May 21, 2009

A Hospital-Based Chapter: Members and Meetings

Aultman Hospital is located in Canton, OH. It has 682 beds, more than 550 active physicians in 43 different medical specialties and a staff of more than 5,000 employees, Aultman is Stark County's largest hospitaland largest employer. Aultman is a separate entity from my medical school. It is actually one of a number of hospitals in Northeast Ohio at which we have the opportunity to rotate. The hospital has its own training programs in nursing, physical and occupational therapy, etc.

I did a number of my third and fourth year rotations at Aultman Hospital. During this time period, the medical education staff and I grew to know each other and each other’s interests quite well. When the opportunity to start a chapter of the Open School was presented to me by one of Aultman Hospital’s physicians, I knew that Aultman, because of its positive learning environment and drive to constantly improve upon an already established high quality of patient care, would be a great place for the Open School.

At the time, the Aultman Chapter was unique in that it was one of the first hospital-based chapters of the Open School. Because of this, it presented unique challenges as well.

As stated above, the hospital had students apart from those of my medical school. The thought of a hospital-based chapter was exciting to me because of the opportunity to work with students from other health fields. The challenge was and continues to be the fact that schedules and interests between groups of health professionals and health professionals-in-training vary widely.

Initially, I dealt with this challenge by using my advisors’ connections at the nursing school to get in touch with nursing classes which dealt specifically with issues of quality improvement and patient safety. Honestly, I was not sure how nursing students would approach the meetings. I was a student with interests in helping to improve patient care, and my hope was that there were some nursing students with similar interest. At the meeting, itself, I got the sense that there were 2 groups of attendees – those who were present because of their interest in the subject and those who were present mainly to fulfill class credit. Nevertheless, both groups found common ground in the discussion of clinical cases. For instance, one of the main topics of discussion was the differences in the type of patient care that was taught in classes and that which was witnessed during clinical rotations.

Finding members from the medical school, itself, was a different issue altogether. Having obviously been an M1 or M2 myself, I knew that discussion of clinical cases may find some interested students, but medical students at that level of training have not yet had clinical rotations. Further, many of the students really are worried about 2 things: exams and building CVs. I could not promise that the topics we cover would be on Step 1, but I could promise them that I would work very hard to involve them in a research project that was both interesting and applicable to daily practice. The medical school Open School “kick-off” occurred about one month after my meetings with the nursing students. Jordan Bohnen was invited to speak about his experiences in the field of QI/PS as well as with the IHI. A meeting was scheduled a month later for interested students. And, at that first meeting, the goal of a research project was discussed with input from those present. Next, details of the research project were hammered out between my advisors, the group’s VP, Holly Dyer, and myself. Finally at the second meeting with the medical students, the research project was established. Responsibilities were assigned, etc.

At the next meeting, the groups of nursing and medical students will be combined and the discussion will include the research project (as well as inviting interested nursing students to help), a broader discussion of the research topic (medication compliance and management), and discussion of topics such as QI in the curriculum and clinic cases. My hope is that the merging of the groups will be seamless. Though, that remains to be seen…..

So, what worked?

1. Finding common interests and allowing your audience to see that you, the chapter leader, are passionate about the very topics you are asking them to care about. The fact that people are showing up to meetings may mean many different things: fulfilling class duties, merely building one’s CV, or even deep interest in the quality of patient care. Nevertheless, keeping a captive audience and then keeping a captive audience coming back means more than merely being animated and interested - it means keeping things interesting for them too. Leaders must show their passion and even infect others with it!

2. Network. On several occasions, at both the hospital and the medical school, I was introduced to people who grew to become very involved and important people to the chapter. These people who I speak of are extremely interested in the quality of patient care and very passionate about the topic. Further, they too understand the importance in sharing this passion with others. The thing is – I was introduced to them by people who were only slightly interested in IHI and in patient care. Therefore, I quickly learned that the networking I do may not directly improve the Chapter, but it may do so indirectly. In other words, it may not be who you know that is important, but who knows the people you know!

3. Assign responsibility. You cannot do it all alone – although, if many of you are like me, you may want to. The individuals in your group have their own gifts and talents and are hoping to use them. Some are organizers, budding web-designers, meticulous note-takers, etc. Ask who wants to help and allow your members to gain your trust. They will end up feeling like they have a personal stake in the Open School and, hopefully, that personal stake will quickly transform into a passion to achieve the ideal of perfect patient care.

4. Lastly, stay organized: away from and then during meetings. As I mentioned earlier, people have schedules and other responsibilities. My medical school and Aultman Hospital are about 35 minutes apart from each other. Therefore, people may be traveling quite a ways to attend my meetings. I do not want to waste their time by fumbling through documents, and I most certainly do not want meetings to lose focus. The opportunity for everyone to be in one room together may be rare and many goals can only be best accomplished while everyone is in the same room and able to discuss – ie. not through e-mail. Face to face is better than e-mail. It creates community. It allows people from different backgrounds to get to know one another. So, create an agenda, email the agenda to your members prior to your meetings, and do your best to follow that agenda during the meeting. Limit the official length of meetings to an hour and if the meeting goes over that time-period, invite those who must leave to leave and promise to inform them about the meeting's subsequent events through e-mails or phone calls.

Now, quickly, what did NOT work. Of course, these things may work at other hospital-based chapters, but did not work at mine.

1. Posters, stacks of free informational handouts with contact information. There is so much visual “noise” at the hospital that these things tended to get lost amongst the posters of events for CME credit, daily lunch menus, resident block schedules, computers, notes to staff, random Post-It notes on walls, etc.

2. Conversations based on e-mail, alone. Most of my conversations to gain interest that occurred only by e-mail turned up as empty leads and wasted key strokes. One is better off setting up face-to-face meetings – even for 15 minutes – in which one focuses on 3 things: what the IHI Open School is, how it will benefit the student, how it will benefit the hospital.

3. Letting meetings run themselves. Meetings absolutely need goals and these goals need to be accomplished. At the very first meeting of the Open School, I made the mistake of letting the first half be too open to being driven by the conversation alone. My original goal was to let everyone get to know each other through conversation, but what resulted was less than perfect. The first half of the meeting was aimless and nothing was accomplished in terms of setting the tone for the Chapter or even dispersing information about my goals for the Chapter. I cannot even recall what the discussion was about – but I do remember the emptiness I felt when that conversation came to its natural end. So, create an ice-breaker, if you must, but do understand that your members will feel more positive about your meetings when goals are established and eventually accomplished.

What worked and what did not work at your chapters??

My next post will focus on the topics of the reaction to my Chapter in the medical school and hospital community and transitioning from one Chapter Leader to the next.

Government Reports Criticize Healthcare System

I came across a recent article in the New York Times that discusses the fact that american healthcare has in fact not made that much progress in quality improvement, that the disparities gap is not narrowing, and that patient safety may be declining. This report was released by the Agency for Healthcare Quality and Research.

This raises several interesting questions regarding the impact of interventions such as the campaign to save 5 million lives, CVL checklist to decrease catheter related infections, the introduction of rapid response teams, and numerous other quality interventions in the inpatient and outpatient arena. We should certainly be better off than we were a number of years ago.

Clearly shows the need for the Open School and the need to train agents of change among the next generation of health professionals so that quality improvement and patient safety are principles that are taught in school and connected with patient and system examples during the clinical years and beyond. The need for formal curriculum is quite evident at this juncture.


May 20, 2009

Teach Us How to Let Go

In life, some skills are taught. They are passed down through parents, friends, and teachers. These include how to swim, ride a bike, multiplication, and even basic things like eating. And then there are some things that do not have a formal teaching process. We move through life reacting and observing to pick up these untaught skills. Building experience that will prepare us for the next time. One of these untaught skills is how to deal with the end of life.

It's a sensitive topic. The end of life means death is at the door, which carries with it for all involved a wide array of complex and oftentimes painful emotions. I'll admit that it has taken me at least 10x longer to blog about this topic compared to other posts I have written. In health care, the topic of end of life is very sticky.

Health and medicine is conventionally about curing illnesses, fixing problems, and prolonging life. And many of us enter the field of health care for those very reasons. However, end of life care makes most health care providers uncomfortable because it throws a twist on a core belief: medicine allows people to live life to their fullest potential.

In a WBUR special titled: "Quality of Death: End of Life Care in America: Inside Out," Jim Conway, an IHI Senior Vice President and chair of Massachusetts' Committee on End of Life Care, said, most in health care believe that "doctors are not in the business of death, they are in the business of hope." If I am not feeling well, I do anything possible to feel better and reach out to medicine for help and hope. When I've caught a cold and have difficulty breathing through my stuffed nose, I take some pills to decongest my nose. If I'm experiencing lower back pain, I seek physical therapy to help realign my hips and spine. In these cases, the medical remedies are restoring or enhancing my ability to live my life to its fullest potential. As Dr. Jim Januzzi was quoted saying in the WBUR special, "The default is to do everything. Americans view medicine as a way to avoid deaths."

Medicine is a business of hope. That's what we've been trained to believe. George Annas, Boston University professor of health law, as quoted in the WBUR special explains, "The longer we live the less comfortable we are with dying; the more we fear it and the more we look to medicine to try to cure it." Jim Conway, counters this conventional notion by stating, "A respectful death is also a form of hope." In our fear of death, we place great effort in treating people during the final weeks and months of their lives. What we often don't realize is that in doing so, we are exposing these people to unnecessary pain and suffering.

When is the right time to stop aggressive treatment? When should palliative care begin? Palliative care aims to increase comfort while giving patients and their families the opportunity to explore treatment options beyond aggressive medical care. It also helps patients and their loved ones come to terms with the inevitability of death. Palliative care includes pain management and psychological care.

From a numbers perspective, palliative care makes sense. Studies have shown that while the majority of people would like to die a quick and painless death at home surrounded by family and loved ones, 80% in the US die in hospitals, sometimes hooked up to machines. Studies have also shown that when patients are started on palliative care at an earlier stage, they use less medical care and are more satisfied in their final months. A third of Medicare's annual budget is spent on the last year of life. That's about $144 billion. 70% of health care costs are for the elderly. Unfortunately, the amount of care received does not translate to better outcomes. Research has shown that greater intensity of care at the end of life is not better for these elderly patients, but is actually worse care.

Palliative care also makes sense through the lens of patient-centered care. Elderly patients in seeking aggressive treatment oftentimes bounce back and forth between hospitals, nursing facilities, or home. Many times, the treatments leave patients feeling confused, agitated, and sick. Studies have shown that when patients and their loved ones discuss end of life issues early on, the patients are more likely to have a comfortable death and their loved ones are less likely to suffer from prolonged grief and depression.

However, despite all of these rational reasons, I think it is still easier to talk about treatment options instead of palliative care and hospice options. Health care tends to attract type A overachieving personalities. So, how do you train future health care professionals to understand that palliative care does not mean you are giving up or that you are accepting failure? How do you let go? How do you make the transition from treatment to comfort? When is the right time to make that transition? It's not easy as a family member to watch loved ones pass, so I'm sure it is just as difficult for health care providers. I am no where near practicing medicine on my own, but I am already dreading the time where I'll have to initiate the palliative care conversation with my future patient and his/her family.

This complicated situation really should have a manual, but none exists. Since there is no manual, we must rely on experience. But, we can't wait till we start practicing independently to begin learning how to navigate these situations. Conversations about end-of-life care should be happening now while we are training. We need to experience it before we start running the show. End-of-life care should formally be included in our curriculum. A rotation in hospice or a nursing facility? We should all have the privilege to join a care team that is caring for an elderly patient nearing the end-of-life. At the very least, our professors and mentors should not hesitate to initiate discussions about end-of-life care with us. Only with this experience and support will we be able to deliver the care our patients truly want and deserve.

Help us build our experience. Prepare us for the next time.

Listen to the WBUR special titled: "Quality of Death: End of Life Care in America: Inside Out. In this documentary, special correspondent Rachel Gotbaum investigates end of life care in the US. What prevents many patients from having a dignified death? What kinds of challenges do patients, providers, family, and society face when dealing with end of life care? Click here to listen.

Talk Health IT with Dr. John Halamka and Dr. Brian Robson on WIHI

Did y'all get a chance to tune into WIHI's discussion about hospital readmissions with Dr. Amy Boutwell and Dr. Thomas Lee? If you did, I'm sure you can't wait for the next installment of WIHI.

Well, you need not wait any longer! Tune in TOMORROW with Madge Kaplan for a discussion on Health IT and electronic medical records (EMR) with Dr. John Halamka, Chief Information Officer of Beth Israel Deaconess Medical Center, and Dr. Brian Robson, Clinical Director for eHealth across NHS National Services Scotland, at 2PM. Don't forget to register here.

Just a reminder:
WIHI is an exciting new audio program from IHI. It’s free, it’s timely, it's interactive, and it’s designed to help dedicated legions of health care improvers worldwide keep up with some of the freshest and most robust thinking and strategies for improving patient care.

Each episode is 60 minutes and there's a new broadcast every other week. You can listen to WIHI live— via computer or telephone or both — or you can download an archived audio file for listening later (see the Technology tab for more information). All you need to do is register in advance.

The WIHI broadcasts will be hosted by IHI’s Madge Kaplan, who brings a wealth of experience to WIHI from her years reporting on health care for public radio. IHI’s Director of Communications since 2004, and the regular “voice” of the 100,000 Lives and 5 Million Lives Campaign conference calls, Madge is known for her ability to create a shared space for lively and enriching discussions.

Click here for more details about registering and listening in on WIHI.

Past WIHI broadcasts are archived and available for download here.

May 19, 2009

Health Reform: What Can YOU Do?

President Obama said X about health reform. Secretary Sebelius makes Y announcement about health reform. Senators Baucus and Grassley consider Z, A, B, and C in regards to cost-saving and health reform. Finally, physicians, employers, nurses, insurance payors, and many other stakeholders are sitting at the same table to discuss health reform. But, what can you do?

Join this free webinar hosted by The Commonwealth Fund and the Institute for Healthcare Improvement this Friday May 22nd, at 11AM to discuss how physicians and others can help create a health care system that offers high-quality, affordable care for all Americans while containing costs. Click here to register. Panelists will include:

The panelists will address quality improvement, integrated delivery, and payment reform as well as cost-saving measures that can help finance the coverage of the uninsured. Don't miss out and hope to see you on the webinar!

JAMA's "A Piece of My Mind"

What do toenails have to do with patient-centered care? Read last week's "A Piece of My Mind" column titled, "Beyond the Numbers," written by Dr. David Wu in JAMA here and share you thoughts on the blog!