Wearing My IHI Blue Shirt Every Day

I couldn’t look away. I didn’t know what it was or where it came from, but I couldn’t look away. Was it someone’s sandwich wrapper? Perhaps it was a sheet of paper that someone was too lazy to toss? Either way, I had no choice.

I was compelled to pick a piece of dirty, white paper off the Orlando International Airport floor and throw it away.

You might be wondering why. (Or, you might not be very impressed: “Way to go, man. You picked up a piece of paper and threw it away. Do you want a medal?”) But it’s not so much that I picked it up. It’s why I picked it up.

And the reason can be summed up in five words: I’m an IHI Blue Shirt.

If you’ve ever been to an IHI National Forum, you’ve seen us. Flocks of us. We leave Boston’s Logan Airport by the dozens in early December – all of us bright-eyed, curious, and excited. We come home six days later – all of us bleary-eyed, content, and exhausted. The long hours in between are draining and intense. Sore feet, blisters, and sleep deprivation are more the rule than the exception.

Yet after my first experience in the blue polo shirts last week, it’s something I can’t wait to do again.

Let’s back up and define an IHI Blue Shirt. Technically speaking, we’re IHI staff members (mostly from our headquarters in Cambridge, MA), that come down to the National Forum and help make the 5,000-attendee event a success. More specifically, we run registration, check rooms, greet attendees, manage shuttle buses, create signs, maintain the staff office, provide first aid, dispense conference materials, communicate important updates to hotel staff, comprise the human wall during keynote sessions, and perform any other necessary job.

In short, IHI Blue Shirts exist to do one thing: Delight our National Forum attendees. Lost on your way to your session? Right this way, ma’am. Wondering what time the exhibit hall is open? It’s 11 - 2, sir. I hope you enjoy it. Think we can do something better next year? That’s a great idea. Let me share that feedback at tonight’s staff debrief. (And rest assured that we do discuss it!)

But I learned it’s more than just the simple tasks and extra assistance. It’s more than helping attendees wheel their luggage from one end of the hotel to the other. It’s more than walking more than 10 miles every day. It’s more than the 5 a.m. wakeups, countless paper cuts, and long stares at the gorgeous Florida sun (and glistening pools) through large hotel windows.

What is being an IHI Blue Shirt really all about? Simply put, it’s about going out of your way to help others. And the biggest life lesson I took away from my first week wearing an IHI Blue Shirt was that there’s no reason to ever take it off.

Even when the event ended at 5 p.m. on Wednesday, I wanted to help. I wanted to help clean up. I wanted to help people find the hotel lobby. I wanted to pick dirty pieces of paper off airport floors.

And in a moment of clarity (in between the hours of exhaustion), I realized that even though the experience lasts only one week each year, I should always “wear” my IHI Blue Shirt under my clothes. Why wouldn’t I hold doors, greet people with a smile, or point people in the right direction? Why wouldn’t I go out of my way to help others?

Come to think of it, what if we all wore our “Blue Shirts” every day? People would smile more. People would say “thank you” more. People would connect more. And maybe, just maybe, the world would be a better place.

I do, however, know one thing for sure: The floor of the Orlando International Airport would be cleaner.

- Mike Briddon, Managing Editor, IHI Open School

Tackling Quality Improvement Projects At Georgetown University

As the Community Manager of the IHI Open School, I have the joy of periodically visiting our Chapters to get to know them, hear about the exciting work they’re doing and, help with the challenges they face. This November, it was a pleasure to travel to Georgetown University for my first site visit.

What stood out most about the visit was the passion and energy this Chapter is putting toward its quality improvement projects.

Chapter founder, Dr. Daniel Alyeshmerni, a hospital resident, and Chapter leaders, James Cervantes and Mark Fischer, (both health systems administration students) are guiding many of the Chapter’s 70 students on eight different interprofessional projects at Georgetown University Hospital (GUH). IHI Open School Chapter at GU working group members: Cervantes, Horak, Alyeshmerni, Fisher and O’Mally

The group, which comprises students from medicine, nursing, health administration, and pharmacy, is working on these projects that began approximately 8 months ago:

- Central Line Associated Blood Stream Infections (CLABSI)
- Inpatient Handoff Communication
- Venous Thromboembolism (VTE) Prophylaxis
- Discharge
- Inpatient-Outpatient Handoffs
- Interdisciplinary Rounds
- End-of-residency Handoff Communication
- Hand washing

Just getting started can be a challenge, but the students at Georgetown have been both resourceful and creative. One of the project teams utilized the IHI Open School’s Mentor Matching Tool to identify mentor hospitals with similar demographics and low rates of CLABSI. After identifying New York Beth Israel and Swedish Medical Center as mentor institutions, the Georgetown team hosted regular conference calls with them to learn from what they were doing. From there, the CLABSI team went to hospital leadership, who recommended ideal units to pilot the project. And after initial success, they are now rolling these out to other units at GUH.

The eight projects are in various stages – some are just getting off the ground, others are already collecting data – but each one has the same goal: to improve care for patients in the hospital. (Note: Georgetown is serving as one of 20 test sites in the IHI Open School Quality Improvement Practicum. Click here to learn more.)

And, I was delighted to learn, the QI projects are only one initiative within this vibrant Chapter. Faculty advisors Bernard Horak, Professor of Health Systems Administration, and Dr. Eileen Moore, Assistant Dean for Community Education and Advocacy, along with other faculty members are committed to making this improvement work real and permanent. The group is also striving to:

- Engage more students in their Chapter
- Secure funding for Chapter events and activities
- Integrate QI in curriculum

Georgetown University recognized IHI with a certificate of appreciation for their educational contributions! (From left to right: Fischer, Horak, Cervantes, Perlo, Alyeshmerni and Moore).

Thank you, IHI Open School Chapter at Georgetown, for an excellent first site visit. After a day with your group, I am absolutely inspired by our community of healthcare professionals and can’t wait for the next site visit!

- Jessica Perlo, IHI Open School Community Manager

IHI Open School San Antonio Chapter shines in photo campaign

This fall, the IHI Open School launched a photo campaign to promote empathy, compassion, and patient- and family-centered care. We asked students, residents, faculty, and health professionals to put themselves in the shoes of a patient for one day and take a picture.

As you can see from the colorful collage here, the response was wonderful.
One chapter, the IHI Open School San Antonio Chapter, took center stage. Turning it into a Chapter activity, the members visited a local health care facility and snapped dozens of colorful pictures.

We asked them a Chapter leader Jessica Schwartz, a health care administration student at Trinity University, a few questions about the experience:

Why did you get involved in the photo campaign?
One of our faculty advisors called my attention to this photo campaign and I’m so glad that she did! The concept of asking future healthcare professionals to stop what they’re doing and force themselves to see healthcare from a different perspective is such a valuable opportunity. This process of viewing something familiar from a different vantage point can be quite educational, but also brings us back to what’s important: patient care.

Where did you go to take the pictures?
The Center for the Intrepid in Fort Sam Houston, Texas. Recurrent images of the patient’s perspective are generally in civilian hospitals and portray something negative. We decided to show something different. San Antonio has a large military population and unprecedented capabilities to not only treat them, but bring them to a level of physical and emotional strength thought to be impossible given these injuries.

Center for the Intrepid is an outpatient rehabilitation facility for soldiers who are active duty or veterans. This nationally recognized Armed Forces Rehabilitation Center was donated by more than 600,000 Americans. It offers state-of-the-art facilities for amputees and burn victims. Members of IHI Open School San Antonio were graciously welcomed into this incredible place to capture the miracles that occur there on a daily basis. The pictures that we have submitted include their “clinical, research, and administrative space, a gait lab, a computer assisted rehabilitation environment, a pool, an indoor running track, a two-story climbing wall, and a prosthetic fabrication lab” (CFI brochure).

Who knew the patient’s perspective could be so inspiring?

What were you looking for when you took the pictures?
I tried to capture a day in the life of a patient at Center for the Intrepid. This includes rehab facilities and prosthetics of all kinds in a military setting. I hoped to relay frustration, confusion, and loss, coupled with inspiration, perseverance, and strength.

What was the best picture you took? Why?
Sorry, but I have two! No. 6 and No. 11. (Both are below.)

Picture No. 6 is a detailed aerial view of many of the physical therapy exercises with natural light shining in on the beautiful facilities. It is evident here that you really have to put in work to improve.

Picture No. 11 is a simple image, but very impactful. Two prosthetic legs are seemingly crossed and casually leaning against the table, as if they were already attached to a human being. The running shoes send a powerful message to me. These are not ordinary walking shoes; it is clear that this person was/will be a competitive runner and/or is training for a physical challenge. This describes the majority of patients who come into CFI. They have been physically and mentally strong, focused, and competitive and they will do anything to return to that elite level. Of course there are running shoes already attached to prosthetics.

What lessons did you learn from participating?
I am thankful for this opportunity to further appreciate not only the patient perspective, but also the wounded soldier perspective and road to recovery. In addition to the outstanding capabilities of this facility, I was reminded how important the patient-provider relationship is for a full recovery. Both the patient and the providers (physicians, trainers, etc.) give over 100% every day to yield the best possible result. I walked out of there with a new view of patient care and a new perspective on life.

New Course Provides Refreshing Perspective on Care Delivery

Health care consumes one dollar out of every seven in the US economy, but it remains disappointing in terms of availability and quality of care. It is no surprise that it is central in media coverage and political debate.

Despite all the attention, little headway is made because of a powerful but false assumption: That whatever good is gained must be traded off for something else in return. The reasoning goes that more or better care must be more expensive, so we must chose between getting more or saving money. In other words, we cannot get more, but pay less.

This premise – and the resulting conclusions – is mistaken. In fact, it is possible to provide better care to more people at less per unit and total cost. Accomplishing this requires applying a more sophisticated approach to managing the delivery of care.

The newest course in the IHI Open School, “Achieving Breakthrough Quality, Access, and Affordability,” demonstrates how this more dependable, reliable approach works. By the completion of the course, students will come to understand that:

· The delivery of care is a far more complex undertaking than in years past because the contributions of many more people – spanning many more specialties and disciplines –have to be coordinated and integrated.

· The complexity of systems creates vulnerabilities that weren’t significant in simpler systems. Given the number of contributors involved and the strong interdependencies among their work, small aberrations – that might have had minimal effect – can gel to cause major harm.

· Certain behaviors, if avoided, and other behaviors, if embraced, both protect against these failures and also contribute to success.

As a result of these lessons, the best of both worlds is enjoyed: The full benefit of complexity is appreciated, diagnoses and treatments incorporate what is best known across multiple disciplines, AND the systems that harness all these contributions are reliable and responsive.

- The course is authored by Steven Spear, DBA, MS, MS, Senior Lecturer at the MIT Sloan School of Management, Senior Fellow at the Institute for Healthcare Improvement, and author of a number of influential articles on operational excellence in general and healthcare excellence, and author of the award winning book, The High Velocity Edge.

Wednesday is "One Day in the Life of a Patient"

The IHI Open School's photo campaign, "One Day in the Life of a Patient," is taking place this Wednesday, October 5.

All over the country -- and all over the world -- students and health care providers will pause and put themselves in a patient's shoes. The reason? To see the patient experience through a new set of eyes.

Many of the photos will be posted on the IHI Open School website and others will be used as part of a larger collage at IHI’s National Forum in Orlando in December.

In three easy steps:
1. Take a picture depicting the patient experience on October 5.
2. Write an email that includes your city/state/country and the time of day at which you took the photo.
3. Send the email to openschool@ihi.org.

Here's a video -- filled with pictures from the IHI staff -- to inspire you:

17 Days Until "One Day in the Life of a Patient"

Get your cameras ready for Wednesday, October 5!

This fall, to kick off the school year, the IHI Open School is launching a photo campaign to promote empathy, compassion, and patient- and family-centered care. Simply put, we want you to put yourself in the shoes of a patient for one day – Wednesday, October 5 – and take a picture. The images, which we hope to collect from around the world, can be sad, happy, funny, gross, ironic, silly, serious, or inspiring.

Many of the photos will be posted on the IHI Open School website and others will be used as part of a larger collage at IHI’s National Forum in Orlando in December.

In three easy steps:

1. Take a picture depicting the patient experience on October 5.

2. Write an email that includes your city/state/country and the time of day at which you took the photo.

3. Send the email to openschool@ihi.org.

To help get you in the spirit, we'll feature a new photo each day on our blog. Here is today's:

3:43 p.m. in Cambridge, MA, USA

Chapter Corner: Three Questions to Consider When Planning Quality Improvement Projects

Quality improvement projects benefit both students and organizations in a number of ways. Students have the opportunity to network and develop their improvement skills. Organizations, meanwhile, have the opportunity to meet enthusiastic students dedicated to improving healthcare, develop fresh ideas with student contributions, and guide and mentor the next generation of health professionals.

We just had our fall information session last week, and students have begun sending in their project applications. This is the first year the Atlanta chapter of the IHI Open School has embarked on establishing quality improvement opportunities for students.

Our goal is for students to gain real-world experience by participating in improvement projects, whether it is a snapshot or the various phases of a project. In addition to skills in quality improvement, some of these projects will also allow students to develop skills in patient safety, teamwork, leadership and patient-centered care.

Finding projects
Our group focused heavily on recruitment to gauge student project interest while simultaneously searching for project opportunities at various organizations. We wanted to ensure that there would be enough student interest to participate, but also wanted to ensure that project opportunities existed for student volunteers. I used contacts from informational interviews, previous internships, and professors to ask if their organizations might be interested in having students volunteer their time to quality improvement projects. If these contacts expressed interest, we then discussed the potential projects over a phone call.

Here are a few of the questions we kept in mind during the project planning process:

1. How can we develop and maintain good relationships with participating organizations?
If we maintain good relationships with these organizations, we might find additional project opportunities in the future within and outside of the organization. To maintain these relationships, we plan on touching base with project supervisors every so often throughout the project. And since this is our first year, we have limited the number of IHI Open School projects so we can focus on successful completion of these few projects.

2. What if we get a smaller applicant pool than we expect?
We wanted enough student interest so that each project would be able to find a number of students from various disciplines that would be a good fit for the organization. We emailed faculty/department advisors and our student government association to forward on our IHI Open School information to students. And since medical students are difficult to recruit due to their incredibly busy schedules, we contacted dual degree MD/MPH students that are in their MPH year, where the schedule is more flexible. Our final applicant pool is still yet to be seen.

3. How can we encourage students to share experience and knowledge with other students? While we want students to develop various skills, we also want them to share their project work and knowledge with other fellow students. We hope that this will create a culture of teaching others, developing leaders, and building relationships. We'll be setting up Open School meetings for students to share what they've learned.

It will be interesting to see how these projects progress over the course of the year. If anyone has any comments or suggestions, we would love to hear them!

- Becky Ng, Public Health student, Emory University

Chapter Corner: The Importance of Sharing Knowledge

By itself, content is limiting. While the information from a book is useful, there is no incentive or opportunity to offer an opinion and receive a response. It is simply a one-way flow of information. It's the people we meet and speak to that hold the real knowledge. As social creatures, others' work and life experiences will resonate more with us when we ask questions and have the opportunity to respond directly, whether it is in person or through email. I know all of these things because I learned them firsthand.

I asked a colleague of mine if they knew anyone working with process improvement in healthcare, and they put me in contact with two professors at Emory University's School of Medicine. From these connections, I was put in touch with a director at a nearby hospital's center for clinical performance improvement, as well as the Chief Quality Officers at two other hospitals. I've learned a tremendous amount from my conversations with them.

My conversations with these people were the true driving force that sparked my interest in quality improvement in healthcare, and I try to drop a line to say "hi" every few weeks or months. I'm even working with the director at the clinical performance improvement center to establish a quality improvement project for the Atlanta IHI Open School students. It's experiences like these where I find value in establishing new relationships, especially with those so willing to give back to students.

Here are some other ideas on sharing knowledge:

• Take advantage of others' knowledge by talking to fellow students, teachers, leaders - anyone you can make time for (and can make time for you).
  
• Search on LinkedIn for professionals in the area who are involved in healthcare improvement (after all, wasn't LinkedIn made for networking?).
  
• Email leaders from other schools in your region, or across the country. See what others are doing and network to share ideas.
  
• Read the "Chapter Accomplishments" on the IHI Open School website and find ideas that interest you and your group.
  
• Contact schools to learn more about their methodologies and challenges to accomplishing their goals. (It's been my group's experience that IHI Open School chapter leaders are extremely receptive to sharing ideas.)
  
• Talk to others to share knowledge and to generate opportunities. People generally love to talk about themselves, and would be more than happy to meet or speak about their experiences (probably more willing to do so than you might think).
  
• Talk to professors and coworkers, and ask them about what they do and how they got there. Ask if they know others in quality or process improvement, and see if you could set up a time to chat with them for 15 minutes. This could lead to new partnerships with your chapter, quality improvement projects, mentorships, additional IHI Open School exposure, among other advantages. Once you've developed those relationships, maintain them by following up throughout the year.

I reached out to one of my public health professors to ask about her work in quality improvement and told her about my involvement with the IHI Open School. After some meetings and phone calls, we eventually established two quality and process improvement team projects for IHI students to be involved in, and we hope to find the right students to make these initiatives a success! It's my hope that I'll be able to give back the same way that these professionals did for me.

I've found it invaluable to have these discussions with others, and I encourage other chapters to do the same. It sounds simple, but it can be tough work to find and maintain these relationships. We will always have something new to learn from each other.

- Becky Ng, Public Health student, Emory University

Another Health Care Workshop? Five Reasons Why SQLA is Worth Experiencing

It's been almost six weeks since I left the IHI Open School Student Quality Leadership Academy (SQLA). Admittedly, I volunteered to put together a blog post weeks ago, but my hectic schedule as an outgoing student (classes, work, research projects, job interviews, networking, and summer visitors) kept stealing my attention.

As an emerging health professional, I have availed myself of numerous free networking events and educational seminars (and food). Eventually, after attending so many that fixated on the need for change in health care, I became jaded about how much these events actually contribute to inspiring innovation. But when I heard of SQLA, knowing IHI's great reputation for visionary leadership in health care improvement, I couldn't shake the feeling that this program was going to be different from the rest. Since attending, I have felt inspired to share my experiences with prospective attendees and, in the process, encourage you to apply for next year's Academy.

Upon reflecting on the lectures and activities from the SQLA weekend, there are five reasons why I would recommend taking part in SQLA to all students in any field of health care (I personally am a clinical social worker and MPH candidate in Health Policy & Management):

1. Exposure to Diverse Perspectives: At our table alone, we had two international students, a nursing undergraduate, a physician, several advanced med students, a Masters-level nurse, and a public health social worker (yours truly), representing great diversity in geography, race/ethnicity, age, and education. Each member contributed thoughtful examples and insight from his or her actual experiences, covering an even broader spectrum of sub-specializations (mine is behavioral health). This rich confluence of experiences was very enlightening, introducing me to the perspectives of professionals in other health care areas with whom I have literally never interacted, and may not have for much longer if not for SQLA. For too long there has been an unfortunate dearth of cross-disciplinary collaboration among our segregated health schools, and SQLA breaks down these barriers.

2. Unbeatable Expertise: All of the weekend's presenters were seasoned veterans of health care leadership and innovation. Each one holds or has held very senior positions in national policy advising and/or academic medical centers. This year's presenters were predominantly current or past leaders from Beth Israel Deaconess Medical Center in Boston - one of the most respected, innovative health care organizations in New England. The only one without at least 20 years of professional health care experience was Dr. John Halamka, who is merely the youngest chief officer in the history of BIDC, had served as a key health information technology (HIT) advisor to the Obama Administration, and was recently contracted by Japan to assist development of a new HIT system across their Northern region following this year's devastating earthquake and tsunami. To say his knowledge and perspective are expansive is a serious understatement, and each presenter was of equally strong caliber.

3. Gaining Essential Management Skills: Take a walk in the woods to build rapport with your opponents and identify shared values. Use interest-based negotiation methods to manage and overcome conflicts. Implement "double-loop learning" to learn from and prevent future conflict situations. Carefully choose when to identify people instead of numbers when quantifying problems. Learn how leadership vision and operations management can foster an environment that minimizes conflict. The "Transition Curve" framework offers a method for managers to conceptualize and facilitate change processes with minimal staff resistance. Before embarking on a difficult conversation, ask those involved about their understanding of a situation, and let this guide your approach and language. These are just several of many examples to evidence that SQLA actually covers concrete management techniques that any of us can apply to improve our team's performance, morale, and ability to adopt innovations.

4. Assessing Personal Strengths and Needs: Through exposure to new management concepts, personal anecdotes from presenters, and group and individual exercises, the weekend at the Leadership Academy gave me the time and tools I needed to identify where I may struggle and succeed as a new manager in the health care industry. This self-understanding will be handy for upcoming job interviews, and also in identifying positions where I'm most likely to succeed.

5. Having Fun! Of course, after days full of challenging sessions, self-evaluation, and passionate presentations on health innovation, we were able to unwind. Harvard Square (and the rest of nearby downtown Boston!) offers a plentiful assortment of interesting activities and quality spots to pass the time with good people and entertainment. This year featured a public dance party in front of Cambridge City Hall, which closed down the largest roadway through town and featured thousands of locals partaking in a good old fashioned outdoor celebration. After three years in the same social and professional circles, networking, story-swapping, and joke-telling with 100 new, equally passionate students was rejuvenating. The city offers an eventful, lively locale for this gathering, which is pivotal because our work, no matter how valuable or urgent, cannot become our entire life. So once the lessons have been learned, there is much-deserved time to get out and play! So come early, stay late, and enjoy the marvelous landscape, history, culture and nightlife of Boston. Good things should come to those who wait (and bravely work on the daunting challenge of health care improvement)!

- Sandy Cohen, MSW, Boston University School of Public Health

Chapter Corner: Happy Hour in Atlanta!

This is the newest installment in a series of posts written by chapter leaders and members. The goal, simply, is to share best practices and creative ideas with other chapters around the globe.

I love happy hours. But I love them even more when they are an excuse to spread the word about the IHI Open School.

My group, the Atlanta IHI Open School Chapter, is made up of students from Emory University and the Georgia Institute of Technology. We kicked off recruitment for 2011 on July 7th with an IHI Open School information session. We followed this up with a happy hour the following Saturday.

Why did we do a happy hour? We think social events like these build solidarity between group members from different schools. These are opportunities for our current and prospective members to meet other students outside of our particular programs. Events like the happy hour will help develop friendships and create an added incentive to participate in IHI Open School activities throughout the school year. We had a turnout of about 10 at our happy hour session, despite the pouring rain. The vice president of Health Students Taking Action Together (HealthSTAT) was also in attendance, and she and our president have discussed plans of co-sponsoring events throughout the year.

Even better, our summer information session turnout was great with over 20 attendees, including a handful of healthcare professionals. At our meeting we included snacks and distributed a fact sheet that summarized the IHI Open School, our goals for the year, and proposed upcoming events.

Here are three questions - and answers - we think might be helpful for other Chapters:

What did we include in our information session agenda?
1. A Denver Health patient safety video
2. Introductions around the room
3. Small groups to briefly share any personal stories of patient harm or unjust culture
4. A short presentation made by our chapter president describing what IHI is, the Open School, and what we've done so far
5. An overview of what we have planned for the year, including:
- Monthly "lunch and learns"
- IHI modules to be integrated into school curriculum
- Upcoming quality improvement projects
6. Don Berwick's Introduction to Open School video
7. A survey asking about interest in events and involvement

Why start recruitment in the summer?
We want students to start thinking about the IHI Open School and talk to their friends about it. We feel the interest-we just have to get the word out! We also want students to start preparing for any quality projects they might be interested in by taking the IHI quality modules as early as possible to prepare.

How did we advertise our event?
We asked our schools and departments to forward our event email and flyer to the current and incoming class, as well as posted flyers around schools. We also emailed any connections we had with faculty and professionals to pass on the word to any interested individuals.

We're trying to foster a supportive environment where we can build relationships and share ideas. Social events like the happy hour can help facilitate this, in addition to our group meetings and learning events. What are your thoughts?

- Becky Ng, Public Health student, Emory University

Chapter Corner: Five Rules of (Student) Engagement

This is the first in a new series of posts written by chapter leaders. The goal, simply, is to share best practices and creative ideas with other chapters around the globe.

One of the biggest challenges that we face as a group at UMass (in Worcester, MA) is encouraging people to come to our events and classes. The topics and the speakers may be fantastic, but the audience consists of only about 10 students. It is difficult to engage students in anything outside of the board exams even if the material will be important in their careers. We worked hard to increase student interest and attendance at events this past year. Things did not always work out for us, but the following are some of the strategies that we used to bring students in:

1. Make it personal for the students. Take a story that will really hit home and organize a speaker or a class around that one story. For example, we had a death at UMass Medical Center on the telemetry floor. The story was all over the local news broadcasts and many students were discussing the case, especially saying that they were embarrassed to represent UMass. We took a different spin and invited the physician who was working to solve the problem to come and speak. He talked about what UMass was doing to prevent future incidents of alert fatigue and really excited the students to get involved in solving the problems instead of gossiping about them.

2. Early preparation is critical! We had one event that had great speakers and a really interesting topic, but we had the worst luck getting a room. The day before the event a room finally opens up, and we emailed out to all of the students with the room assignment. The morning of the event room reservations calls us and switches the room. So we email again saying, "Last minute room change!!" Later that day, mere hours before our event, we get switched to yet another room. So we send out another room change email, but at this point, it is just about time to get started. In the end, we had fewer than 10 students in attendance. Lesson learned? Get all your ducks in a line quickly and early so you can accurately advertise long before the event.

3. Get creative with your advertising. This example doesn't come from our IHI Chapter, but one of the global health groups on campus sponsored an HIV/AIDS awareness event. To advertise, they gave out small goodie bags in class. These contained two condoms and enough M+M candies to represent a day's worth of antiretroviral medications. They also included a short written piece with some facts about HIV and an invitation to their event. Even if people didn't attend the event, they were exposed to the problem and the ideas they were promoting.

4. Bring in the big guns! Include professors and administrators in the planning, and definitely send them an invitation. It adds legitimacy to events that you are organizing. We ran a panel event on interprofessional communication, and we had the dean of the school of nursing in attendance. She really encouraged nursing students to attend. We had great turnout from the school of nursing, especially relative to medical and graduate students.

5. Schedule informal events around your class breaks. We started a series of "lunch and learn" events during the lunch breaks in our class schedules. These were short events, usually about 45 minutes, where students would pack a lunch and we would lead a discussion of a case study or recent article. The Open School web resources are fantastic for this sort of forum and attendance was good because people were sitting around campus anyways.

These were some of the strategies that really helped us this year, but we still have a long way to go in engaging students in QI and patient safety. Sadly free food tends to be the best motivator, and we just don't have the budget to feed hungry grad students with every event.

What have other people done at their chapters?

- Aubrey Samost, medical student, University of Massachusetts

Lessons Learned from the IHI Open School Student Leadership Academy

On June 24 and 25, many healthcare students and professionals converged on Harvard Square in Cambridge, MA, for a two-day forum on leadership. I think I speak for more than just myself when I say the weekend was fantastic -- both highly entertaining and educational. Our moderator for the weekend was Dr. James Reinertsen, the former CEO of CareGroup and current president of The Reinertsen Group. Over the two busy days of the conference, somehow his energy never flagged, and he was able to keep us energized and engaged. At the end of the weekend, Dr. Reinertsen left us with a parting message on life-long learning and how there are three equally important components of it:

1. The continuous acquisition of knowledge


2. Personal experiences


3. Reflection on the first two parts

So, just for you Dr. Reinertsen, these are my reflections on the incredible amount that I learned and the wonderful experience I had during those two days in Harvard Square:

The easiest, but perhaps most complicated place to start is to ask, "What did I learn?" Through didactic sessions, I learned conflict management (I wasn't surprised to find that I'm an avoider) and how to take a walk in the woods (a negotiation technique, actually). Through the lectures and anecdotes from the invited speakers, I learned about how to lead through a crisis (like a massive computer system crash), how to lead without authority, and the benefit of a fancy job title. Through exercises, I learned how to effectively have awkward conversations (like dumping a guy or firing an employee) and how to assess the safety of a patient care unit by observing its teamwork. All of these skills I anticipate using throughout my career and life.

While the lectures were useful and enlightening, I would be greatly remiss if I didn't discuss everything I learned from the other participants, the other students. We were assigned seating right from the start to force us to meet people we might not have interacted with otherwise. I ended up sitting with one other medical student, a psychology student, two nursing students, and three healthcare administration students. This medley of backgrounds and people's unique experiences made the discussion very lively. It was eye-opening to hear everyone's perspective on a problem because they could be so different from my own. Looking back, it makes me really appreciate a drawing that Dr. Barry Dorn (one of the speakers) made of a cone in a box which highlighted an important lesson: Where you are looking from greatly influences what you see.

Needless to say, I learned a lot this past weekend, both from the speakers and from my peers. The lessons I learned are not found in textbooks or medical school lectures even though they are critical to our future work. I am extremely grateful that I had the opportunity to attend the Leadership Academy. The knowledge and experiences that I gained are definitely going to stick with me as I continue on my path toward becoming a physician.



- Aubrey Samost, University of Massachusetts

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

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.

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!

Swiffer Solutions for Health Care

Eva Luo “co-blogs” with guest contributor Curtis Chan, an analyst at Innosight, an innovation consulting firm in Watertown, MA co-founded by HBS professor and innovation expert Clay Christensen.



When I imagine a world without the Swiffer, I see it as a post-apocalyptic dustscape. Dead skin cells sublimate and overtake nitrogen as the most prevalent constituent of the atmosphere. People have acclimated to the ubiquity of filth, spills, and dirt: soil is no longer tracked into the house – your mom yells at you for adding a fresh coat to the carpet of mud. And, fully unbridled, wanton dust bunnies spawn like, well, bunnies.

Fortunately, Swiffer does exist. Launched by Proctor & Gamble (P&G) in 1999, the cleaning product had 75% market share of the quick-clean market, which totaled $750 million in revenue in 2005. (1) With the massive success of the product, have you ever stopped to think to yourself: “It’s a disposable towel. On a stick. Where the heck did Swiffer come from? And how in the heck did P&G dream it up?”

The answer, it seems, is by just looking. As revealed in The Innovator’s Guide to Growth, Swiffer was the product of an observational study conducted by P&G that followed consumers around their homes, looking around the house, observing behaviors, and generally hunting for clues as to what kinds of things consumers need to get done throughout the day. (2) The observed consumer needs and desires that the researchers observed helped inform P&G how to create and design innovative products or processes to help meet those needs and desires.

For fun, I’m going to take more than a few liberties with the details of an anecdote from the observational study here, but the message is faithful. This is how I would imagine an episode of the P&G study:

Two P&G researchers followed a nice, grandmotherly lady as she ambled about, showing them around her house. When she flung the doors of her closet open, the researchers noticed that a broom covered with dust stood in the corner. In another closet, a vacuum cleaner sat, unused and forlorn. The researchers nodded conspiratorially at each other as they jotted notes.

They all wandered into the kitchen. Jarring the researchers from their note-taking frenzy, the woman asked them, “Would you nice boys like some coffee?” The researchers agreed, blushing at being called “nice boys.” As the woman took a can of coffee grounds down from the pantry and opened it, the can slipped from her hands. She cried out as the can tumbled to the ground, strewing coffee grounds across the floor.

Instantly, she grabbed a paper towel and attacked the mess, muttering to herself as she crouched on the floor. When she stood again, the researchers were staring at her, befuddled. “What?” she asked, the look of puzzlement on their faces engendering a puzzlement of her own. “You didn’t use the broom,” one researcher remarked. “Or the vacuum cleaner,” the other chimed in.

With a sigh, the lady vented her frustration –the broom wouldn’t do a good-enough job and would leave coffee grounds on the floor, and the vacuum cleaner was heavy, cumbersome, needed to be plugged in, and was just overkill for the small mishap.

The researchers nodded and wrote. Then, flipping their notebooks closed, they smiled and glanced at each other again with that same conspiratorial look, the gleam of excited insight shining from their eyes.

P&G took the findings from their observational research and created the Swiffer, a dispensable electrostatic cloth fixed on the end of a long handle, which got the job done of cleaning up small spills just right. By employing an observational approach – in the natural setting of consumption – the researchers were able to see what the old lady would never have been able to tell them in a survey or a focus group; they were able to notice products around the home that went unused and were able to watch actual behaviors during real-time events. Based on real environments and behaviors, researchers can ask more informed questions to garner more useful, reality-based consumer responses. Indeed, by employing observational research, P&G was able to understand their customers and precisely what they needed and wanted to get done in the day.

Are there health care Swiffer stories? Can observational research help us better understand our patients and what they both need and want in order to achieve better health and experience better health care? The answer, it seems, is yes.



One such example is Project HEALTH, a non-profit organization located in Boston, MA that seeks to break the link between poverty and poor health outcomes. The story of Project HEALTH’s birth is a story of observational research, just like the Swiffer story. Dr. Barry Zuckerman, Chief of Pediatrics at Boston Medical Center and Co-Founder of Project HEALTH often tells this story:

A six-year-old boy who suffered from uncontrolled asthma arrives at the Boston Medical Center for care. Despite receiving daily oral doses of corticosteroids, a common asthma prevention medication, he was absent from school once or twice every six weeks. As a result, his mom was forced to miss work in order to take care of him and bring him to the hospital for care. The boy has insurance, so access is not the problem. He is also seeking care at Boston Medical Center, a reputable teaching hospital, so neither is quality of care the cause for his frequent visits to the hospital. Why then is asthma a major disruption in his life and the life of his family?

On a visit to the young boy’s home, the visiting nurse discovered asthma triggers: mold due to a leaky water pipe and wall-to-wall carpeting harboring dust mites. Thus, each step of improvement the young boy tried to make was inevitably countered by his poor living conditions. Dr. Zuckerman often says, “I can provide the most updated form of medical care for low income families, but they would still get sick.” Upon discovery of the asthma triggers in the young boy’s home, negotiations with the landlord led to replacement of the leaky pipe, clean-up of the mold, and removal of the carpet. Within six weeks, the young boy had stopped corticosteroid asthma treatment and was attending school regularly. (3)

Rebecca Onie, Co-Founder of Project HEALTH adds another layer to Dr. Zuckerman’s observational research. Onie notes that several physicians understand this connection between poverty and poor health outcomes but are “frustrated because the clinical interventions that they can do in 18 minutes are not enough to change the health of their patients.” Furthermore, physicians are often unaware of what they can do to help address these psychosocial issues. This physician and caregiver inaction is a systems design problem.

Combining these two parts of observational research has led to a health care Swiffer: an innovative new care model that meets the patients’ needs called Project HEALTH. This is the logic: The hospital is the site where health care is delivered—and with just a minor stretch is also a convenient site where psychosocial interventions can be introduced to better and more comprehensively improve the health of kids and their families. The systems redesign answer is a crew of motivated college students stationed in the hospital. If doctors feel their patients need assistance obtaining housing, have food insecurities, or can benefit from utilities bills discount programs, doctors can now refer patients to Project HEALTH volunteers who work with patients to obtain those resources right there in the hospital.

A simple solution that has achieved great positive change, Project HEALTH now has locations in New York, Providence, Chicago, Baltimore, and Washington D.C. Project HEALTH was also just recognized by Michelle Obama at Time’s 100 Most Influential People Awards Gala. This year, 600 Project HEALTH volunteers will dedicate 100,000 hours to connect over 15,000 low-income children and adults with the resources they need to be healthy. (4)

How could health care improve if observational research was more commonly used? Are there Swiffer-like solutions for every health care problem?

Following the model of observational research itself: Let’s look and see.

Patients Take Center Stage in Gawande's Writing

It's been nearly three weeks since Atul Gawande's article, "The Cost Conundrum," was published in The New Yorker. But the buzz and excitement has not even begun to dwindle. On the contrary, my friends who never paid any attention to health care are now asking me questions like, "So, what's with the health care costs in the US?", "What is Obama talking about?", "Dartmouth Atlas? What is that?", "Is the US going to get universal health care?", "Can we fix the incentives to reduce waste?", "Is the overuse mainly a result of practices of defensive medicine?"...

To all of my friends who have asked me questions, thank you and keep them coming! As a very soon to be medical school student, I care a great deal about health care. While I understand everyone has their own passions, it has always surprised me by how little people cared about a system that everyone has had experience with. But, thanks to Atul Gawande, I now have an excuse to blabber on ad nauseam about health care to all!


Word Cloud from Atul Gawande's "Cost Conundrum" piece


Word Cloud from Atul Gawande's University of Chicago Pritzker School of Medicine Commencement Address

Why the sudden shift in interest? The facts that Atul Gawande is a eloquent and powerful writer, Obama has made Gawande's article mandatory reading for the White House, and that it's all over the news are important factors. However, for the first time, I think the health care reform agenda is being painted in a new light. Sure, insurance and coverage are still big topics; but there are new ideas being tossed around like quality, patient-centeredness, culture of medicine, and team work. Just take a look at the word clouds of Gawande's pieces!

Most importantly, patients are now a big part of what many see as the pathway to a better health care system. What do patients need and want? How can we as health care providers and engineers of the health care system provide better care for the patients? Since we are all going to be patients at some point in our lives, these arguments hit a very personal chord. Hopefully, as we continue to search for the best health reform plan, we can all dig deep and remember the true purpose of health care and let that notion guide us.

Thanks to Ben Tseng for sending me this piece in the Washington Post with the Gawande word clouds. These images are all too powerful!

Here is another great related Atul Gawande piece that focuses on quality: "The Bell Curve" published in The New Yorker.

Pay for Performance and A Glass Jar for Marbles

Throughout elementary school, middle school, and high school, the best term that would describe me would be, "teacher's pet." I was not trendy, funny, sporty, or rebellious. I was good at following the rules. And most importantly, I was recognized for following the rules both in a good way (by my teachers) and a bad way (by my classmates). I'm not entirely sure what motivated me to follow the rules, but thinking about my quest for good behavior through a "pay for performance" lens may provide some interesting insights.

"Pay for performance" or P4P is a hotly debated topic in health care. Many who see the perverse misalignment of incentives in the current "fee for service" or FFS payment schemes often suggest P4P as an alternative. P4P, as defined by Dr. Don Berwick, is "a contingent relationship, enforced, and implemented in an organizational hierarchy, in which supervisors judge the merit of the work of those below them in the hierarchy and, based on those judgments, give out variable and contingent financial rewards."

In the second grade, the P4P system looked like this: Each student had a glass jar sitting in the corner of his or her desk. Ms. Gabso always carried with her a handful of marbles. Whenever she saw us behaving well, she would drop a marble in our jars. Good behavior meant not talking when she was talking; sitting quietly with our hands folded at the start of each day and as we waited for dismissal; having all of our books ready whenever we switched between subjects; and raising our hand to speak in class. Once our jar was filled with marbles, we got the chance to open the treasure chest on Ms. Gabso's desk and pick out a trinket to take home with us.

In Ms. Gabso's class merit was good behavior and our rewards were marbles. That sounds simple and fair, right?

Well, not exactly. True to being a "teacher's pet" I probably racked up the greatest number of trips to the treasure chest. But, I don't think I was the best behaved student in class. Even though I was just a second grader, I quickly picked up on my fortunate advantages. Consider the following important factors in being awarded marbles:

1) Location in classroom: Ms. Gabso dropped marbles into our jars as she walked around the classroom. The path she walked most often was between her desk and the front of the classroom. I happened to sit right along this path. That means poor Tommy who sat in the back corner of the classroom would never get marbles unless his extraordinary good behavior caught Ms. Gabso's attention or she happened to walk by that corner of the classroom.

2) Material and appearance of the marbles: The marbles were identical and made of glass. Being slippery, they were not easy to maneuver in Ms. Gabso's hands. This made it difficult for her to accurately control the number of marbles awarded. Sometimes one marble became three marbles because two would slip out. Because all of the marbles looked exactly the same, once you accumulated a good number of marbles, mistakes of awarding too many marbles or too little marbles could not be easily corrected.

3) Placement of marble jar: Glass jars in a second grade classroom is a recipe for accidents. However, our desks were grouped in clusters of six (a two by two square of desks flanked by one desk on opposite sides of the square). Those of us sitting in the square, had our jars grouped in the center. Again, because the marbles often slipped out of Ms. Gabso's hands, a few marbles to my friend Lauren on my right could also mean one or two marbles into my jar by mistake. This meant that my friends sitting on the ends always seemed to have less marbles than those of us in the center.

4) Good posture: Though she never said so, Ms. Gabso was a fan of good posture. Rather than just having your hands folded on your desk at the beginning and end of each day, if you also sat up straight, you were more likely to get noticed and be awarded with marbles.

5) First impressions: After the first few weeks of school, Ms. Gabso had identified a handful of best behaved students and throughout the year it was these students that continually were rewarded with marbles. Ms. Gabso is human after all. So, only consistent exceptional behavior as demonstrated since the beginning of the school year and dramatic improvements in behavior were noticed. If you fell somewhere in between, you were rewarded less frequently.

These five points mentioned have absolutely nothing to do with good behavior and are arbitrary and uncontrollable characteristics of this P4P system for good behavior. From Tommy in the back corner's point of view, Ms. Gabso's marble system was not fair. More troublesome is the attitude that the class developed: we only had to behave when Ms. Gabso was watching. This change in attitude was reflected in the fact that Ms. Gabso never needed to send any of her students to be disciplined by the assistant principle, but our electives instructors did.

Now, if the students were health care providers, the merit clinical performance, and the reward a financial bonus, what could you get in return? A P4P system that encouraged health care providers to only perform well on what was being measured and only when being evaluated. Does that sound like an improved and reliable system to you?

I will have to admit that my "teacher's pet" feathers have not completely been shed. Since Ms. Gabso was the only teacher to have such a P4P system in place, what continues to motivate me to follow the rules and always be on my best behavior? I think it must be the intrinsic satisfaction I must gain from following the rules and behaving well. For example, I don't need a bouquet of flowers after every dance performance to enjoy dancing and performing.

In health care, there is natural satisfaction gained from relieving pain, answering questions, working in a team, and helping those in need. Personally, I'd want my doctor to give me medical advice and the correct prescriptions not because he'll get an extra bonus at the end of the month, but because of the pride and joy he gains from caring for others.

Now, with that in mind, is P4P really a health reform panacea?

WIHI: The Blogosphere's Hospital CEO

Did y'all get a chance to tune into WIHI's discussion about hospital readmissions or the last broadcast about health IT? If you did, I'm sure you can't wait for the next installment of WIHI.

Join Madge Kaplan this THURSDAY for a discussion with Paul Levy, President and CEO of Beth Israel Deaconess Medical Center. Paul Levy with his blog "Running a Hospital" has become a true pioneer in health care. His blog entries are "must-reads" for any health care leader, administrator, or clinician interested in building cultures of improvement, safety, and transparency. Don't forget to register to listen here.

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

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

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

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

Past WIHI broadcasts are archived and available for download here.

If you have been following these WIHI broadcasts, please let us know by leaving a comment!

Teach Us How to Let Go

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

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

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

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

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

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

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

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

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

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

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

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