn't use his hands and legs. He actually was in in-patient setting for nine months. It was quite a long experience for my father and my mother and my sister and I. And, I began, at the age of 10, noticing that health care had some pretty major opportunities for improvement. It's kind of just... When you start asking yourself why are things like this or why is there this...? Why is he suffering? Why is it taking so much time? All the questions we ask when we're patients and family members of patients.

And so, that was my first, I think, itch to make things better in health care. I didn't have much exposure to health care. My family wasn't in health care prior to that. And then, my father lived for 18 years, so there was a journey there that we... Ups and downs with that journey and when we cared for him and... And then, I decided I was going to go to medical school and very, very soon after that decided I would lead into improving health care, not only providing health care to pediatric patients, but working on improving it.

Adrienne Boissy: It's hard to even comment after you tell that story. I mean, A., thanks for sharing it with me and us. I mean, first of all, I'm so sorry, and, wow. Nine months as an in-patient. I have to tell you that in my job, when people are sitting at the bedside or going to visit their loved one, their insights are so compelling and powerful. I mean, often, they'll literally sit with a notebook and scribble about what's going on and who's coming in and what they said and what they saw. I mean, as you reflect back on that time, what could we have done better? It wasn't us, per se, but we as in health care. Like, there's 18 teams and they're trying to talk to people. What...? What do you walk away with?

Leslie Jurecko: You know, there is so much. I'll start with the really good that I walked away with and that was we developed some pretty close relationships to our nursing caregivers at the time. We still send each other cards. I keep in touch with probably, oh, five of his nurses from when I was a little girl, my sister and I do. They came to our graduation parties, you know? So, the relationship and bond with his caregivers was really... They became part of our family. They would follow up with my father after he left and I remember that making an impression on me, this kind of, gosh, altruistic way they leaned in to his care and him as a human and a father and a husband.

And... And, maybe the flip side to what I noticed is he lost a ton of his independence, if you can imagine, with him being paralyzed. Couldn't do anything. He ran a small business prior to that, a construction business, so our goal was to get him back on the construction site and leading his team. But at the time, there just wasn't that much technology. Like today, voice activation, he would have had a much better chance at kind of becoming a more successful member of society. Now, he did. He made it back to the site, but not without a lot of help. He would be there every day, but he'd need my mom or a caregiver full time.

And, I think it was the idea that he knew that's what his goal was, but I'm not sure his care team ever thought he was going to get there. Almost a little bit limiting to him and what he could achieve, what his goals might be. That was interesting to me, where I thought they would help us clear the path of how he would be able to do that, whatever accommodations he'd need to get to his goal. So, it was a little bit deflating.

Adrienne Boissy: Hmm. Reflecting on that. So, I don't know if I ever told you, but my dad died when I was three. So, we're not comparing dad stories, but my dad died when I was three and I actually never knew him and... Right? I was three. I mean, I... I have fleeting memories. But when I was older, probably about the time I was applying to med school, I... I had it in my mind that I had to write the woman who hired him, who was at the NIH. Her name was Stephanie. And, it was at a time where if you had a pre-existing illness, you didn't get hired, and he was very upfront about the fact that he had leukemia and he was dying and we had... They had moved to Bethesda.

Anyway, to get to the point, she... He had interviewed for no less than 27 jobs. Everybody said no. And, she hired him and he worked for her for many, many years and then he died. So, right when I was applying to med school, I was like, "You know, I'm going to find this woman and I'm going to... I'm going to tell her thank you." And, I did. I sure enough looked her up, found her. She had no idea who I was. And, I reached out and said, "I just... This is what I heard. My mom tells me this story about what you did for my dad and I... I want to thank you for caring about him as a human, right? Rather than a disease. And, you knew him better than I did. Like, that makes me kind of sad. But thank you for taking care of him in a way that I would have liked to have."

And, she wrote back this amazing letter about what a special person he was and she sent me his hand-typed first report of statistics. It was so touching. But my point in resonance in your story is these people who care for people that we care about, right? It's like you can't even imagine what that means to us on the other side. For me, my example was outside of health care, in his HR world. And, for you, nine months in an in-patient setting with nurses you still communicate with and stay in touch with. Like, it... That never has gone away. It didn't go away for me and it doesn't sound like that meaning has been lost on you, either.

Leslie Jurecko: Mm-hmm

And, it's happening every day here. Can imagine the lives are caregivers are touching every day across the country, not just here at the Cleveland Clinic? Really selfless.

Adrienne Boissy: And, the impact is like... I don't even know if half of them realize the impact they're having, right? Like, I... I really don't know. And, you're exactly right. It is happening every day, every moment, on every floor in every unit, this is happening to people. It could be the worst day or the best day of their lives or somewhere in between. So, thank you for sharing that.

You said that you are inspired by unlocking the hidden potential of health care organizations. I haven't heard you say that, but that's not how you talk when we normally talk. That sounds very official.

Leslie Jurecko:It does, doesn't it?

Adrienne Boissy: I mean, talk to me about what... What does that actually mean? I mean, you've been doing quality and safety for some time. You did experience as well in your prior job at Spectrum. What does unlocking that potential mean and how does that even start?

Leslie Jurecko: Yeah. It is a big statement, isn't it? I think what I want to see and I'm sure you want to see, Adrienne, is our teams being able to show up each day and be able to do the things we just talked about, those really empathetic care traits, the things... Things we want them to bring their whole self to the bedside or to the Clinic or to the procedural space. When they can bring their whole self and... And, when I say unlocking it, it's because often, I feel like we put them in a complex system full of barriers and it creates this messiness where they start by bringing their whole self and then we slowly chip away at that whole self, and... And, not intentionally, but when you're a complex system, there's... And, you get big and large. Our caregivers, we just put more, I think, curves in the road for them to be able to do things that they want to do, more obstacles in the way.

And, it can be little things that add up over time and it really does degrade the human being that they are. So, I think it's unlocking the potential for not only them helping us solve those problems, but the potential for us to actually see those problems and remove them so they can just really innately be there, be present and show up with their whole self and whole heart.

Adrienne Boissy: So, you have been talking to me and certainly at our executive meetings about just culture. And, I'm just a chief experience officer, but I've heard many of these safety terms for a long time, right? High reliability, just culture and other mnemonics over time, as I'm sure you have in experience as well. And yet, the way you have been talking about just culture recently resonates and rings a bell for me, and I want to highlight for this audience what that has actually meant. So, as an example, we are an organization that likes perfection, right? We always want to be striving to be the best. And, sometimes when problems occur, things happen, we jump on it a certain way. And, you have been really effective at sort of highlighting or talking about other ways that we might respond. Can you talk about that a little bit?

Leslie Jurecko: Sure.

Adrienne Boissy: Because I... I want people to hear your philosophy on it.

Leslie Jurecko: Thanks for asking, because this has been a leadership journey for me, to be honest with you. I think when I was a younger leader, I was pretty reactive, you know? Being in safety and quality, you hear a lot of badness happening and early on, would react and start asking questions. And, what I was seeing is what it was doing actually to the teams involved, you know, especially when an executive leader is kind of asking the why's behind what happened. And so, a couple pivots I made as I kind of matured in leadership was... One is what I call the high reliability leader and it's in that first 24 hours after, let's call it some case or some messiness happens, either with a provider, a caregiver, a team. All you have to do in that first 24 hours is care about each other. Of course, care about the patient, family that were involved, but surround each other and quite frankly, yourself, with support.

And, I use 24 hours just as a kind of gauge for me to, to... Then, after that, we can start asking the why's and saying what happened. All too often, I'll see not only leaders, but kind of peers... What happened? Because that's our... That's our normal way about it. We want to diagnose what happened. What could we have done better? And, I love that learning spirit, but right away, it's too raw. And so, if we can just surround the team, the caregivers, of course the patient and family, with support in that first 24 hours. And then, after that, we can figure out all the facts. We can figure out what did and what did not happen, how we can improve it. And so, I've really committed to that and it really keeps you from not being kind of seen as that reactive leader and it also takes a lot away.

And, I'll give you a personal example. When I was probably two years into my patient career, meaning out as an attending on my own, there was a case and it was really complex, a child case, and there was a team of us caring for that child and everything didn't go as planned and we took it really, really hard. And, I remember getting a phone call that night from actually a non-traditional leader, but someone within kind of the quality safety department. And, all they said to me was, "We have your back." You know? "Don't fear. We have your back. We know there's always more to the story."

Adrienne Boissy: Whoa. I just got chills when you said that.

Leslie Jurecko: And... And, I still remember that to this day, like, oh my gosh. The organization has my back. Because what I was saying on the way home to myself... I was telling myself all these stories, right? New attending. All of this stuff was happening and I kept thinking I'm going to get fired. I'm going to get fired. How do I rationalize all this? And so, I was really leading with this fearful... You know, just full of fear, versus when they called me and said that, it just changed my whole mindset. It's like my organization has my back. They know what we do is really complex and difficult and they knew I was not intending to do anything and the team around me was not intending to do any harm to the patient and it's a high risk, what we do. And, it changed the way I thought of these events and how I lead to this day.

Adrienne Boissy: And, you're still talking about it, right? What, like, umpteen years later? I'm going to bring my neuroscience in, so get ready. Brace yourself.

So, something that's really interesting as I was reflecting on what you were saying... You know, if you take people in trauma and crisis, right? Where they're... They're amygdala is all hijacked, right? And, the adrenaline's all rushing and we try to have a logical, fact-based discussion about what happened in a classic root cause, you're never going to get there, right? Because people are hijacked by this emotion. You said raw. I think that's the right word. But it... Even from a neuroscience standpoint, it doesn't make sense when people are in that flight or fight.

Leslie Jurecko: Mm-hmm

Adrienne Boissy: And, the other point I was thinking about is just to remind our audience that the amygdala, that part that drives that guttural, I'm going to save your life here and protect you, sits right next to the hippocampus, which is this part of the brain that forms memories. And so, within that first 24 hours, if those narratives that you were telling yourself exist unencumbered, right? Your memory of that event will be that.

Leslie Jurecko: Mm-hmm

Adrienne Boissy: I failed. Right? This person suffered because of me. I'm no good as a doctor. I... Nobody loves me. Like, wherever you take that.

And, we do have the opportunity. It's such a powerful thing when I think about the neuroscience of that, to... To mitigate that or to contradict some of that and balance that with some message of you are a good and worthy physician. You are a good and worthy nurse. And, we have your back and it's... We will get through this to get... Right? It doesn't have to be some glossy fairy tale one, but some narrative that counterdicts that will shape how you think about that forever. And, it's just what you've described here so beautifully, so I just want you to know your brain is working and it all makes sense.

Leslie Jurecko: I'm glad. Thanks for the diagnosis and thanks for the anatomy lesson.

Adrienne Boissy: Well, there might be other diagnoses. We don't have time for those.

Leslie Jurecko: Yeah. I'm not going to reveal all of them today.

Adrienne Boissy: To hone in on this for a moment, I... I don't know if you remember. There was... There was recently a case as well where we lost a patient and the physician was standing up, talking about that loss at one of our meetings, because we review these regularly at the executive team meetings, as you know. And, the physician was nearly... You could just hear in the voice, was overcome with emotion. And, sometimes I've addressed that in that meeting publicly so that we model empathy, and other times, I follow up privately. And, I followed up privately with this person in this situation and I said, "I... I just feel for your loss and I'm sorry."

And, the... The person wrote back. "I remember the name of every patient I have ever lost."

Leslie Jurecko: Mm-hmm

Adrienne Boissy: And, I don't know that people know that enough about our caregivers, right? The story you just told... I have the names of patients in frames that I've lost.

Leslie Jurecko: Mm-hmm

Adrienne Boissy: Just... Just as a reminder, as a... Hopefully it serves to remind us what a privilege it is to care for them. But it is not a loss that ever goes away for so many.

Leslie Jurecko: Correct. And, what... Especially when... And, you mentioned root cause analysis, and some of the cause analysis that we should do. Sometimes we have to do it because of regulatory reasons. We have to be very, very careful of those individuals involved. It's just not worth it and we... You know, the term second victim, which we talk about, but making them relive that over and over with the constant questioning. So, at least we can lead with that support right away. I'm glad you called them, Adrienne. That was great. I tend to do that after I hear about a safety event, too. I call them right away. I can only imagine what they're feeling that first day, that second day. So, that's what we need to do as leaders. That's great. I'm so glad you did that for that person.

Adrienne Boissy: It's not about me. I'm just...

Leslie Jurecko: No, but that's great leadership behavior to lead for a culture of safety.

Adrienne Boissy: Well, and to always stay curious and to model that, of course, for many it feels like failure. Our prior CEO, Toby Cosgrove, talked about that several times, that he, as this renowned surgeon, every time he lost a patient, it felt... It didn't matter. He felt like a failure. And, how do we...? How do we keep impacting that narrative, that despite us not being failures, but despite us doing our best...? And, if the system is not supportive, right? We may fail and, unfortunately, the consequence of that in health care, of course, is quite serious and devastating.

Let's stick on that note just for a second because I know you're interested in making sure that that process has more humanity baked in or that we're coming at it from that non-judgmental, non-reactive space. I just want to applaud you for bringing that piece to us. I heard you talk about it and you call us out, I've heard, a few times, too. And, I can be very reactive because I want us to be on top of it. But talk to me about some of the things you're thinking about changing or implementing that will help us get there in that process.

Leslie Jurecko: I think it's great, especially at the Cleveland Clinic, but elsewhere in health care, that there's a huddle process, right? To raise information up and down the organization in a timely manner. But with that becomes the information, the bits of information that then can maybe induce a reaction too quick, where the facts haven't been found. And, that's what I worry about. I... You know, here we have those six tiers, and so, by 11:00 each day, our CEO and top leadership team find out about everything that there... It's great situational awareness. Everything that has gone wrong and could go wrong. It's exactly what we want a high reliability leader to do. But then the key is what you do with those bits of information and how you act on them. Some of those behaviors we just talked about. Do you go into that supportive mode or do you go into that how could that have happened mode?

And then, often, what I see is that gets down to the front line as not, "Oh, they're caring about me." It's, "Oh no. The CEO or Leslie Jurecko, the chief safety and quality officer, they want to know what happened and why." And, it feels punitive, even if that wasn't the case, because that's what they're hearing all the way down. And, what is really, really important, and it goes back to that... The just culture, is not only that we take the time to figure out what happened when that time is appropriate, but that we know time and time again it's the system that we put our people in. It's hardly ever the human. It's hardly ever the caregiver themselves.

And, all too often, we generally want to blame a human. We do. It's just... I'm sure there's a neurological…

Adrienne Boissy: It's much easier.

Leslie Jurecko: It's much easier and I'm sure you're going to tell me that the amygdala is involved.

Adrienne Boissy: I'll spare you.

Leslie Jurecko: Or the frontal lobe. I don't know. But...

Adrienne Boissy: It's good that you know the frontal lobe, though.

Leslie Jurecko: It's just what we do and it... Because you're right. It is easier, versus actually saying, "Oh, wait. I'm a leader. I've created this system where my people are exhausted. I'm having them take care of six more patients than they normally take care of every day. Oh, and by the way, we're in a pandemic." And, you can layer on the complexity we put. So, that's kind of the behavior I want. I'm trying to shift us just a little bit [inaudible 00:22:14] on how we think through things.

Adrienne Boissy: So, you've alluded to it already and I'm going to jump right in, into high reliability and your thoughts on that. I am learning constantly from you more and more about it as a conceptual framework. And, you've also mentioned high reliability leader behavior. So, if you... I mean, if there are other ones there that you want our audience to hear, I think that'd be helpful, and then maybe lead into what does high reliability really mean for organizations.

Leslie Jurecko: Yeah. It's a really great question, Adrienne. I think a lot of organizations are confused what to do with that big term. I think there's days where I'm confused what to do with that big term. And, I would say it's a coupling of safety culture as your foundation plus high reliability. And, high reliability is really just that consistent performance each and every time. You could say it's the promise to the patient. You could say it's decreased suffering. All of those things together. And, the key about it... It's... It's behaviors that you expect yourself, your leader, your colleagues, to participate in. So, it's... It's that culture of safety, the behaviors and processes that support that.

If you put those all together, you can create a high reliability organization, and a lot of folks think to nuclear and airline industry and I try not to do that because I just think there's... There are just different. They're different in their own ways. It doesn't mean it's easier. They're just different in their own ways. And, I try to think of it in health care... And, you and I have talked about this a lot. It involves not just a typical nurse or a physician at the bedside. It involves your transport caregiver, your individual helping park cars with our valet. It stems across the whole organization. It's our finance team.

These reliability behaviors, that performance consistently over time, it all marries together to become a high reliability organization. It cannot just be your nurses doing it well. It's got to be everybody in the system doing it well for us to actually achieve that true definition.

Adrienne Boissy: So, something I've been thinking about with you, I know, and I would also just offer our listeners is it's classically talked about in the safety and quality world and yet, I think there's just as many lessons... I mean, if I were to steal your language, right? It's how do we reduce suffering every day. Right? How does every caregiver reduce suffering every day? How do we create joy every day for every patient? Those are good questions to be asking because I do feel like people aren't quite sure, with everything going on or the system that they're in, the 1,800 safety quality metrics that we have and experience metrics, what they're supposed to be doing to function, bring their whole self to work in those environments.

Leslie Jurecko: Yep. There are definitely a lot of quality and safety and experience metrics that sometimes get... And, we're... I'm guilty of it. We get too much focus. And, you know, it's been interesting lately. We've been talking, Adrienne, you and I haven't talked about this, but really some more metrics around harm and suffering and why don't we put more of that, I would say, humanize some more of those metrics. And, one of the metrics lately that I've been thinking about is that time to treat metric.

I'm sure all of you listening have had that experience where yourself or a family member is just sitting there at home. Their whole day, week, month is rocked because they are waiting for an answer. Either that's a positive or negative answer. They're waiting for a lab, a diagnosis, to get in, to be seen. I've just been thinking about that a lot and how do we shorten that psychological harm we're putting on patients. And, I know there's some measures out there to look at that, but I think that would be a really great partnership for you and I and the Cleveland Clinic to think about that deeper.

Adrienne Boissy: Ah. Well, think of how cool that metric is, right? I mean, a credit to Brian Bolwell, who leads our Taussig Cancer Institute. But with the foresight to acknowledge that what we had been doing historically as we thought about access was, did you have an appointment within seven days of discharge? You know? Did you see your primary care doc within 24 hours? I mean, it was all these different arbitrary time points. And, we added, did you get an appointment when you wanted it, to try to meet the patient where they were in terms of preference.

And then, in cancer, they had sort of that... Right. You first felt a breast lump and then how long to your first appointment? But Brian had the vision around is that even the first appointment, right? It's... That's not even the point. The point is I know... I suspect it's cancer. How do I get to when I'm going to start getting treatment? Which is actually probably the most important thing on people's minds. It's not, "Boy, when is my first appointment where I talk about what we might do?". But when is the appointment? It's a brilliant metric and we're really excited to see him play with expanding that and how could... How could we leverage that?

I think on the aspirational side of metrics, I love it and I love thinking about reduction of suffering.

Leslie Jurecko: And, absolutely. And, Brian's team, kudos to them. They are... Now, you can get an appointment with... A virtual appointment with them instantly. It's amazing. And, maybe that's not time to treat, but it certainly shortens the time to diagnosis and often shortens the time to treat, which... Yeah. They're doing amazing work and I think that's where quality needs to go. Quality, safety and experience, it needs to go into those kind of new frontiers.

Adrienne Boissy: Yep. The other one I heard from my dear colleague at Mayo, Thomas Howell, when he was articulating his wish list of aspirational goals, was around, right. What were the patient's goals and did we achieve them? You know, the patient wanted to be able to run a marathon. But if he wanted to run in a marathon, right? Did we get you back to achieving that? And again, framing those goals in the eyes of our patients is an enormous opportunity. We're far... We're not there yet.

Leslie Jurecko: No, we're not there yet.

Adrienne Boissy: All right. Talk to me about the future. I mean, you've been here now long enough, a couple months, to know that you've gotten that lay of the land. You your outside, your 90 day plan, I'm sure. You've listened. As you think about us... And, you've alluded a little bit to the future with respect to measurements. What else is on the landscape for the future of quality and safety?

Leslie Jurecko: We've talked a lot, Adrienne, you and I, about... And, others around here, about as systems are growing and touching more lives in different areas... Cleveland Clinic, of course, is spread out both nationally and internationally. But what I worry about and think about a lot is are folks getting the same care at each of those sites. And so, we talk about that reducing variability as actually foundational to that next step in high reliability or achieving even... To be able to even say we're the best place to receive care, I've got to know we're the best place to receive care everywhere. And so, I'm seeing more and more of that play out in the quality and safety world, absolutely. Talked about the work systemness, but for me, that means that my loved ones can go anywhere in our system and really anywhere across the country and receive that high quality, the safest care with the best experience.

So, that's where I think it’s going. To actually measure that, I hope the measurement gets less and less and that redundancy around this measurement gets less and less, and I do think, from CMS, we're seeing some of that already to reduce the burden. But I would love for them to do is say, "Okay, let's narrow down the work we do to quote, unquote, measure you and let's let you just do the work of improvement around that." And, I think every quality leader across the country struggles with that every day. We have so much and the paperwork of what we do versus actually being out there and improving what we can do, and you wonder, to find that... I would love to find that balance a little more on that active improvement side versus this kind of passive reporting side.

So, I think the future's going to go that way. It's certainly going to go into big data, AI. That is a frontier that will help us. I think it'll help us in the safety realm with more triggers for action. So, not relying on each other and humans as much as technology to help trigger things that we need to react to sooner. So, that... That'll be a really interesting place to go and see how we can help a patient's journey with that.

Adrienne Boissy: Yeah. You reminded of the conversation around the system that supports, and I remember reading an article about why health care caregivers shouldn't have to be heroes, right? You shouldn't have to rely on individual heroism of one single person to save a life or to do something amazing. It should be the system that supports it. Can you...? I mean, I want to just drive that concept home because I think you were talking about how complicated we make it at times with the multiple measurements and you sprinkle COVID on top and are we really creating an environment where people can be successful but not have to be heroes? Right? It doesn't depend on you, Joanie. It... We know the system is foolproof in that Swiss cheese model, but maybe you can talk through about... Have you seen that done well? You've talked through some components of that. What could we do there?

Leslie Jurecko: You'll have to help me bringing in more of the patient voice to that. So, it's all about designing systems that are truly error-proofed and reliable. A lot of our work is around that, in that socio-technical. So, how do Leslie and Adrienne show up and work with all of this equipment around and how do we make it fail-safe? So, there's a really interesting study in what they call human factors integration, but it's based on social technical science of that... You know, my interaction with technology and equipment and how we can make that as reliable and error-proof as possible.

So, that's kind of where... It's evolving into that more and more. I would say in health care, we're probably 20 years behind, as in other places have figured that out, right? Other companies, other industries, have absolutely figured that out. Automated things where they could, made it reliable. We just haven't. Part of the reason, I think, we haven't, is because we... Our consumer or our patient, we haven't maybe understood them enough to bring them into the solution. And, I know you can talk more about that. But I think that is probably the next frontier for us.

Adrienne Boissy: Well, I also think, just on that note... I also think that some of the rules around what we can know about a patient within the system have been a barrier, right? That we know a whole bunch on the marketing side and then it goes dark, essentially, once they're in the system, where we're starting over, as opposed to applying that knowledge. And, that's dictated not just by our systems. That's dictated by some of HIPAA and other things and sharing. And, I also think that patients aren't as comfortable sharing all of the information about their health with everybody in health care, right? What you might share with the HUC is different than what you might share with the clinician. I'm sorry, the unit coordinator or the patient service specialist. And so, how do we make sure that we're protecting privacy at those different levels and yet creating that Amazon-esque experience that people are being trained to expect in our world is definitely, definitely an area of need.

You talked about something I wanted to pick up on around alarms. I just want to hone in on alarms because such a tangible example is alarms, right? We did this study of alarms in our system and there were like... I'm going to make the number up. I want to say like 17,000 alarms that went off in a short period of time, maybe even more. That system, with alarms beeping and different places you have to go look... Can you comment on that? You probably know much more about it than I do, but it... It's a real tangible barrier.

Leslie Jurecko: Well, it is, and you multiply that by all the alarms in the electronic medical record now, with all our alerts happening. It's... It's compounding, absolutely. And, there... It's a real concern for not only safety leaders, nurse leaders, all of us, around which ones are the most important and prioritizing those and trying to get rid of the other ones. And, everybody wants their project or their... What they're trying to achieve to be a tie to something like a reminder, right? Because we have... But that's not actually... We get to a point where we can't, and you know this from being a neurologist, that we can only take in so many inputs. And so, we see that, especially in our ICUs. Tons of alarms and alarm fatigue and it's missing that most critical one, is our concern.

So, a lot of what we try to do is tiering and then also what I talked about before is designing systems that are automated and takes the human out of it where we can so that they can focus on... And, this is the whole thing about standardization, which can be an evil word to some people. But to most of us, standardization is about doing the things for our teammates so they don't have to think about those things, so they can use their brain and their critical thinking to think about the things we want them to think about, the tough stuff. You know, standardize where we can because that's going to free them up to not only bring their own self, but their whole brain, too, and not clutter them with other things.

Adrienne Boissy: Oh, now you're just trying to get on my good side. I mean, the phrase I think we were playing with recently, right, was standardize where we can, humanize always. Right? Like, to... Because, to your point, if we are freeing up their brain, they should be able to sit at the bedside. They should be able to hold the hand. They should be able to make that emotional connection. And, that's... In those moments is where we'll find joy and meaning and purpose, not in responding to an alarm over there, up there, underneath the bed, et cetera. It's... It... I think it's a beautiful example that you're trying to drive, particularly around high reliability, and in setting up systems to help our people.

We've talked about a lot of topics, but I want to give you a little bit of room to free associate on what do you want to share with our audience about health care, either things that are top of mind or tips you have, lessons learned. What would you say?

Leslie Jurecko: If we have all day for this. So, a couple of things. I think... You know, I can't say enough about the listening, the behavior of listening, and...

Adrienne Boissy: What'd you say?

Leslie Jurecko: Oh, you're good. You are good. So, I mean, I'll share an example and it's something I think about all the time and it's [inaudible 00:37:55] listening to your teams, your spouse, but absolutely the patient, so families and the work we do. And, I was taking care of a patient, really... I still stay in touch with them. Young baby at the time. And, it was one of those days where [inaudible 00:38:13] you could tell your team was just ready to go home. Like, they wanted to wrap up. They wanted to get their notes done. They wanted to do their thing and get home. It's just a long day and going to see this baby and the mom and you know, already we had kind of told the nurse, "You know, get them... Get... Kind of get them keyed up for discharge." You know how we do that. Like, we kind of run the list and, oh, this patient should be ready to go today, because we know all, right?

Adrienne Boissy: We are all-knowing.

Leslie Jurecko: We are... We... We are all-knowing who should go and who shouldn't. So, I go in and I see them. They have the bag out and they're packing, you know, all the baby's stuff and the mom's getting her coat. And, she's just... She looks at me and you know, she's just like, "I'm a first time mom and I know you know I'm a first time mom, but something is not... It's just still not right with my baby." And, this is seven weeks old. I could feel this tension in the air, the shuffling behind me of my team with their papers and trying to back out of the room.

And, something inside me... I don't know if it was the way I just paused to listen to what she was saying even a little bit longer, looked in her eyes. I said, "You know what? Let me just examine your baby one more time." And, I did and I looked at the nurse practitioner that was my partner and the nurse and with my stethoscope. And, a long story short, I picked up on a murmur that I hadn't picked up in the two days prior. Like, the... You know. I had examined this baby for three days in a row now and neither had the nurse practitioner. And, we looked at each other and we told her to take her coat off and keep her stuff, keep the baby's stuff.

And, we got an echo and sure enough, this baby had a critical coarctation of their aorta and...

Adrienne Boissy: Oh, I got chills again.

Leslie Jurecko: Oh, my gosh. I mean, first of all, as a practitioner, you guys all know we barely ever get to diagnose anything with a stethoscope anymore. It's CT, MRI, a bunch of labs. And, this baby was in surgery that night. I mean, it was a critical coarct and the mom... I mean... And, I kept telling the mom, and we've stayed in touch. Gosh, he's now... His birthday is this summer. He'll be four. It was her. I mean, she saved his life, you know? Because had she not raised her voice and even just communicated to me and had I not listened, of course, but it was just a moment of like, always take that time to just... It takes 30 seconds more to just listen.

Adrienne Boissy: I don't even know what to say. I can't tell you how many patients today we don't listen and plead with us to listen. And, the fact that your takeaway for our entire audience is about listening makes me heart warm. And, I would go so far as to say it is about... I'm going to sprinkle on to your story, the humility that you had, and it is willingness. If we don't have willingness, it doesn't actually matter what the person is saying if we aren't humble enough in our own space to double check or think twice or pause. And, you're working against the grain. Holding up a discharge is not a popular item for our length of stay metrics and all these other metrics that we're held accountable for.

And so, I applaud you. I think not just listening to the mom's words, but then laying on hands and stethoscopes and really listening changed a life. So, thank you. I have no doubt you've done that innumerable times. I am learning from you all the time, including today, so thank you so much for joining us, Leslie.

Leslie Jurecko: Thanks, Adrienne.

Adrienne Boissy: This concludes Studies in Empathy podcast. You can find additional podcast episodes on our website, my.clevelandclinic.org/podcasts. Subscribe to Studies in Empathy podcast on iTunes, Google Play, SoundCloud, Stitcher or wherever you get your podcasts. Thank you for listening. Please join us again soon.