Positive Example to Bring Good Cheer to the Thanksgiving Holidays

Wow!

As a med school student, we are constantly reminded that we know nothing. Perhaps this is to motivate us to stay awake during the wee hours of the night to learn the muscles involved that help us point our feet (plantarflexion) verses flexing our feet (dorsiflexion). In any case, being at the bottom makes us feel useless. Where are we supposed to direct our do-gooder energy in the two years we are stuck in the lecture halls?

Below is a great example of students making a positive impact on patient care. Are you a health professions student and want to make a positive impact? Join the "Check a Box. Save a Life." student campaign to improve the safety of surgery.

How Undergrads Make Doctors Wash Their Hands: "

Doctors and nurses don’t wash their hands as often as they’re supposed to. So we were interested to read about a program at UCLA Medical Center that managed to boost compliance with hand-washing guidelines from 50% to 93%, according to a paper published today in the journal Academic Medicine.

The trick was getting undergrads to volunteer to come lurk in the hospital.

By the time the undergrad program launched about five years ago, UCLA had been trying to improve hand-washing adherence for a while, with mixed results. A program that enlisted nursing staff to conduct peer audits of hand washing led to reports of 100% compliance — despite the fact that “feedback from patients and their family members, as well as from the staff and physicians who had been patients, indicated that not all staff members adhered to the standards.”

About 20 students per year are selected for the undergrad program (described at length here), and they record 700 to 800 observations per month. They look for compliance with hand-washing guidelines, as well as adherence to rules for giving medication and handing-off a patient for surgery (adherence to those measures have improved sharply as well since the program launched).

It’s possible that hospital staff have simply learned to follow the rules when undergrad volunteers are looking over their shoulders. Still, it seems reasonable to infer that the gains measured by the undergrads is, at least to some extent, a reflection of an overall improvement. And the program is cheap — about 0.3 FTE during the first year of the program, which fell to 0.1 FTE by the fourth year.

Image: iStockphoto

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What EpiPens Can Teach Us about Human Factors and Patient Safety

Last Monday, at the University of Michigan IHI Open School Chapter November Speaker Event, we heard from Dr. John Gosbee, Human Factors Engineer and Healthcare Specialist. He gave us a brief overview of the history of human factors research in health care and also brought in two very exciting demos.



The first demo involved EpiPens, emergency treatment for individuals with severe allergies. Do you know how to use an EpiPen? It turns out, it's not very easy to learn, especially under the stress of saving someone's life! To simulate such an emergency situation, Dr. Gosbee asked us to "save his life" by reading the instructions and delivering the life saving dose of epinephrine correctly while holding our breath!

Read the full recap of our great speaker event, written by Chapter Leader Amy Silverstein, on the University of Michigan IHI Open School Blog!

A Grey’s Take on To Err is Human

Hi, my name is Eva and I watch Grey’s Anatomy.

I started about three years ago with the hotly anticipated Season 2 Finale and have been addicted ever since. I have tried to stop and had hoped that a change in environment (back in school and no TV) would stop this unhealthy habit. But, I have been unsuccessful. In fact, I believe I have reached a new level of addiction.

At the end of every episode I watch, I have been able to extract a lesson to justify my time spent following the lives of the characters at Seattle Grace Hospital. I tell myself that these lessons learned will help me become a better doctor…

For example, episode 6 of Season 6 ("I Saw What I Saw"), in my eyes, is a clear case study on patient safety and systems thinking. Let me explain.

The system at Seattle Grace Hospital: The economy has shaken the foundations of Seattle Grace Hospital. Like leaders of hospitals around the country, the Chief of Surgery has had to make some tough decisions. A solution to some of the financial problems was a merger between Seattle Grace and Mercy West, a neighboring hospital. This led to staff cut-backs and an influx of new colleagues from Mercy West. The Mercy West additions were given no formal training to the ways of Seattle Grace. Caring for patients should be the same no matter where you are, right? Compounding this situation is the distrust and tension between the staff at Seattle Grace and the staff from Mercy West because they all anticipate more layoffs.

"Survival of the fittest" is everyone’s mentality. Everyone seeks to capitalize on the other’s weaknesses. In emergency situations, patients needing care are wheeled in and taken care of on a first come first serve basis. Patients are viewed as opportunities to shine. Everyone envies the surgical resident asked to assist on a patient with tough and difficult injuries. No one takes responsibility for the patients who don’t have “cool” conditions. The episode takes place just shortly after the merger of the two hospitals.

The case: Mrs. Becker and her son were just two of an influx of patients involved in a large fire at a hotel. Mrs. Becker presented with minor burns and her son appeared unscathed. Both Mrs. Becker and her son were very scared. After an initial hurried physical exam, Mrs. Becker and her son were left alone. She received treatment for her 2nd degree burns and morphine for her pain. By the end of the night, she suffered a pneumothorax (a collapsed lung) that was emergently treated with a cricothyrotomy, and then passed away due to respiratory distress followed by multiorgan failure. A disjointed “team” of seven residents (some of whose names many are still unfamiliar with) had attended to Mrs. Becker through the night.

The episode, filmed in the Rashomon style, retells the night from several vantage points to simulate the Chief of Surgery’s investigation on the death of Mrs. Becker. At the end of the interrogation, it was discovered that Dr. April Kepner had not completed Mrs. Becker's initial physical exam thoroughly. She missed the soot that had accumulated in Mrs. Becker's airway and lungs. The soot was the cause of Mrs. Becker's organ failure.

Leadership actions taken: Dr. April Kepner was fired for her negligence.

We are very quickly approaching the 10th anniversary of the Institute of Medicine’s (IOM) landmark patient safety report, To Err is Human: Building a Safer Health System. One of the most important messages of the report was that systems failures cause most injuries, not bad clinicians. Judging by the Chief's decision to fire Dr. April Kepner, he clearly has not read the report. Dr. Kepner was not a flawed or bad doctor, she was simply forced to operate in a bad system: She was not taught how to navigate the new hospital. She received no support from her colleagues. The process of admitting patients was chaotic and disorganized. Dr. Kepner and Mrs. Becker had no privacy. And communication between all of the physicians present was abysmal. Is it a surprise that Dr. Kepner would make such a simple mistake? I think it's a bigger surprise that more catastrophic mistakes didn't happen that day. Firing Dr. Kepner would not prevent a death like Mrs. Becker's death from happening again.

Dr. Shepherd has probably read To Err is Human. He understands that every system is designed to achieve the results that it gets. To prevent harm to patients, the Seattle Grace team needs to reduce the chaos and improve their work processes in order to fix the system. A point for those who swoon over Dr. McDreamy!

To have patient safety and systems thinking be major themes to an episode of a popular television show should be a good sign of progress in the field of quality improvement and patient safety, right?

Today's health care reform environment has thankfully showcased some of the many activities taking place at hospitals and professional societies to improve health care. Signs that quality improvement and patient safety are on the national radar have been allocation of funds in the Recovery Act towards comparative effectiveness research and reduction of hospital acquired infections. How to improve the quality of health care delivery while reducing costs has also reached the national scene (addressing overuse and underuse of health care). At a more local level, actions are being taken to reduce hospital acquired infections, reduce medication errors, and standardize safer and best practices (addressing misuse of health care). New accreditation standards and regulations such as no payment for "never events" adopted by the Centers for Medicare and Medicaid Services can also be taken as a sign of progress.

But, do I feel safer or sense the improvements made whenever I interact with the health care system? As this episode of Grey's Anatomy demonstrates, tangible and measurable progress is probably still not yet within our grasp.

Once we get there, this episode should be rewritten. Seattle Grace will be a shining example of the transformation of the culture of medicine. All of the characters would not be individual heroes searching for glory, but would support each other in order to deliver better care for their patients. The Chief and hospital leadership would not bury mistakes like Mrs. Becker's death, but would take the time to identify root causes of the error and fix the system. And every single person would critically evaluate and make improvements to the complex work processes of delivering health care.



The best indicator of progress in "Grey's speak" would be a scene where Dr. Cristina Yang pouts because she was not named as the resident who discovered and made the greatest number of improvements in the Department of Surgery, rather than the fits we see her in now whenever she is not named the most technically accomplished surgical resident.

I should probably take a few seconds to look up the medical term for severe addiction now...

Join us at the IHI National Forum in December!

Check out these student-centered events!

• Apply for a student or faculty scholarship (50-75% scholarships).
• Apply for a Student Travel Stipend ($250).
• Follow the Student Track to choose your sessions.
• Submit one of the three types of Student Posters.
• Join the Forum Students Facebook Group!
• Is this your first conference? Review Student Forum Survival Guide!
• Listen to the Student Audio Advice to hear what other students say about the Forum.

Dec. 6-9 in Orlando, Florida. Join us to Re-Form Health Care.

An Economics Lesson: Local Solutions

Because I now have less time to read things that don't look like textbooks and lecture notes, I've become a frequent podcast listener. Some of my favorite podcasts are This American Life, NPR's Fresh Air, IHI's podcast, and The 10th Wonder. I have about an eight minute walk to class, so a week of walking takes me through about two hour long podcasts!

After listening to two phenomenal This American Life podcasts coproduced by NPR's Planet Money team about the rising cost of health care, I've started listening to NPR's Planet Money podcast. One of the most recent NPR Planet Money podcasts is a short interview with Elinor Ostrom, the first woman to win the Nobel Prize for economics. The podcast describes her Nobel Prize winning work: qualifying the concept of The Tragedy of the Commons.

The Tragedy of the Commons is a famous economics dilemma about shared or common resources published in Science in 1968 by Garrett Hardin. The dilemma looks like this: a large group of people, hypothetically farmers, share a common resource, a pasture. No one owns the resource and each individual farmer, acting on self-interest, will use as much of the shared resource as possible. This leads to overuse and the ultimate destruction of the limited pasture. The tragedy of the situation is that everyone loses and everyone is stuck in this unfortunate situation. Any solutions to the problem must come from an outside source: government intervention or transforming the resource from a shared one to divided private ownership. Health care can also be seen as a Tragedy of the Commons situation.

Elinor Ostrom's work qualifies Hardin's original theory. In studying farmers in the Swiss Alps, she has found communities that have been able to maintain common properties for centuries by choice. Ostrom identified groups that used these shared resources as a community. In this example, the farmers share a common meadows pasture. The environmental driver for this shared resources model is that the meadows are "patchy." Unpredictably, some parts of the meadows would be lush and perfect for grazing, and at other times, those same parts would be covered with snow. Thus, it is in everyone's best interest to share the pasture. Over time, the community of farmers organized rules and regulations on their own...a local solution to a local problem, to regulate overgrazing and maintenance of the commons. These "rules" then became part of the local culture.

Here's where the "IHI bells" began to ring in my head! Reforming or transforming health care probably operates on the same principle. At the How Do They Do That? Low Cost, High Quality Health Care in America meeting in July of this past year, one of the big take home messages that I learned was that the solutions for low cost and high quality care were local, home-grown solutions. What worked in Temple, TX was the opposite of what worked in Sacramento. And Cedar Rapids was a bit of a hybrid of Temple and Sacramento. Operating under the guidelines of critical self-evaluation of their cost and health care outcomes, each hospital referral region (HRR), developed their own solutions. And over time, these practices became part of the local culture-- "that's just how they do things."

Ostrom believes that humans are complex: we do operate on principles of self-interest, but we are also able to act for the good of the group. The solutions to our common problems don't need to be imposed upon by an outside third party, they need to come from the community experiencing the collective problem. Perhaps the role of the third party would be to facilitate community problem solving by sharing success stories and making it easier for us to learn from each other.

As I work on the Check a Box. Save a Life. initiative, I see the need to emphasize that every group of health professions students hoping to promote, implement, and analyze safe surgical practices will be faced with their own unique set of challenges. How each group of students will get involved will be a local solution. But, I do hope everyone will share their experiences. We'll take a note from Ostrom's Nobel Prize winning economics work by following the examples of positive deviants and making local adaptations to our common problem.

and Take Off!

Thank you all for joining the "Check a Box. Save a Live." campaign launch. We were thrilled to be joined by Drs. Atul Gawande and Don Berwick, as well as students from around the world.

Our list of partners has grown quickly to include students from at least 14 countries. We are very excited to be working with you on the First Global Student Sprint to Improve Healthcare.

We want to provide you with some brief information about how to proceed following the launch:

• Please visit the IHI Open School website to view a recording of today's webcast:
  
• http://www.ihi.org/IHI/Programs/IHIOpenSchool/CheckABoxSaveALife.htm
Coming this weekend to our website:

• http://www.safesurg.org/student-mentors.html
• "Check a Box. Save a Life." Pledge
  
• Online Sign-Up Sheet
• Detailed materials to help students:
• Spread awareness
  
• Promote Implementation of the checklist
• Collect data about checklist usage
• Suggestion box

For those of you who experienced a technical difficulty with today's calls, we apologize and hope that you will watch both Drs. Gawande and Berwick's keynote addresses, posted on our website.

Questions? email us at StudentSprint@gmail.com

Thank you again for joining us on this global student initiative and we look forward to hearing back from you soon.

- The Global Student Sprint Team

Transforming Leadership: From Individual Patients to the Community

About two weeks ago, I flew out to LA to take refuge from the Michigan cold. LA was unseasonably chilly, so I didn't quite get the sun and warmth that I had hoped for, but I got something better.

I attended the annual Asian Pacific Americans Medical Student Association (APAMSA) National Conference and spent my three days in LA meeting other medical school students and listening to inspiring lectures and workshops. The majority of the sessions focused specifically on health issues in the Asian American population. These include the incidence of Hepatitis B, the large number of uninsured in the Korean American community, the incidence of lung cancer, health awareness and education, and cultural competency.

California has a very large and diverse Asian population. I visited the Monterey Park/Freemont/Arcadia area on my last day in LA and could have sworn I was abroad! Because of this large Asian population, Asian American specific health issues are very apparent in California and there have been several great stories of progress. We had the privilege of hearing from Assemblywoman Fiona Ma of the San Francisco area and Assemblymember Mike Eng of the Los Angeles area describe the great strides that California has made in making the Hepatitis B issue a city-wide awareness and screening campaign (Hep B Free). We also heard from Dr. Jimmy Hara, Community Benefit Lead Physician for Kaiser Permanente Southern California, Dr. Arthur Chen, Medical Director of Alameda Alliance, Captain Cynthia Macri, M.D., Special Assistant of Diversity to the Chief of Naval Operations in the US Navy, and Dr. Paul Song, Director of Clinical Quality Improvement for Vantage Oncology who have all expanded their medical careers to address large scale efforts and discussions on how to better deliver health care, increase access, and shape national health policy. To top off this list of inspiring speakers and the many not mentioned here, our conference closed with talks from Dr. Sammy Lee, the first Asian American to win an Olympic gold medal for the US and Dr. Eliza Lo Chin, president-elect of the American Medical Women's Association.

Since most of these speakers hailed from California and have done such admirable work in the state of California, I felt a little discouraged at first. My hometown in South Florida's greatest health issues are geriatric and centered around ensuring that our seniors are able to live quality lives and obtain the health care that they need easily. My second home in Boston has nearly achieved universal health care access through its individual mandate, but now struggles to iron out the financial details of managing and continuing this initiative. And my new home in Ann Arbor? Unemployment is everywhere. I have yet to gain a better understanding of the health issues in Michigan, but my guess is that access is one of the top five concerns. With significantly smaller Asian communities in these three locales, how am I supposed to take the inspiring and encouraging words from the APAMSA conference and transform them into action locally?

The conference may have been for Asian Pacific American medical students, but the big themes of the conference were universal. The field of health care is changing as we speak and in order to prepare ourselves for the future we need to develop and transform our mindset and develop leadership skills. There are several junctions within a patient's pathway through the health care system that we as health professions students can act: from drug and medical devices development to care access to care delivery to care management. The one big thing that each of these areas of work have in common is expanding care from each individual patient, to care for a community and working with others as a team. I don't have to recreate the Hep B Free initiative in Ann Arbor. There are at least a million and one ways students can make an impact in health care. The safe surgery initiative: "Check a Box. Save a Life." is just one example (Tune into the launch tomorrow!).

As I think about transforming leadership and health care, here are a few considerations as illustrated by the Hep B Free initiative:

1) Get to know and understand your community, your team, and the "system" in which they operate and function.
Measure the burden of Hepatitis B in San Francisco, who this affects.
2) What do you want to accomplish?
Increase awareness about Hepatitis B, reduce the incidence of Hepatitis B, provide assistance to those who must manage Hepatitis B
3) How does that benefit your community and your team?
Decreased burden of disease and develop a replicable model for other cities to adopt
4) How do you develop support for your goal?
Involve community members, political figures, and anyone interested. This is a community effort that benefits the community, so the community itself should feel a sense of ownership for the initiative. To publicize the initiative and develop community support, the Hep B Free initiative hosted several dinner banquets at local restaurants with the understanding that "Asians bonded over food"
5) What kind of help do you need?
Medical support and expertise, community support, political clout, publicity, financial support
6) What's the plan and how will you execute it?
Launch educational messages to increase awareness, follow-up with health fairs that will provide screenings and vaccinations, provide information on how to manage Hepatitis B, train health professionals about Hepatitis B and how to help patients manage it.
7) How will you adapt to change?
Consistent feedback
8) How will you measure your progress?
Measure the number of people vaccinated, screened, trained, etc.
9) What kinds of improvements can be made?
Understand the best communication pathways: television/radio public service announcements, health fairs in conjunction with big holiday street fairs, transportation advertisements, how best to train health professionals, communication with public officials
10) How will you share your progress?
All materials are available on a website and direct support has been loaned to help Orange County launch a similar campaign

Don't be afraid to be creative and think out of the box! Also, words of advice from Dr. Dexter Louie, another great speaker at the conference, "Do what you can. We can't expect everyone to save the world quickly. Understand that whatever you do will be meaningful and will make a difference in the lives of others."

As I boarded the plane to head back to Ann Arbor, an idea popped into my head that I hope we as medical students can take ownership of to make positive change in our community. The Hep B Free initiative had developed lots of materials to educate their communities about Hepatitis B and the importance of getting screened and vaccinated. The area where they seemed to continue to struggle with was educating and training health professionals that would be caring for this newly informed community. Why should we wait till when physicians have begun practicing? Why not start the education process earlier?

Here at the University of Michigan, we have a curricular component called Longitudinal Cases. Every week, about ten of us meet in small groups led by a professor to discuss a case that is clinically relevant to the material we are learning in lecture. But, instead of focusing on the medicine of the case, we spend time discussing the sociocultural factors that may impact our interactions with the patient, how the patient interprets and manages the condition, etc. Understanding that our time in class is precious and that health concerns like Hepatitis B should be spread to all health professions students, why not develop a case study on Hepatitis B to be discussed in our Longitudinal Case sessions and make it a new standard addition to the curriculum? If we can make this happen, we will be expanding from individual patient care to caring for our community.