Dealing with Culture Shock: The Aviation and Health Care Industries

One of my favorite things to do is travel. Traveling provides me with an unmatched exhilarating feeling of adventure. Whenever I casually walk down an unknown bustling street, my senses are overloaded with new sights and smells. This kind of excitement is unbelievably addicting. My mind just races with comments. What is that brilliant green dress she’s wearing made of? Can you really eat that? Whoa, where did all of those chickens come from? Did those kids just point and laugh at me? Is his cell phone really that tiny? Why is everyone so tall?

Do I ever experience culture shock? Sure. Every new environment will take some time to adjust to, but the challenges of getting around and living outside of my comfortable apartment in Michigan is all part of the fun of traveling.

What about the culture shock of transitioning from one industry of work into another? The University of Michigan IHI Open School Chapter’s Monthly Speaker Series guest, Gary Sculli, probably does not have many positive feelings associated with his move from the airline industry into health care. Gary Sculli is currently a Program Manager at the National Center for Patient Safety in Ann Arbor, MI. He has both extensive experience as an airline pilot and is a registered nurse.

As Sculli starkly contrasted the two industries, it was clear that the airline industry and health care were two very different beasts. While it may have been difficult for me to adjust to taking cold showers while I was in Ghana, “traumatic” would be the word I’d choose to describe a move into health care from the airline industry. Here are some differences at a quick glance.

Airlines	Health Care
Team training	Hierarchical barriers
Human Factor awareness	Human Factors NOT emphasized
Standardization	Varying degrees of standardization
Checklists discipline	Expectation to complete outside functions
Formalized recurrent training	Haphazard recurrent training
FAA mandated performance checking	Absence of mandatory performance checking

Not only are there differences in work environment between the two fields, but health care is associated with higher error rates—rates that make up the harrowing statistic of up to 98,000 deaths a year due to medical errors, published in the IOM Report, To Err is Human in 1999. A recent study evaluating quality improvement in health care’s progress since the publication of To Err is Human reports the sobering fact that not much has changed. Just as many people become victims of medical error today. While a lot of improvements have been made, we still have a long way to go. According to the Joint Commission, at the root of many of the errors we see in health care are communication and organizational culture. So, what health care needs is a cultural transformation. With the likes of Gary Sculli, we are well on our way on the journey towards safer health care.

Being flexible and keeping an open mind are two important items to pack when traveling to ensure a positive experience. Gary Sculli surely did not forget to pack these on his move. He took the lemons he found in health care and made lemonade by applying effective communication and leadership strategies practiced in the airline industry to health care in order to make health care more effective and reliable. In his discussion, Sculli outlined the concept of crew resource management as a team building effort to not just strive towards eliminating error, but more importantly, how to manage error when it does occur. He also discussed different leadership styles, being a dictator or facilitator, and the health care consequences associated with each. What else is needed to make health care more reliable? Sculli illustrated the need to redesign health care to support “situational awareness,” being able to perceive, comprehend, project, make decisions, and perform actions on variation in one’s environment. Check out the University of Michigan IHI Open School website for more information on topics discussed at the Monthly Speaker Series event.

The application of many of these airline tools have been able to make some great changes in health care. With the use of checklists, many hospitals have been able to effectively standardize procedures and eliminate hospital acquired infections. Through communication training among the staff of the operating room, physicians have been shown to be more adept at soliciting feedback and taking appropriate actions, while nurses and other members of the OR team have moved away from the “hinting and hoping” strategy of declaring an error to providing feedback in a direct, concise, and specific manner.

Perhaps what I love most about traveling is that once you move past the initial jolt of shock that the differences of a new location can give you, people are really all the same. I’ve learned so much from the cultures and people I have interacted with on my travels and have adopted some of these practices into my daily life. Personally, these adopted practices have made my life better. Is health care really so different from the airline industry? They are both fields that include teams of individuals performing highly specialized skills with extreme risk and small margins of acceptable error. With the help of inspiring leaders like Gary Sculli, health care is adopting the best practices from other industries. If we keep moving in this direction, I’m sure the next culture shock health care will give is one of success that we can all be proud of.

Student Teams at the Forum

The IHI Open School team cares about maximizing the value you take away from the National Forum. This year we've incorporated student teams -- a new team-based approach, exclusively for IHI Open School attendees--into our programs. The student teams concept is our answer to a simple question: What are the habits of the world's best conference goers? How do the seasoned veterans leverage a few days' meeting into the knowledge, networking, and inspiration to fuel a year's worth of success in improving health care? It must take more than coffee.

The response has been terrific and we have 10 teams coming to the Forum! Each team is formed of 4-6 students and residents with a mix of professional and demographic factors. We'd like to thank all of you who will be participating in this unique experience. The student teams received their team assignments last week and were asked to develop their team's learning mission by making a comment at the end of this blog post. You'll be able to see what other teams are working on and hopefully find opportunities to collaborate while at the Forum. We've collected a set of best practices from other conference goers below.

How to optimize your IHI National Forum experience:

1. Active learning. With so much packed into three days, it's easy to miss a key insight in the blur of PowerPoints and plenaries. The best technique, we learned, is to think up questions well before the end of a talk. Keeping questions in mind throughout the conference, continuously searching for answers, and reflecting on daily lessons are key best practices of active learners.
   
2. Networking for collaboration. The knowledge to be gained at the Forum is world class, but it's called a meeting because that's what you're supposed to do! To make the most out of your experience, you'll want to be sure to meet the right people. You may find it difficult to find colleagues who share your interests in health care improvement at your school or institution, but student teams are designed to provide an immediate addition to your network of colleagues with common interests, and to provide a starting point for connecting with people you want to meet.
   
3. Connecting to core values. What makes the IHI National Forum so valuable is that improving health care is not just a specialty, it's a movement. Along with a list of great ideas and a stack of business cards, you leave with a sense of joy and excitement about the mission of improving health care that will carry you through the challenges of the year. The IHI Open School hopes that with the help of the student teams you will be going home at the end of the Forum energized and inspired. We hope that the Forum will be as much about learning what's new as rediscovering the core values that sparked your passions in the first place.

To our student teams: We're excited to see the results you come up with while at the Forum. Now's your chance to share your team's mission with the rest of the IHI Open School Community! Please share your team's mission in the comments section below.

See you in Orlando!

--Daniel Henderson

Gut Check: University of Michigan's Medical Error Disclosure Program

We're all familiar with the story of George Washington and the cherry tree that gave rise to the famous line, "I cannot tell a lie, father, you know I cannot tell a lie!"

What motivated him to tell the truth? Was it some sort of rumbling gut feeling that told him that it was the right thing to do? Probably the same motivating forces that led the University of Michigan Health System (UMHS) to transition to a medical error disclosure program that is fully integrated with the hospital's quality improvement and patient safety efforts in 2001.

Unfortunately, our health care world today is one in which we don't follow George Washington's leadership. Medical malpractice is guided by a "deny and defend" approach. Insurers and counsels often urge secrecy, dispute fault, deflect responsibility, and make it as slow and expensive as possible for patients to continue the already unfavorable process. As a result of this approach, it's not uncommon for medical lawsuits to take five or more years to resolve. Information about the cause of injuries is also denied to patients and families for long periods of time; and compensation is unavailable to those who most need it. Worst of all, there is little meaningful quality feedback for providers. Patients and providers are placed in adversarial positions, allowing fear to fester in between.

Turning the current, "deny and defend" approach to medical liability on its head, the current system at UMHS emphasizes full honesty and transparency between staff and patients and encourages the participation of risk management, regardless if a medical error is involved. At UMHS medical errors are identified and collected by all staff, patients, and family members. Experienced risk managers with a clinical background investigate the claims, and care quality is evaluated. The system's three guiding principles are:

1. Compensate quickly and fairly when unreasonable medical care causes injury.

2. Defend medically reasonable care vigorously.

3. Reduce patient injuries (and therefore claims) by learning from patient's experiences

Most importantly, conclusions of the investigation are shared.



We were fortunate to have Rick Boothman, UMHS Chief Risk Officer, join the University of Michigan's IHI Open School for our first Monthly Speaker Series event of the year to discuss UMHS's medical error disclosure program. Boothman's presentation was focused on the underlying principles of quality improvement that help inform the disclosure program.

Boothman's extensive experience as a trial lawyer has given him a strong and intuitive sense about cases that he can almost accurately predict if he can win a case. But, he does what he refers to as a "gut check." Would he accept this kind of care for his own mother?

The undercurrent of quality improvement has led to some great results. As reported in the Annals of Internal Medicine in a paper written by Allen Kachalia et. al., with implementation of UMHS's disclosure-with-offer program, the average monthly rate of new claims decreased from 7.03 to 4.52 per 100,000 patient encounters. The average monthly rate of lawsuits decreased from 2.13 to 0.75 per 100,000 patient encounters. The median time from claim reporting to resolution decreased from 1.36 to 0.95 years. Average monthly cost rates decreased for total liability, patient compensation, and non-compensation-related legal costs.

A system that makes patients and physicians happier...and saves money at the same time? My gut is telling me that this is a system that we should take a look at.

NY Times article about Patient Safety

From http://www.nytimes.com/2010/11/25/health/research/25patient.html?_r=1&hp

Mistakes Still Prevalent in Hospital Care, Study Finds

By DENISE GRADY

Published: November 24, 2010

Efforts to make hospitals safer for patients are falling short, researchers report in the first large study in a decade to analyze harm from medical care and to track it over time.

The study, conducted from 2002 to 2007 in 10 North Carolina hospitals, found that harm to patients was common and that the number of incidents did not decrease over time. The most common problems were complications from procedures or drugs and hospital-acquired infections.

“It is unlikely that other regions of the country have fared better,” said Dr. Christopher P. Landrigan, the lead author of the study and an assistant professor at Harvard Medical School. The study is being published on Thursday in The New England Journal of Medicine.

It is one of the most rigorous efforts to collect data about patient safety since a landmark report in 1999 found that medical mistakes caused as many as 98,000 deaths and more than one million injuries a year in the United States. That report, by the Institute of Medicine, an independent group that advises the government on health matters, led to a national movement to reduce errors and make hospital stays less hazardous to patients’ health.

Among the preventable problems that Dr. Landrigan’s team identified were severe bleeding during an operation, serious breathing trouble caused by a procedure that was performed incorrectly, a fall that dislocated a patient’s hip and damaged a nerve, and vaginal cuts caused by a vacuum device used to help deliver a baby.

Dr. Landrigan’s team focused on North Carolina because its hospitals, compared with those in most states, have been more involved in programs to improve patient safety.

But instead of improvements, the researchers found a high rate of problems. About 18 percent of patients were harmed by medical care, some more than once, and 63.1 percent of the injuries were judged to be preventable. Most of the problems were temporary and treatable, but some were serious, and a few — 2.4 percent — caused or contributed to a patient’s death, the study found.

The findings were a disappointment but not a surprise, Dr. Landrigan said. Many of the problems were caused by the hospitals’ failure to use measures that had been proved to avert mistakes and to prevent infections from devices like urinary catheters, ventilators and lines inserted into veins and arteries.

“Until there is a more coordinated effort to implement those strategies proven beneficial, I think that progress in patient safety will be very slow,” he said.

An expert on hospital safety who was not associated with the study said the findings were a warning for the patient-safety movement. “We need to do more, and to do it more quickly,” said the expert, Dr. Robert M. Wachter, the chief of hospital medicine at theUniversity of California, San Francisco.

A recent government report found similar results, saying that in October 2008, 13.5 percent of Medicare beneficiaries — 134,000 patients — experienced “adverse events” during hospital stays. The report said the extra treatment required as a result of the injuries could cost Medicare several billion dollars a year. And in 1.5 percent of the patients — 15,000 in the month studied — medical mistakes contributed to their deaths. That report, issued this month by the inspector general of the Department of Health and Human Services, was based on a sample of Medicare records from patients discharged from hospitals.

Dr. Landrigan’s study reviewed the records of 2,341 patients admitted to 10 hospitals — in both urban and rural areas and involving large and small medical centers. (The hospitals were not named.) The researchers used a “trigger tool,” a list of 54 red flags that indicated something could have gone wrong. They included drugs used only to reverse an overdose, the presence of bedsores or the patient’s readmission to the hospital within 30 days.

The researchers found 588 instances in which a patient was harmed by medical care, or 25.1 injuries per 100 admissions.

Not all the problems were serious. Most were temporary and treatable, like a bout with severe low blood sugar from receiving too much insulin or a urinary infection caused by a catheter. But 42.7 percent of them required extra time in the hospital for treatment of problems like an infected surgical incision.

In 2.9 percent of the cases, patients suffered a permanent injury — brain damage from a stroke that could have been prevented after an operation, for example. A little more than 8 percent of the problems were life-threatening, like severe bleeding during surgery. And 2.4 percent of them caused or contributed to a patient’s death — like bleeding and organ failure after surgery.

Medication errors caused problems in 162 cases. Computerized systems for ordering drugs can cut such mistakes by up to 80 percent, Dr. Landrigan said. But only 17 percent of hospitals have such systems.

For the most part, the reporting of medical errors or harm to patients is voluntary, and that “vastly underestimates the frequency of errors and injuries that occur,” Dr. Landrigan said.

“We need a monitoring system that is mandatory,” he said. “There has to be some mechanism for federal-level reporting, where hospitals across the country are held to it.”

Dr. Mark R. Chassin, president of the Joint Commission, which accredits hospitals, cautioned that the study was limited by its list of “triggers.” If a hospital had performed a completely unnecessary operation, but had done it well, the study would not have uncovered it, he said. Similarly, he said, the study would not have found areas where many hospitals have made progress, such as in making sure that patients who had heart attacks or heart failure were sent home with the right medicines.

The bottom line, he said, “is that preventable complications are way too frequent in American health care, and “it’s not a problem we’re going to get rid of in six months or a year.”

Dr. Wachter said the study made clear the difficulty in improving patients’ safety.

“Process changes, like a new computer system or the use of a checklist, may help a bit,” he said, “but if they are not embedded in a system in which the providers are engaged in safety efforts, educated about how to identify safety hazards and fix them, and have a culture of strong communication and teamwork, progress may be painfully slow.”

Leah Binder, the chief executive officer of the Leapfrog Group, a patient safety organization whose members include large employers trying to improve health care, said it was essential that hospitals be more open about reporting problems.

“What we know works in a general sense is a competitive open market where consumers can compare providers and services,” she said. “Right now you ought to be able to know the infection rate of every hospital in your community.”

For hospitals with poor scores, there should be consequences, Ms. Binder said: “And the consequences need to be the feet of the American public.”

Student Events at the 22nd Annual IHI National Forum

The 22nd Annual National Forum on Quality Improvement in Healthcare is only a few weeks away! The IHI Open School team wants to make sure that you get the most out of your Forum experience that you possibly can. Read on to learn about the great student-focused events that will be taking place.

3rd Annual IHI Open School Chapter Congress

December 6, 4:30 PM - 7:30 PM

The Chapter Congress provides Chapters with an opportunity to come together, share their successes and challenges, and generate ideas for the new year. Chapter members will be able to meet other leaders in the community, share best practices, and build new skill sets. At this free, pre-conference event, Kate Hilton and Matt Lewis of Leading Change at Harvard University will lead us through the Story of Us and Now, and will review public narratives. Please review the IHI Open School Public Narrative Guide. This will be a great opportunity to meet and interact with IHI Open School Chapters!

Student, Faculty, & IHI Faculty Reception
December 6, 7:00 PM - 9:00 PM
The Faculty and Student reception will provide an opportunity for students and IHI National Forum faculty to network. Meet other students and faculty members and have a chance to make lasting connections.

Graduate Medical Education Interest Group Meeting
December 7, 7:00 AM - 7:45 AM
The IHI Open School is receiving overwhelming interest from the GME community. How can we use the IHI Open School courses to teach residents about improvement? How can we structure an improvement project during a one month rotation? Meet us in the Student Lounge (Tampa) to meet others in this group.

NEW! Student Dine Arounds

December 7, 6:00 PM - 8:00 PM
Are you interested in creating a QI elective or course on your campus, strategic planning for your IHI Open School Chapter, or QI in the context of health reform? Discuss these topics over dinner with people who have similar interests. Sign up at the Forum and IHI will make a reservation for your group at a local restaurant.

IHI Open School Breakfast Session
December 8, 7:00 AM - 7:45 AM
Join the IHI Open School special interest breakfast session to hear from the Regional Chapter Leaders. In this interactive session, the Regional Chapter Leaders will lead a discussion about Chapter sustainability. Learn about successful Chapter fundraising, developing a Chapter constitution, Chapter leadership succession, and other sustainability issues that Chapters face.

Student Lounge
The Student Lounge is a place for students to meet during the Forum. Go to the student lounge (Tampa room) during breaks and lunch to meet up with other students and for the latest information.

NEW! Student Teams
For the first time, students have an opportunity to join student teams at the Forum. Student teams are interprofessional groups of 4-6 students with similar areas of interest who will meet up throughout the Forum. Check back for a blog post about the student teams in a few days!

Follow & Tweet with us at the Forum

Make the student and faculty presence known by tweeting with us at the Forum. Use the #IHI hashtag.

If you have any questions, please email the IHI Open School team.

Goin' Out West... to UC Denver

I've been at IHI for over two years now; working with the IHI Open School since it was first dreamed up. I've made appearances at a few of our events (2009 IHI National Forum, 2010 Student Quality Leadership Academy) but for the most part I've been behind the scenes to our Chapter Network. About two weeks ago I had the opportunity to venture out west with, my colleague Shannon, to the University of Colorado - Denver to see what's been going at one of these Chapters, something I don't typically see.

Now I know you must be thinking "leaving the cold of Boston just to visit the cold of Colorado?" It couldn't be further from the truth. 70+ and sunny, we began our day exploring the separate schools that make up UC - Denver's campus as well as shared halls often used for interprofessional learning. We also saw a few simulation centers, including a unique home-care simulation. Later in the day, we were able to return to the simulation centers to watch four nursing students and one medical student work through a sepsis simulation. It was great seeing this type of collaboration between professions in their training, watching each team member take on a different role, and working together to assist the septic patient.

The main reason we visited UC - Denver was to attend the Chapter's workshop on debriefing a medical error. Before the workshop, approximately fifteen students were assigned a different roles to recount the event. Based on a true story where a chest tube was removed from the wrong patient due to many lapses in communication, about 20 students and faculty were assigned roles and worked through the event review. Another 20 or so watched and participated in the discussion that followed. Using an SBAR format, the Chief Quality Officer and Patient Safety Specialist from The Children's Hospital led the group through a thought-provoking discussion. Where was the miscommunication? What could have been done better? Who was responsible? The parents were told, but were they told everything? Is it the hospital's job to discuss the error even after the patient is home safe and making a full recovery? All of these and more were discussed. Who knew that so much could be be packed into an hour-long workshop. In the end, they suggested important communication tools and ideas such as repeat back, critical language, difficult conversations, and a Just Culture.

After the workshop, we watched the nursing student simulation followed by informal rounds at the Children's hospital with the Chief Quality Officer. They're doing a lot of great work on fall prevention, interdepartmental communications, and correct labeling of blood samples. The hospital staff also repeatedly mentioned the initiative to use at least two patient identifiers at all times.

After a busy day, it was time to fly back to Boston. A huge thanks to Wendy Madigosky, Jamie Dhaliwal, Nicholas Bishop, Dan Hyman, and to the Chapter Steering Committing for making the day possible. It's exciting to see what the Chapter has done, how engaged the students are, and how dedicated the faculty are to teaching students about quality and safety. I could not have asked for a better first Chapter visit.

Navigating Medicine's Next Frontier

For those of us in health care, it's an accepted fact that we will spend years and years working towards our goal to interact with patients and make a difference in the world. Given the hierarchical pecking order in medicine, it's not uncommon to allow those immediate goals like passing a renal pathology exam, completing medical school, or making it through a long night on call cloud one's original motivation for entering the field of health care in the first place. We're all running on this rigid track hoping that we won't lose steam along the way. Thankfully, there are plenty of opportunities to refuel.

I took some time this past weekend to refuel by attending the Asian Pacific Medical Student Association (APAMSA) National Conference in Baltimore. Since the conference is organized by medical students, the programming has always been great because it usually addresses and answers a lot of questions that any medical student would have: how to survive third year clerkships, applying for residency, what a career in oncology is like, etc. The APAMSA conference also has several sessions dedicated to Asian American health concerns such as Hepatitis B, which disproportionately affects Asian Americans (more information here). I was particularly impressed by this year's programming because it really spoke to the unique position we as medical students are in given today's changing health care climate.

The conference title was "Navigating Medicine's Next Frontier" and the session led by Dr. Sunny Ramchandani and Dr. Paul Song truly captured the great potential we have although the future of medicine is filled with more uncertainty than ever before. Medicine is no longer just about absorbing every bit of medical information printed in textbooks and journals, and then applying that to care for patients, but also about actively being engaged in our health care challenges and working to shape the future of our field.

The current medical school curriculum does not adequately prepare us for these health care challenges. How many medical schools have time set aside for communication skills, a systems approach to medicine, basics in health care economics, or even to discuss health reform? The field of medicine has evolved to encompass much more than just the individual interactions between doctors and patients. We as a profession need to build an awareness of the health system as a whole and develop skills to allow us to engage in this larger perspective--to better serve our patients.

In order to address this new demand on future physicians, the APAMSA national conference had several sessions designed to broaden our view of medicine. These included a session about applying business skills and concepts to improve our everyday interactions with patients, discussing provisions in the Patient Protection and Affordable Care Act that address health care disparities, implications of the new 80 hour work week, how to start a community clinic, mental health and disability awareness, the physician's role in policy and politics, medical errors and adverse events, and much more.

Moving forward from my experience at the conference, I'll refer to Dr. Sunny Ramchandani's advice (paraphrased): we need to break out of the mentality of mindlessly climbing the medical career ladder and take steps toward becoming more aware of the system that we are destined to be a part of. Health care and it's challenges are spiraling out of control and as future physicians, we have the opportunity to contribute to the discourse on finding solutions.

So, every once in a while, I'd recommend taking a quick glance at Kaiser Health News or another health news source to start developing an awareness of medicine and our future. We can always come back to that pathology textbook in 30 minutes.

Patient Centered Medical Home: An Anchor in the Ocean of Health Care?

The health care system is a ruthless and turbulent ocean. For many patients, even a regular visit to the doctor can be quite unforgiving. With patient safety, effectiveness, patient-centeredness, efficiency, timeliness, and equity concerns, health care visits can feel like navigating the ocean on a flimsy fishing boat. Now that we are transitioning into the phase of implementing and executing health reform, we must push patient-centeredness to the forefront of all our efforts to inform us on how to improve the quality of our health care system.

For example, the concept of the medical home that many say will transform health care into a more coordinated and comprehensive system isn’t just implementing electronic medical records, restructuring care teams that group physicians, nurses, physician assistants and other allied health workers together, redefining scheduling, or figuring out how to pay for these new services. The medical home needs to be a patient-centered medical home—one that actively engages the patient’s needs and concerns. Our system’s struggles with achieving patient-centered care is most evident in how health care providers deliver bad news to patients.

Kris (*all names changed to maintain privacy) is a multiple sclerosis (MS) patient and my longitudinal patient experience patient volunteer. Her experiences of reaching and finally receiving her diagnosis were far from ideal. Not only was her fishing boat almost completely destroyed by the big waves of the health care ocean, but she was also left alone to salvage the pieces. The first symptom she developed was a rapid decline in her vision. A busy nursing student at the time, this was the last thing she needed. She visited an optometrist to increase the prescription of her glasses--that’s all she thought she needed to alleviate this perturbance of age. But, Dr. Ortiz, the optometrist, was worried by what he saw. He explained his concerns of multiple sclerosis, encouraged her to see an ophthalmologist, and offered his kind words and a prayer.

This one good experience was soon overturned when Kris had to battle the sea monsters of scheduling and physicians simply not understanding the gravity of this impending diagnosis. Before Kris’s MS was even confirmed, one physician had told her that there was no rush for her to have an MRI because her diagnosis was not going to change.

The health care ocean is now littered with online resources that provide health care information, good and bad. Kris consumed all of this information and already had a clear picture of the worst case scenario before she was finally diagnosed. As Kris reflects, “You are going to destroy and completely change someone’s life with what you say, but instead of being just the wrecking ball, bring the rescue team with you.” Too often does our health care system see patients as floating vessels of transactions—bait it, catch it, and then throw it back into the ocean. A diagnosis is not the first step towards a pathway of reactive care services. How that diagnosis is reached is life-altering and how it is delivered today allows us to lose the tremendous potential the health care system has to truly help and support our patients.

What Kris needed on her odyssey to her diagnosis was a patient-centered medical home, a supportive health care team that acknowledged and respected her voice in the system. She did not need a physician to tell her to quit nursing school and she could have had more support than the kind words and encouragement of Dr. Ortiz. Our health care system failed to learn and understand Kris’s values and life goals. As a result, she spent years struggling to manage her MS. How could she take daily steroid injections when she was afraid of needles and the side effects were threatening to further derail her life? No one ever talked to her about her fears of becoming completely incapacitated or how the image of her first rotation at a nursing home with a patient with severe MS haunted her. Kris was a patient lost at sea. On her worst days, she would hold onto the knowledge of her ailing mother’s bag of potassium as a source of comfort and control. Where was the health care system while all of this was happening?

As a medical student, I often think about Kris’s story and what I would have done differently. On an individual level, I strive to have the positive impact that Dr. Ortiz had on Kris. He was her sole guiding oar and provided her with not only support, but also empowered Kris to take control of her diagnosis and life. Dr. Ortiz took the time to understand Kris and tailored his medical support to fit her needs. Today, Kris is not just an MS patient. She is a strong woman, a mother of two adopted children, and a NICU nurse, who happens to have MS. On a system level, we need to move away from being disparate objects floating in the ocean that patients can helplessly grab at, and move towards becoming the anchor and compass of their care—a patient centered medical home.

Until patients feel that they can interact with the health care system with the same level of comfort and ease, like on a luxury cruise liner, than we have a long way to go. As a first step, let’s allow our compassion to resurface and start our care with improvements in delivering bad news.

A personal story about quality

Happy Birthday Open School! My mom and I have both had the privilege of being involved with IHI Open School. She is a physician and professor, and serves as the proud faculty advisor to a chapter in Ohio. I served as a chapter leader while I was a nurse practitioner student at Yale Nursing School.

This past summer we became more intimately familiar with the importance of quality in our medical system than either of us would have liked.

My mom suffers from Parkinson’s disease and had progressed to the point where the disease was getting difficult to manage medically. After a great deal of consideration, our family decided that our best course of action would be for her to undergo the deep brain stimulation surgery. To shorten a very long and painful story, I will say that she got the surgery but endured multiple complications (including a faulty generator, a life threatening infection, and extra fairly high risk surgeries). At the worst times, she was unable to speak or move due to infection in her brain. We did not know what kind of recovery she would make. In addition to being terrified that we may never know our mom as we once knew her, her team had to take everything they had put in her brain, out. Four months later she is still on antibiotics and is still not sure if or when she will be able to do the surgery again. She has not been able to work, something that is very important to her. We are very hopeful but we still have a long way to go and the process thus far has left us shaken.

I share this very personal story so that we may be reminded once again of the importance of the work that we are doing. People trust us to take care of them. I cannot think of something that deserves more humility, respect, and appreciation. Procedures and physicals become routine to each of us. We have days that we are tired or distracted. But for each patient we see, let’s promise that we will treat them like they are the only person we see that day.

So from my mom and me, THANK YOU for caring about quality in care. Please keep up the good work. Happy Birthday IHI Open School.

WIHI: the Buzz about Medical Training: It’s (Slowly) Changing

Thank you for joining today’s WIHI – the Buzz about Medical Training: It’s (Slowly) Changing. Today we heard from:

• Lawrence Smith, MD, Dean, Hofstra/North Shore-LIJ School of Medicine; Chief Medical Officer, North Shore-LIJ Health System
  
• John Rock, MD, Founding Dean, Herbert Wertheim College of Medicine at Florida International University
  
• M. Brownell Anderson, Senior Director, Educational Affairs, Association of American Medical Colleges (AAMC)

Learn about how IHI is addressing student training about quality improvement and patient safety through one of its newer initiatives – the IHI Open School for Health Professions. If you missed today’s WIHI, please listen to the recording that will be posted later this week.

1. Students, are you studying at a new medical school? What is it like? Do you feel like you’re missing out or learning more than students in traditional medical schools?


2. Faculty, what do you think? Do you think your school is developing different types of future doctors?


3. Physicians, what do you wish you could change about your medical training? What would you like to have learned? What are your recommendations for today’s students and faculty?

Please share your thoughts or questions with us below in the comment section below!

The Gift of Stories

Last year, I shared a story about what I’d like to call a healthy degree of precocious curiosity about the human body and what my parents refer to as an inexplicable amount of craziness that led me to voluntarily staple my tongue. That courageous and completely unnecessary self-inflicted surgical procedure has left me with a permanent scar on my tongue. This unusual accumulation of granulation tissue on my tongue is now not only an interesting anatomical and histological finding, but represents the story of a “unique” phase in my life.

As I studied anatomy last year, your loved one, my very first patient, shared innumerable stories with me. Each lab session was filled with incredible medical discoveries. Muscles, nerves, and blood vessels are all logically arranged to accommodate our daily actions and behaviors. The mighty organs throughout our body are carefully protected by bone and layers of tissue. And individual body systems, like the eye, operate with an awe-inspiring amount of coordinated refinement. The smartest engineers and most brilliant architects may be able to create an equally powerful human body with various updates and improvements, but they will never be able to surpass the exquisite original because the artificially constructed designs cannot capture the exceptional narratives of your loved ones.

Your gift to me was much more than a gift of medical discovery because you have given me the privilege of being a part of your favorite stories about your loved ones. The slightly enlarged triceps and biceps of the right arm that we studied during our musculoskeletal sequence illuminate a possible vigorous tennis career. I bet his tennis serves were dramatic and the lightness of his feet meant he also had an unbeatable net game. The beautifully tapered fingernails that we delicately worked around as we studied the intricacies of the hand echo elegant dinner parties. Did she have a string of pearls that always added an extra touch of grace to her favorite blue dress? The clarity of the lungs that gleamed at us the first time we were able to take a look at the thoracic cavity give hints about a love for the great outdoors. Hiking, fishing, hunting, it’s likely that he did it all, but his favorite thing to do was probably taking the family out camping, right?

The most remarkable aspect about your gift is that it is a boundless gift that continues giving. This summer, I had the fortune of traveling to Ghana to conduct research. Since I’m still in the preclinical phase of my medical education, I jumped at every opportunity to shadow doctors, sit in on procedures, and interact with patients. I brought your loved one with me wherever I went. If I needed to take a pulse, I’d quickly locate the radial artery. While watching a hernia repair, I’d almost instantly recall the contents of the inguinal canal. Where is the anesthetic injected for spinal anesthesia? That’s right. The subarachnoid space. Every single time, I instinctively made correlations to what was in front of me to my first patient. Did you ever think that your loved one would have the opportunity to travel across the Atlantic Ocean to Ghana? And I’m just a second year medical student whose career in medicine is only just beginning. The stories of your loved ones will travel even farther and will touch more patients than you could ever imagine.

My first year of medical school was defined by the time I spent in anatomy. I spent hours probing through various anatomical structures and yet I feel like I only scratched the surface in my pursuit of medical scholarship. But what I did learn during those hours in anatomy lab, as I slowly built an intimate rapport with my first patient, was the invaluable lesson of the joy and fulfillment gained through listening to the stories of every bump, kink, and scar. It is the magnetic draw for these patient narratives that led me to inevitably mature from the dangerous narratives of attempting surgical procedures on myself to attending medical school and working towards becoming a doctor. Your special gift, my first patient narrative, is one that will always stay with me as I continue to learn and never stop listening. Thank you.


Delivered at the University of Michigan Medical School Anatomical Donations Memorial Service (Sept. 15, 2010)

The first IHI Open School advanced case study

A few months ago, a 29-year-old woman was living independently in a small suburb in the southwestern United States. She enjoyed cooking for friends and playing her guitar. Today, she's been admitted to a nursing home because she can no longer care for herself. What happened?

Two weeks from now, students and residents all over the world will gather in interprofessional teams and analyze the complex series of events that ended up harming this patient. They'll also design an improvement project that could help prevent similar problems from happening to other patients in the future.

Want to participate? Here's how the IHI Open School's very first advanced case study event will work.

• Visit the advanced case study page and download the instructions.
• Form a team. Teams can consist of 2-12 people and must represent at least two professions. Residents and students from a broad range of fields, including nursing, business, pharmacy, medicine, law, policy, engineering, public health, and related fields, are encouraged to participate. If you need teammates, find them on our Facebook page.
• Register your team by Friday, October 1st. Registration is capped at 25 teams, so register early! (Registration is open now.)
• Download the case from the IHI Open School home page on Thursday, September 30th. You'll have two weeks to work on it with your team.
• Email your team's presentation to openschool@ihi.org by Thursday, October 14th.
• Selected teams will present their work to IHI faculty in a series of live webinars the week of October 25th-29th. Teams will be notified by October 20th about whether they will be invited to present.

We are really excited about this case study event. It's a chance to flex your knowledge of safety and patient-centered care, lead system improvement, practice your teamwork skills across professions -- AND get feedback from the experts at IHI.

We hope you'll form a team and sign up! If you have questions, leave a comment or email openschool@ihi.org.

Costs of Care Essay Contest!

Medical bills are a leading cause of personal bankruptcy and health care providers decide what goes on the bill.

According to the Congressional Budget Office, the United States spends $700 billion dollars each year on tests and treatments that do not measurably improve health outcomes--a figure comparable to our total spending on the Iraq War. And here is where things become truly awkward: few providers understand how the decisions they make impact what patients pay for care.

Let's recap. Medical bills are bankrupting Americans, providers decide what goes on the bill ($700 billion dollars of which might not need to be there), and providers rarely have information about what things cost. That seems like something we ought to fix, doesn't it?

If you agree and have a story to tell about it, there could be $1000 in it for you. Remember a time you got a medical bill that was higher than you expected it to be? Or a time when you wanted to know how much a test or treatment might cost and couldn't find out? Costs of Care, a Boston-based nonprofit, is offering $1000 for short anecdotes illustrating the importance of cost awareness in medicine. We want to hear your story.

The submissions will be judged by a high profile crew of policymakers, doctors, and journalists that include Atul Gawande, Michael Dukakis, Jeffrey Flier, Michael Leavitt, and Tim Johnson. Submissions will be due by November 1st to contest@costsofcare.org. Additional details are available at www.costsofcare.org/essay

Dr. Neel Shah is the executive director of www.CostsOfCare.org, and a resident in Obstetrics and Gynecology at Brigham & Women's Hospital in Boston.

The IHI Open School is Two!

Two years ago, the IHI Open School team was building a startup. We were pretty sure students would be interested in learning about quality, but there were lots of things we weren't sure about. Would busy students be ready to take on another commitment? Would faculty embrace the IHI Open School concept? Would students of nursing, pharmacy, medicine, business, and other professions find ways to collaborate to improve patient care?

After many late nights and weekends in the office, our team crossed our fingers and launched this initiative on September 15, 2008. Two years later,we are constantly humbled by the energy, accomplishments, and sheer numbers of students, residents, faculty, and health professionals who have plunged into the IHI Open School's offerings -- and taught us a lot about the work that preceded this initiative and made it possible for so much to happen in such a short time.

Exactly how far have we come together in just two years? Check out the numbers:

• 38,000+ students and residents are registered on IHI.org
• 9,000 students and residents have completed a course
• 8,000 faculty and deans are registered on IHI.org
• 700 students have earned an IHI Open School Certificate of Completion (all of the courses)
• 250+ Chapters have been started in 35 countries

We offer a big, loud THANK YOU to the Chapter Leaders and Faculty Advisors who’ve taken on the challenge of leading a Chapter and getting others -- whether students, residents, or health professionals -- involved in quality improvement. Our thanks also to the health professionals who have made time to invite these students into their organizations.

Help us celebrate the last two years by telling us what the IHI Open School means to you. How have you used what you learned in the courses? Did leading or participating in a Chapter change your career? How is the IHI Open School shaping your personal and professional goals? And -- finally -- what do you want the IHI Open School community to do next?

Preparing for the Future

This summer, while I was traveling around Ghana conducting clinical quality and management research focusing specifically on the changes posting an OB/GYN specialist in district hospitals has on the hospital and the immediate community, my classmate Charlotte was busy administering a laparoscopic surgery training module to bring the technology of laparoscopy to Komfo Anokye Teaching Hospital in Kumasi, Ghana. Laparoscopic surgery, especially for gynecological surgeries, has been available to developed countries for at least 20 years, but this minimally invasive form of surgery has yet to become standard practice in Ghana. The benefits of laparoscopic surgery are many. It is cosmetically favored by patients and medically, reduces complications like hemorrhaging and has shorter recovery times. It is no exaggeration to say that Charlotte's work is ushering Ghana into a new surgical future that will bring a tremendous amount of public health benefit.

In 1910, Abraham Flexner's report titled, "Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching" ushered and shaped medical education into it's current form. The Flexner Report called for standardization of medical education that was rooted in sound and rigorous biomedical and clinical science challenging the American and Canadian medical education systems to train the highest quality of physicians. Flexner, not a physician himself, wrote a book-length report that was framed with the greater society in mind. He wrote, "The public interest is then paramount, and when public interest, professional ideals, and sound educational procedure concur in the recommendation of the same policy, the time is surely ripe for decisive action."

It has been 100 years since the publication of the Flexner Report and with 100 years of experience of modern medical education, we are due for some reflection on the alignment of the medical education system and the public interest. In an article published in Academic Medicine, Drs. Don Berwick and Jon Finkelstein write and discuss a, let's call it "Flexner Report 2.0", shaping a medical education system that will better prepare physicians to meet the needs of a today's world of health care. Read the article here.

In the article Berwick and Finkelstein outline new values that should complement the current emphasis on biomedical science we receive in medical school. These values include "patient-centeredness, transparency, and stewardship of limited societal resources for health care." There is no time in the current curriculum to add on training in these new skills, many educators would argue. Berwick and Finkelstein also review the innovative programs, including the IHI Open School, that attempt to provide medical students and residents with a foundation in these new skills, as well as outlining a new frame of reference for medical curriculum change that will incorporate these invaluable skills. I certainly can't reproduce Berwick and Finkelstein's eloquence, so I will leave the explanation of the fine details to the article. Definitely a must-read!

In the 100 years since the publication of the Flexner Report, the medical education system has trained millions of physicians who have dramatically transformed health care. It was this cohort of physicians that popularized laparoscopic surgery! Looking just at performance outcomes, we have made incredible gains in both the length and quality of life for our patients. However, there is much more we can do. If we adopt Berwick and Finkelstein's recommendations, we will be poised to create a new physician workforce adept at navigating and continually improving the complexities of health care to consistently meet patient needs. We all need to collectively reflect on and brainstorm innovative interventions to fold the skills of systems thinking into our current medical education system. If we can develop the technology of laparoscopic surgery, I'm confident that we too can succeed in reinventing ourselves to better treat our patients with the tools of quality improvement. In 100 years, the world will surely look very different. I'm imagining a modern metropolis not unlike the life of the Jetsons. But, what will medicine look like? What kinds of public health accomplishments can we celebrate in the next 100 years? Let's work together to reshape medical education so that we will have plenty to celebrate in the future!

What do you think of the Berwick and Finkelstein paper? Leave a comment!

Statistics in baseball and medicine

I went to a baseball game with my father last week (go Sox!). Our pitcher wasn’t doing so great – his strike rate was hovering around 50%, and it was taking him almost twice as many pitches to get through an inning. I knew this because my dad kept pointing out statistics – live, updated – on the board. And that was a simple statistic, calculated as I watched. But they only got more complicated. I began to envision a gigantic database in my head. They reported the number of errors a player had made while in that position (so the database must have a field for position played). Then the number of times a pitcher pitched a strike when there was a full count (the database must have not just the number of balls and strikes, but the order). I was very impressed. But then I realized it couldn’t be that hard to design a good, if complex, database. I mean, they’re doing it for baseball.

But then I went back to work the next day. I’m a grad student doing health care quality research. We’re trying to answer a relatively simple question about medications and laboratory monitoring. Little has been reported on this information before because almost no one has even more basic data on prescribing rates and test ordering rates. Besides, prescribing databases are unreliable because patients may not fill the prescriptions, while claims data isn’t always reliable because some people pay out of pocket, for example. So we can’t answer simple questions like how many people got appropriate monitoring tests to better target interventions and improve care, much less the complex ones.

Imagine if we had the stats of baseball in health care. Imagine what we could do. Which is more important?

Lessons from Bo Schembechler

My second year of medical school is off to a great start. I applaud the psychological considerations that went into making cardiology our first sequence of the year because I've never been so alert in class. It's no surprise now as to why so many people want to become cardiologists--the electrophysiology, pathophysiology, and the pharmacology of the heart is awesome stuff!

Because heart disease remains the number one killer of Americans, the scientific advancements in the field and the amount of potential in uncharted territory in regards to genomic and vascular manipulations to cure disease are astounding. Only at the University of Michigan would we have a lecture about the legendary football coach, Bo Schembechler, to illustrate the complexities of managing heart disease and the scientific advancements of the last forty years that have made living with heart disease a possibility.

Bo Schembechler coached the University of Michigan Wolverines football team from 1969-1989. He led the team to 13 Big Ten Conference titles and holds a career record of 234–65–8. I don't really follow football, so I'm going to focus on his medical narrative.

Every time Bo Schembechler had a coronary event, starting from his first heart attack at age 39, a new scientific therapy was available to him:

1960s: Coronary Bypass Surgery (vein grafts)

1970s: Aspirin, blood thinners, beta blockers, diuretics

1980s: Internal mammary artery grafts, statins, diet

1990s: ACE inhibitors, ARB's, spironolactone, ICD's

2000s: BiV pacers, hemoperfusion

Taken directly from Dr. Kim Eagle's slides

Bo Schembechler needed all of these new treatments. It is not uncommon to find a patient these days who is managing heart failure, hypertension, hypercholesterolemia, arthritis, and diabetes all at once. What makes Bo Schembechler a remarkable case study is how his disease course outlines the history of how we manage cardiovascular disease. His life was changed tremendously with each scientific advancement. Bo Schembechler is not just a University of Michigan story, but a medical success story that anyone who has ever spent time with a biochemistry textbook dreams about.

The Bo Schembechler medical narrative doesn't stop there. The lessons we can learn from him extend far beyond the biomedical disease model. Extending his coaching career into his health, Bo realized that an integrated team of health professionals who practiced patient-centered care was the best play in the game of achieving a healthy life. As Dr. Eagle describes:

He had an integrated medical team. He chose his doctors based on whether they communicated well with him and other physicians. He said to me, "I want to go to a doctor who makes me feel that I am their only patient at that time. If they are looking at the computer or writing; they ask me two questions and then say see you later, then they are not on my team."

Bo believed that he was put on this earth to build young men. He may have built over 500 young men through coaching football. But just through listening to Dr. Eagle's account of what it was like to be Bo Schembechler's cardiologist, Bo was coaching people all around him to be better people all the time. Here's what Dr. Eagle said about what he learned about the practice of medicine through Bo:

...a lot of times, we rush through. And modern medicine rewards that. More RVUs, more revenue, less personal touch. So one of the challenges you will have is to do that. You will have choices. You will have choices to see more patients and make more money, or see fewer patients and connect. I would argue that modern medicine can never take the professionalism away. Only you can give it away. If you choose to, you can. But don't. Resist that temptation. Design your professional life so that you can connect. Because most of you came into this because you have a yearning to have that connection. To get paid to hep people is an amazing gift. But, to focus on helping them requires discipline.

Much to my college football loving cousin's chagrin, I don't follow college football at all. I sadly didn't even make it to a single University of Michigan football game at the Big House last season. The Wikipedia article about Bo Schembechler can catch me up on all of his sports accolades. Perhaps it's because I'm a medical student with a bent for quality improvement, but the Bo Schembechler, Heart of a Champion medical story is so much more meaningful. It's not easy to find a case that is as interesting clinically as it is in regards to health care delivery all in one. But, Bo Schembechler does just that. He's another reason why I'm happy to be at the University of Michigan.

IHI Open School at the General Assembly of the IFMSA

Dear all,

from the 31. of July to the 6th of August I participated at the 59th General Assembly of the International Federation of Medical Students's Associations in Montrèal, Canada. Over 600 medical students from all around the world took part in the event, and a lot of them got to learn something about the IHI Open School.

IHI Open School had four of it's Chapter members present in Canada, and together with a prospective Chapter Leader from Trondheim and Anthony Gifuni from the local Montrèal-Chapter we were able to promote the Open School day and night. =)

IOS-Oslo gave an introduction to Patient Safety to the participants in the Standing Committees on Medical Education (SCOME) and Human Rights and Peace (SCORP), and the OS was presented at the Regional Meetings of the Americas, Asia&Pacific and Europe.

A regional Chapter-event was held on the 3rd of August, and 32 students participated in that event, and the feedback we got was very positive. There is a growing interest of health system improvement and patient safety among health care professional student's all over the world, and hopefully we'll come together and learn through the IHI Open School-network.

The next IFMSA General Assembly will be in Jakarta, Indonesia in March 2011, hopefully there will be someone representing the Open School there too =)

What's happening...at the University of Chicago

Last week, I visited the University of Chicago, one of the first IHI Open School Chapters. On Friday morning, I met with student and faculty representatives to learn about the medical school and prepare for the M1 class we’d attend later that morning. The University of Chicago opened its doors to medical students in 1927 and welcomes approximately 88 new students each year. The first year medical students (M1) have only been on campus for two weeks. The class we attended was an orientation to the quality and safety track for the entire class of first year medical students.

Medical School: Quality & Safety Scholarship and Discovery Track
The students are introduced to each of the Scholarship & Discovery tracks so they can decide whether or not they’d like to delve into research, receive mentorship, and do a project in one of five areas - scientific discovery, medical education, quality and safety, community health, and global health - during their four years in medical school. The Chapter helped design the Quality & Safety track and incorporated the IHI Open School courses.

Medical School: Quality Improvement Elective
As part of the Scholarship & Discovery track, students can take a quality improvement elective during the spring quarter of their first year. It’s a 10 week elective during which the students learn quality improvement tools and setup an improvement project. A couple of students presented their projects including one working with general medicine to develop developing checklists to prevent the CMS no pay events (they increased adherence to the quality indicators by 20%) and a second project that studied the time to antibiotics for pneumonia patients in the ER.

The class also included an overview of the Institute of Medicine’s definition of the six dimensions of quality, process mapping, data describing patient satisfaction with quality of care they receive and provider satisfaction with their ability to provide high quality care, the World Health Organization’s ranking of healthcare systems, and challenged students to look how hospital’s in their hometown faired on the Department of Health And Human Service’s HospitalCompare and the Commonwealth Fund’s WhyNotTheBest websites…and that was just the introduction to quality!

Chapter Meeting
After the orientation course ended, we ventured to the biomedical building for a lunchtime Chapter meeting attended by medical students, health administration and policy students, residents, and faculty. Since the Chapter was founded, it’s been led and focused on medical students, but is now developing a partnership with students from the Graduate Program in Health Administration and Policy and is also planning to engage pharmacy residents. This year, the Chapter is planning to focus on building an interprofessional network, with quarterly socials events, and giving students the opportunity to participate in a hands-on project. After some brainstorming, the students decided to pursue an improvement project that will focus on the referral system at a local women’s shelter and health clinic.

School of Social Services Administration
In addition to the medical students' exposure to QI, the Graduate Program in Health Administration and Policy (GPHAP), which is housed within the School of Social Service Administration and draws students from the Booth School of Business, the Harris School of Public Policy, and the School of Social Service Administration, introduces students to quality improvement. Students are required to take two of the IHI Open School Quality Improvment courses in their Special Issues in Healthcare Management course. Students also have the opportunity to use the IHI Open School courses to fulfill their co-curricular requirements during one of their academic quarters.

The students' early exposure to quality improvement and the support from the faculty on their campus is encouraging and exciting! We expect to see great things from this Chapter over the next year. If you’re a student or faculty member at the University of Chicago, check out their IHI Open School Chapter Website on Chalk!

Thank you to Vinny Arora, Andrew Schram, Greg Kaufman, Laura Botwinick, Julie Oyler, Lisa Vinci, Marcus Dahlstrom, and the University of Chicago School of Medicine and GPHAP students and faculty for inviting me to your campus and hosting a terrific site visit!