Words, Words, Words

- Alex Anderson, Executive Assistant at IHI

Recently, I joined my family in remembering Harriet Berman. At Harriet’s funeral, her children celebrated her life in many ways. Among the many stories and reflections, one message stood out to me: Harriet deeply disliked the language used to describe the experience of being a cancer patient—being a victim of cancer. Fighting a Battle with cancer. Living as a Survivor of cancer.

Harriet did not like the implications of the language. Battling something implies there is a winner and a loser. It implies that if you’re fighting, and losing, then you are not fighting hard enough. If you could fight just a little harder, with stronger or better tools, you might survive a little longer.  

This immediately made sense to me. I never thought to question the ubiquity of the cancer-patient language. After thinking about the language, I was surprised that a conversation around it has not sprung up at IHI. I would like to start that conversation.

I do not know what the right language should be. I am sure there are many cancer patients who find the current language comforting, and I do not want to discredit any of the comfort they find in the language. However, I think we can do a better job understanding that different people may respond in different ways to the language we accept as normal.

How can we shift this conversation? What are the words and phrases that will enable us to provide support and encouragement to people facing difficult situations? I do not think that one wordsmith can find the right answer, but if we discuss this together, we may find a more inclusive way to support each other.

Focusing on Patient Safety in South Carolina

Susie Robinson & Amanda Hobbs, President and Vice President, Clemson University IHI Open School Chapter

The 5^th annual SC Patient Safety Symposium, held April 25 in Columbia, SC, proved to be a valuable experience for both of us! We learned a lot about patient safety and had the opportunity to her many leading experts in the field.

(We would first like to thank the South Carolina Hospital Association (SCHA) for sponsoring our attendance and for its constant support of the IHI Open School Chapters in the state of South Carolina.)

Here’s a rundown of our experience:

-          We kicked things off by meeting with leaders within the IHI Open School community, including the members of University of South Carolina’s IHI Open School Chapter and our two Southeast Regional Coordinators. 

-          As the Symposium began, we took front row seats and listened to Maureen Bisognano, CEO of the Institute of Healthcare Improvement.  She first recognized our state for the strides South Carolina has made in decreasing health disparities between populations, especially in Columbia.  Bisognano spoke briefly about the Triple Aim and recognized areas for health care improvement.  Bisognano then introduced Regina Holliday, a painter and patient advocate who painted representations of both the provider and patient perspective throughout the conference.

-          Next, Dr. Atul Gawande spoke about the future of Safe Surgery 2015, and the progress of South Carolina as a pilot state. 

-          After a short break, Dr. Eric Coleman from the University of Colorado spoke about the Care Transitions Program.

-          At lunch, the few students in attendance were recognized and the Lewis Blackman Patient Safety Awards were presented to honor deserving individuals from around the state. (The lunch, accompanied by the South  Carolina Philharmonic Orchestra, was delicious.)

-          As our day wrapped up, we were fortunate to spend some time talking with Maureen, Dr. Rick Foster, SCHA Vice President of Quality and Patient Safety, our IHI Open School Regional Coordinators, and patient advocate Helen Haskell (Lewis Blackman’s mother). 

We are grateful we had this opportunity through our involvement with IHI Open School!

IHI CEO Maureen Bisognano poses with faculty and students
at the 5^th Annual SC Patient Safety Symposium in Columbia, SC.

Introducing The Conversation Project

What if every citizen’s end-of-live wishes could be expressed and respected in a way that was simple and transformative? Would you have the conversation about your views on a “good death” if you knew it would bring peace, security, and calm to your loved ones?

We are all mortal, yet as a society we have been painfully slow in recognizing and acknowledging how many of the people we love are not dying in a manner of their choosing: in comfort, among people who care about them, and engaged in what matters most for as long as possible.

Many Americans assume these conversations should and will take place between doctors and patients, but doctors are often uncomfortable and untrained in initiating these end-of-life discussions, so wishes are never expressed and words are never spoken. The Conversation Project fills a void by bringing these important conversations from the hospital bedside to the kitchen table, so patients’ choices drive the decisions rather than medical finances.

Our mission is to provide individuals, communities and society at large with the knowledge, wisdom and grace needed to have what can be a painful conversation. The Conversation Project is your forum for sharing stories, a coordinated messaging and communications effort, a social marketing campaign, and a web home base for conversation starters. It’s where you will find guides to help you ensure your end-of-life wishes are respected. 

We are not interested in a temporary change, but rather a full cultural shift that will enable us to remove the stigma and uncomfortable nature of the topic, enabling us to have the conversation within our own families but also, collectively, across cultures, workplace communities and neighborhoods.

Our goal is to help people of all ages engage loved ones, care providers, clergy, and others. Rather than promote a ‘desired’ action, the Conversation Project plays the role of catalyst and advocate for families and circles having these conversations. Those who have had The Conversation report the benefits far exceed any preconceived expectations. We know this is hard, but we also know the number of people who want to have these discussions will continue to grow.

We ask you to join us by having The Conversation with your loved ones. We promise never to steer your decisions, only to support and encourage your discussions.

To learn more, follow @convoproject on Twitter. The Conversation Project website will launch in June.

Former Hospital CEO Visits Chapter at University of Colorado

The University of Colorado IHI Open School Chapter, in collaboration with the Patient Safety Education Partnership, was proud last week to host Paul F. Levy, author and former CEO of Beth Israel Deaconess Medical Center.  

Levy related stories about reducing patient harm, transparency of clinical outcomes, and leadership in medicine. The 80 attendees included students and faculty from the schools of Medicine, Nursing, Pharmacy, Dental Medicine, and Public Health, as well as residents and staff from several area hospitals. 

All attendees received a copy of Levy’s new book “Goal Play,” provided by the Patient Safety Education Partnership, which you can learn more about at http://www.psepartnership.org/.  The Chapter continued the discussion this week through a deliberative dialogue that explored the potential benefits and drawbacks of several strategies for the improvement of patient safety.





Pictured: University of Colorado IHI Open School
Chapter Steering Committee members Racheal Gilmer,
Josi Schwan,Betty Geer, Eric Wannamaker, and Dan Stoll; 
Paul Levy; Chapter Faculty Advisor Wendy Madigosky

Listening to Paul Batalden

Attendees enjoyed many treats at the 2012 International Forum on Quality Improvement and Safety in Paris. Inspiring keynote speeches. Impressive poster presentations as far as the eye could see. Croissants and macaroons around every corner. 

Few treats, though, compared to sitting and listening to Dartmouth professor--and improvement legend--Paul Batalden share his lessons and wisdom at a student lunch session on Thursday. He offered up Improving Health Care: A One-page Book, a book he developed "to open the topic [of health care improvement], not close it." Students, professors, and other improvement gurus (such as Don Berwick) followed along with interest.

"We get so many signals every day about the broken health care system," Batalden said. "The habit we've developed is to ignore them. We have to change that. We've got to figure out a way to make improving a simpler proposition. We have to move from where we are to where we need to be."

As a writer in the room, it was hard not to just write down every word out of Paul's mouth and hit "Submit" on this blog post. It would have been much easier and much better. For example:

"My sense is that the only thing powerful enough to overcome a habit, the only way to overpower that is with community and hospitality," he said. "And that's not tea and crumpits. Find some way to create a local group with curiosity. We didn't set out to create the IHI. We started with a group of people we knew and trusted, and became a community of curiousity."

Anyone who has met Paul has something positive to say about the interaction. He's warm, generous, brilliant, and anxious to share what he knows, which is an awful lot. But it's not how much he knows; it's how he shares it. He tells stories that engage every set of eyes in the room. 

"I remember this visit to one of the parts suppliers at Toyota. They were talking about the employee suggestion system ..." he started at one point on Thursday.

Then another: 

"I remember one time taking care of an 11-year-old boy who developed pancreatitis ..." 

The richness and the lessons of each story stick with you long after he moves on to the next one. And when you think about them later in the day, they mean even more.

The teaching--and the conversation--lasted only 45 minutes, but it's hard to imagine a better way to spend three-quarters of an hour. It was a treat that will last much, much longer.


- Mike Briddon, Managing Editor, IHI Open School

Follow @IHIOpenSchool on Twitter for news and updates from Paris!

Bringing Learning Home from D.C.

Four students—one from Bellin College in Green Bay, WI, and three from Eastern Virginia Medical School (EVMS) in Norfolk—went to the 13^th Annual International Summit on Improving Patient Care in the Office Practice and the Community in Washington, D.C., with hopes of bringing home valuable lessons to their respective communities. The Bellin student was seeking inspiration and some new ideas for her Chapter. The EVMS students were seeking information for Health Outreach Partnership for EVMS Students (HOPES), their student-led free clinic. Here are their experiences:

Kimberly Herman, 4^th year nursing student, Bellin College

I decided to attend the conference with the hope that I could bring back useful information and proven techniques to assist with the quality improvement initiatives that our Bellin College Open School Chapter has undertaken at area hospitals in Green Bay. Having attended the IHI National Forum in Orlando this past December, I was interested in seeing how quality improvement and patient centered care could translate to office and community settings.

I was not disappointed.

It was inspirational to see all of the people in health care that are devoted and actively working to improve the quality, safety, and experience of patients. (I think that too often health care is seen by the public as a business with its focus on making money instead of caring for people, families, and communities.) I attended sessions on interprofessional communication, individualized care, and the use of e-visits and social media as a way to reach out to patients in different ways. This sort of interaction looked into correcting misinformation, informing patients, providing more individualized information, and offering support for a patient during the course of treatment.

From these sessions, I left with realistic and useful ways of helping to provide safe, appropriate, high-quality care in future day-to-day interactions with patients—and several valuable lessons for my Chapter!

ChengXi Wang, medical student, Eastern Virginia Medical School

My primary goal in attending this conference was to gain insight into models of primary care, which I would then share with the EVMS community. Specifically, I wanted to see successful examples of how care can be coordinated across the various health professions and in community-based settings.

I found everything I was looking for—and more.

I learned about the tiers of influence in health care and realized that health education in the doctor’s office just isn’t going to suffice. I saw examples of what worked, including Communities That Care and NUKA (a model of care from the Southcentral Foundation of Alaska), which will serve as frameworks for how I can do the same, albeit on a smaller scale. I learned about Kano and Lean Principles as applied to health care, and cross-training and its importance to team building. Before the last day of the conference was over, I had already sent out correspondences to members of the EVMS community as to what I learned and what we can apply. I even sent correspondences to former coworkers in the Baltimore City Public School System about several hugely applicable principles! (I taught for 5 years prior to attending medical school.) 

To HOPES, I’ve proposed that we revamp the current continuity system so that care coordinators are cross-trained and that at each visit, patients are asked: “What matters to you?” We’ll truly adopt patients as partners in their health care by having a conversation at each visit about contexts and priorities. Utilizing community resources, we’ll help patients with their own goal setting and self-management, celebrate their progress, overcome setbacks, troubleshoot obstacles, and continually re-evaluate their goals and priorities. I hope that this proposal makes its way through the PDSA cycle with results we can then share.

Krishna Aluri and Clay Nelson, medical students, Eastern Virginia Medical School

We went to the conference looking for general ideas and specific strategies for improving the quality and continuity of care in our student-run free clinic that runs on almost no budget and is administered entirely by volunteers. We found applicable and inspiring ideas in talks held by the keynote speakers, in various workshops, and in many other sessions.

Being involved in a clinic that cares for uninsured and underserved patients, we were especially interested in improving continuity of care and ideas for helping patients overcome some of the barriers that they face in receiving and making use of health care. We were inspired by Maureen Bisognano’s discussion of Health Leads and social advocacy (one of our goals and necessities for helping patients), as well as by Dr. Donald Berwick’s explanation of the Health Impact Pyramid— something that we learned to address in the care of patients before I had ever heard of the pyramid itself. In these talks, we learned the importance of assessing each patient’s understanding of their illness and their barriers to care as well as using patient-specific goals, and models for continuity of care to bypass the barriers and get better health care outcomes.

From the learning labs, we took away ideas and goals that included greater automation in our upcoming use of an EMR (such as triggers for e.g. diabetic patients—described by one participant as an IT reminder system for patient care) and the standardization of care using an EMR to achieve specific goals (important for us since the HOPES clinic has continuously changing clinical teams of volunteer students and attendings). Related to social advocacy and continuity of care, we were glad to hear how other clinics and teams improve care coordination by having specific tasks for pre-visit, visit, and follow-up patient encounters that are carried out by a diverse and integrated clinical team (the follow-up, we learned, may have the most significant impact on compliance with treatment plans). Using examples from clinics in underserved areas of the US and abroad, another session showed us how to improve our continuity of care using only limited resources.

In other sessions, we heard about the importance of matching patient materials and education efforts to their health literacy level (which the HOPES clinic and other EVMS programs already strive to do), as well as how to go about assessing barriers and challenges that are keeping patients from reaching their own goals and the goals that their care teams have for them. Along with this, we learned how to study and improve our operations at the clinic by using PDSA cycles to study our efficiency.

We also gained insight into the health care system as it applies to us as a students and future physicians. We were intrigued by comments on sustainable health care and on eliminating the waste in US health care—two major ideas that will affect us as physicians. (Victor Montori’s discussion of patient-centered care was one of our favorite talks.)

Overall, the conference gave us insight into the future of health care implementation that is better designed to meet the needs of the patient population. As a result, we believe we will be able to deliver better patient-centered care and are better equipped to face future health care challenges.

Duke Students Share Three Lessons from the 13th Annual International Summit

As first-year medical students, we spend almost all our time reviewing material related to human health, disease, and the management of illness. This foundation is necessary for practicing medicine.

But we want go above and beyond “necessary and sufficient.” We want to work together with our patients, colleagues, and communities to provide the highest quality, safest, and most effective care—every single time. The skills needed to achieve this goal are lacking in the traditional medical school curriculum.

This is where IHI and IHI Open School come in.

From March 18-20, we attended IHI’s 13^th Annual International Summit on Improving Patient Care in the Office Practice and the Community in Washington, D.C., and were blown away by the advances being made in building systems where each person has the health care that best fits her/him. We walked away with three major themes:

1. For care to be optimal for each unique person, health care must operate in a people-centered fashion. That means considering an individual’s economic and psychosocial circumstances. We learned, for instance, about different case management models that take these factors into account and in which health professionals work with a panel of patients to help them manage chronic illnesses. Work from other countries (Canada, England, Scotland) was particularly revealing in illustrating how different cultures approach these problems, and how, often times, we in the US can be narrow-minded in our thinking of how health care functions and the interactions it can have with other community institutions. On the other end of the spectrum, from large government driven programs, we heard practical advice from leading US solo/small practice physicians in how they achieve high quality care in their relatively resource-limited settings. Seeing how their passion for quality was intertwined with relationships they had formed with their patients over decades was extremely inspiring.

2. We learned that the pace of research on how to improve care is increasing. We live in an era of active research and increasing knowledge on best practices for improvement gaps, such as chronic disease management and avoidable hospital readmissions. As future health care professionals, we need to remain aware of these advances (they may be just as important to our future practice as a drug discovery) and possibly consider becoming involved in health services research ourselves. The panels on the Triple Aim and PDSA were particularly good at illustrating how quality improvement work occurs.

3. Technology provides the backbone to improvement. The process of incorporating technology is cumbersome—both in terms of time and resources. We heard from hospital systems that are using Meaningful Use regulations as a jumping board to achieve higher quality of care. We also learned about the use of mobile apps for individuals to better manage illness. Electronic health records, databases, patient portals, and other technology advances, when used meaningfully, allow health providers and patients to achieve better results. Examples of health data in action from overseas (England, Scotland) offer exciting ideas for how we can also meaningfully use similar data here.

In all, IHI’s 13^th Annual International Summit reminded us once again of the tremendous challenges, but more importantly, exciting opportunities we—as only beginners in our medical journey—will face as we enter the health care field. It is an exciting time. We look forward to staying informed and continuing to work with IHI to build on the great improvement work already being done.

Parastou Fatemi, Medical Student, Duke University School of Medicine and President, Duke IHI Open School Chapter

Marisa Dowling, Medical Student, Duke University School of Medicine and Vice President, Duke IHI Open School Chapter