This year we started a Global Health Initiative within the Harvard IHI Open School Chapter. We aim to make quality improvement and patient safety truly global. Last year one of the members of the Harvard Open School Chapter, Shabnam Hafiz, introduced the Safe Surgery Checklist at three hospitals in Pakistan. Building upon this momentum and furthering the cause of global patient safety I decided to implement the checklist at hospitals in New Delhi, India during the winter break. As I work on spreading the checklist, I will be sharing my experiences with the readers of this blog. I hope you will find the posts interesting and insightful.
In implementing the checklist, I wanted to do it in a manner that could be replicated by other people wishing to create change, sometimes without significant access to the top leadership at a hospital. I wanted to conduct an experiment in bottom-up change.
One of my physician friends was working as a Resident at a government hospital in Delhi. I got in touch with him when I reached Delhi, and over a cup of coffee I explained the surgical safety checklist to him. He offered to set up an appointment for me to meet with the head of surgery at his hospital to discuss the checklist. Two days after that, I went to the hospital and in a five minute meeting explained the checklist to the Chief of Surgery. She was ready to implement it and remembered having read the journal article. I then met with other surgeons at the hospital, and also the Chief of Anesthesiology. Everyone was ok with the idea and it was decided that I would hold a trial run of the checklist in the OT the next day.
The next day I reached the OR early and explained the checklist to the OR nurses and clarified their doubts. Then I ran the checklist in two OR’s. As this was the first time even for me, I felt a little rushed in the first case and did not feel that the process was as effective as it should have been. In the second case I tried to get some nurses to take over from me, but they were a bit hesitant. In the third case another nurse did volunteer to run the checklist.
What was amazing was that on the very first day we managed to identify gaps in care. One of the questions on the checklist asks ‘Has the site been marked’, it turned out that it was not a routine procedure to mark the incision site preoperatively at this facility; the senior surgeon noted this deficiency and told the surgeons to carry it out for future surgeries. A discussion with the anaesthsiologist revealed that mostly preoperative antibiotics were given in the ward, and the gap between the administration of the antibiotic and the skin incision possibly exceeded 60 minutes in most cases.
After the OR trail run I approached the Administrative Head for his permission to hold a formal presentation to explain the significance of the checklist and to show the videos. He was very supportive and the presentation will be held next week during which I hope to train other people in implementing the checklist.
Suggestions, comments and feedback welcome. Watch this space for updates.
I know you're probably still recovering from last night's celebrations. But I wanted you to know that the IHI Open School just published three brand-new quality improvement courses. The courses will be required for our basic certificate of completion. And like all our online courses, they're free for students -- you just need to register with IHI.org.
Here's a quick snapshot of our latest offerings:
Quality Improvement 104 ("Putting It All Together: How Quality Improvement Works in Real Health Care Settings"): The first three IHI Open School quality improvement courses introduced you to the fundamentals of improving health care. In this course, you're going to see how two real organizations actually used these methodologies to improve an important aspect of patient care. You'll start by learning the four phases of an improvement project's "life cycle": innovation, pilot, implementation, and spread. Next, you'll delve deeper into the theory of spreading change - both the foundational work by sociologist Everett Rogers, and IHI's Framework for Spread.
Quality Improvement 105 ("The Human Side of Quality Improvement"): If you want to improve a complex system, you'll probably have to convince the people around you to do things differently. But a change that seems sensible and beneficial to you may feel threatening to others. In this course, you'll learn why culture change is crucial to the success of many improvement projects. You'll discover the most common reasons people resist change, and then you'll practice responding in a way that mitigates that resistance. You'll also learn how new ideas typically spread through a population, and what you can do to help different parts of a population adopt a change. Finally, you'll learn different ways to motivate people -- and which methods are most likely to be effective in your setting.
Quality Improvement 106 ("Level 100 Tools"): This practical course will teach you to create and use three essential tools for improvement: PDSA (Plan-Do-Study-Act) templates, measurement planning forms, and run charts. Working through step-by-step tutorials that put you right in the middle of health care scenarios, you'll learn how to plan a series of tests, collect data, graph your results, and interpret what your graph is trying to tell you. This course is fully hands-on, so get ready to practice what you learn along the way. (Note: You'll need Microsoft Word and Excel to make the most of this course.)
Inspired by the words of Sekou Andrews and Dr. Don Berwick:
Protect our bodies with health nourish our souls with purpose. Pour knowledge into our minds passion in our hearts. Expect efficacy and improvement as its currency.
You asked us to reflect. True desire faces unmet needs with apprehensive tensions Reflections question reality with rude awakenings sending shivers of concern with Goosebumps of guilt. What kind of system have we built?
You asked us to envision. Doubts of broken foundations, shaky pillars, left with bridges that don’t connect. Our patients we fail to protect. Commitment and dedication advancing medical knowledge Measuring its quality brings discrepancy to surface. Pores sweat, mistaken assumptions composed of salty ignorance Sincere passions lost through convections leave us cold. Bold conversations expose realities of a system unjust. Wake up my good friends, this system has rust.
You asked us to change. Analyze criticize fundamentals of our fruit. Bitter a taste of past disgrace transforms into sweet prudent pursuit. Evolutionary regeneration stimulated by a gravitational force Demand higher expectations elevate us to greater strengths Scale up, costs down, aim times three. Sprint to lead map improvement goals of being complication free.
Our school is one open world a challenge knocks. Revolutionaries unlock by developing keys that makes us Better fit to learn, better fit to teach, better fit to reach Out to our patients, communities, and colleagues. Declare legitimacy, demand transparency, institute policy. Strapped with tools ideas for change. Courage in our hearts and energy to proceed. United together, we shall achieve.
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.
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.
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!
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...
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