Vanderbilt Chapter Update

The Vanderbilt Chapter of the IHI Open School has launched with interest and enthusiasm from a diverse group of Vanderbilt students, faculty, staff, and administrators. With the assistance of some close friends and our fellow National Forum attendees, we have secured a faculty advisor--Sebastian Strom, M.D., M.B.A.--and a dean advisor--Bonnie Miller, M.D.--who are committed to engaging students in quality improvement and patient safety efforts.

While the Vanderbilt Chapter is still in its inception phases, we have many things cooking: we are drafting a mission statement to direct our current and future efforts; scheduling meetings with quality improvement and patient safety stakeholders, such as our Chief Quality Officer; and planning our first open meeting, which aims to recruit students from the School of Nursing, Owen Graduate School of Business, as well as the rest of the School of Medicine. In the meantime, we are generating a list of potential chapter projects, which we envision will be independently managed by teams of Open School students with the assistance of key faculty.

Specifically, plans are in the works to create a School of Medicine elective that will allow students to participate in quality improvement efforts across the medical center and earn credit towards their M.D. degree. The elective would be a practical complement to the IHI Open School's online curriculum. Having the Senior Associate Dean for Health Sciences Education as one of our advisors should facilitate some of our curricular efforts: we think we will able to offer this elective by the next academic semester. Eventually, we hope to open this elective to students from Vanderbilt's other graduate schools, but securing administrative support for an interdisciplinary elective may take a little more time.

Furthermore, we plan to work closely with the medical school curriculum development team to integrate foundational quality improvement and patient safety topics into our new medical school curriculum to pique students' interests in the field and draw them to the IHI Open School. Additionally, we hope to create new long-term quality improvement and patient safety research opportunities for students under the School of Medicine's Emphasis Program, building on existing ones that are overseen by Robert Dittus, M.D., M.P.H., one of Vanderbilt's quality improvement gurus.

Finally, we are exploring quality improvement opportunities outside of the traditional acute care setting, e.g., at Vanderbilt's free student-run community health clinic, The Shade Tree Family Clinic, and with Vanderbilt's employee wellness program, HEALTH Plus.

These projects are materializing as the Chapter builds a foundational organizational structure and continues to recruit members from the Vanderbilt community. In the future, we hope to expand our membership to other Nashville universities and hospitals. However, while our plans are ambitious, we are starting small and hoping to secure greater support from our community with early accomplishments.

Irving Ye and Piotr Pilarski
Co-Leaders, Vanderbilt Chapter of the IHI Open School

Muda Reduction and Users' Needs

In middle school, my height greatly concerned my parents. Drink more milk. Eat more fish. Of all of the homespun remedies out there, my parents were sold on the idea that if I jumped more I would grow taller. My dad was convinced that 10 jumps a day would do the trick. So, we bought a trampoline. But after one week, the novelty of having a trampoline wore off. Though the trampoline was unconventionally placed in our living room, it was still located in the room that I probably spent the least amount of time in. Moving the trampoline into a hallway was just not feasible. To keep me on track, my dad hung a ball from the ceiling along the path I usually walk from my room to the kitchen; knowing that I wouldn't be able to resist trying to tap the ball as I walked. This ensured that I jumped at least twice a day, which I guess was good enough for my dad.

What I just described is a very natural and logical process: designing and adjusting a system or service to fit the user's needs. Dr. Don Berwick summaries this idea in a one line maxim, "Every system is perfectly designed to achieve exactly the results it gets." If my dad hadn't hung a ball from the ceiling, I would gradually never jump. New products and inventions are born from the needs of users and the degree of success of a new product is based on the product's ability to satisfy the user.



Google, famous for promoting innovation, takes the opinions of users very seriously in its innovations process. Before releasing a product to the public, one of Google's important first steps is to try the product internally. Google and other industries call this "eating your own dog food." And the feedback process doesn't end there! Most of Google's products have official blogs that encourage users to comment, sharing their thoughts and experiences and eventually helping to shape and improve the product. It's no wonder Google's products are so infectious (I may be biased as I use Gmail, GChat, Google Docs, Google Desktop, Picasa, Google Maps, Google Latitude, Google Reader, and Google as a search engine). The products make my time on the internet effective and enriching.

With the passing of the stimulus plan, President Obama's Tuesday speech, and President Obama's budget, we all know that health care in the US could be more efficient. While most of the talk has been about plans and actions to reduce cost via reallocation of money within the system, a closer look at how a hospital operates today will show that many of health care's processes are inefficient. The Japanese term for this wastefulness that doesn't add value is muda. Some categories of muda include: rework, delays, overproduction, defects, movement, and waste of skill and spirit. So, when trying to eliminate muda, it's not simply change that needs to occur, but change that adds value and is meaningful to the user.

Reducing hospital infections through hand-washing is an interesting example. Hospitals are teaming with tons of microbes that can make people sick. So, sanitation is of utmost importance. Health providers for the most part are very well-meaning individuals who would probably drop everything to care for their patients. Unfortunately, this sometimes means forgetting to wash their hands between seeing patients. Effective hand-washing with soap and water takes time that providers complain that they just don't have. Solution? Alcohol dispensers!



However, simply installing alcohol dispensers was not enough to increase hand-washing. Upon closer inspection, the newly installed dispensers rarely had to be refilled, which indicated that they were rarely being used! To figure out why, infection control specialists had to ask the users. What they found was that providers are often rushing into rooms with several items in their hands: prescriptions, charts, files, and pens. Placing dispensers in the hallways did not make sense because hallways were not where care was delivered. But, the solution was not as simple as moving dispensers into the rooms. Providers had to be reminded to use the dispensers and also needed a surface to place all of their things to free their hands. New solution: place the dispensers within the line of the providers' vision and include a flat surface for their things. Muda reduced.

Google's success, the increase in hand-washing in hospitals, and my dad's intervention all have their respective users to thank. The abilities to improve, innovate, and be agile and responsive are at an extreme premium in today's world. But, underlying all of these abilities is the prudence and sensitivity to address users' needs. Can you think of any other muda processes in your daily life or health care? How would you eliminate the muda and what is the underlying user need?

Perhaps the overall expert in muda reduction is my sister. She just couldn't risk having me grow taller than her. So, after a few days, she removed the ball from the ceiling and I eventually stopped jumping. Her system was perfectly designed to achieve the results that it got. I am at best 2.5 inches shorter than my sister.

Sorrel King is on call

Did you catch today's On Call teleconference with patient advocate Sorrel King? If you had a question or comment that you didn't get to share, here's your chance to weigh in. Sorrel will check this blog frequently and respond to your questions for the next few weeks.

Just click on the "Comments" link at the bottom of this post and leave your question or comment.

If you didn't catch the call, check out the recording and transcript. You can also watch a video of Sorrel telling the story of her daughter Josie, who died in 2001 as a result of medical errors.

Channeling Grief into Action: Creating a Culture of Safety...On Call with Sorrel King

On February 22, 2001, Sorrel King’s 18-month old daughter, Josie, died from medical errors incurred at Johns Hopkins Hospital. Channeling her grief and anger into determination, Sorrel created the Josie King Foundation, which is dedicated to making health care safer by creating an environment where providers, patients, and families can work together.

Sorrel believes that it is up to students to create this new culture in health care – a culture of safety.

Hear her moving story and learn:
• How to listen to patients more effectively
• How to speak up on behalf of patients even when you're at the bottom of your organization's hierarchy
• How to make patients and families an effective part of the care team

Join this free call! Advance registration is required. Click here to register!

Tuesday, February 24, 2009
5:00 - 6:00 PM Eastern Time
4:00 - 5:00 PM Central Time
3:00 - 4:00 PM Mountain Time
2:00 - 3:00 PM Pacific Time

Watch a video of Sorrel telling Josie's story.

This free call is part of a monthly audio conference series that brings experts in health care improvement together with students from medicine, nursing, dentistry, pharmacy, health care management, public health, and other allied health professions. Each hour-long call is moderated by a student, ends with a question-and-answer period, and focuses on an issue that affects you. Visit our website to download audio files or written transcripts of past On Call audio conferences.

Hope to see you all on the call!

How Would You Advise President Obama?

The American Recovery and Reinvestment Act of 2009 was signed by President Obama yesterday. The $787 billion economic stimulus package's health care provisions have demonstrated that health care reform is still on the table. The package includes funding for comparative effectiveness research, health insurance coverage for unemployed workers, health information technology, Medicare, Medicaid, and the NIH. The many concerns that have been expressed in the past few years in regards to health care have not fallen on deaf ears. Now that you have President Obama's attention, what would you advise him to do?

KaiserEDU.org is now accepting entries for its Annual Essay Contest, giving undergraduate and graduate students a chance to win a prize of $1,000 by writing an essay addressing the elements of health reform that President Obama's team should focus on in 2009.

Essay Topic: President Obama has stated that reforming the health care system is one of his top priorities, and there is broad interest from policymakers and the public in making a change. During the campaign, he outlined a framework for reforming health care. The essay should cover: what elements of his plan should be prioritized given the current economic crisis, what elements are most likely to garner support and which ones will be most challenging and why?

Click here to find out more information about the contest!

Check out an article titled, "The Lessons of Success--Revisiting the Medicare Story," by David Blumenthal, M.D., M.P.P., and James Morone, Ph.D. in The New England Journal of Medicine to start thinking about Presidents and health care reform.

Don't feel like writing an essay? Post a comment and share your thoughts!

How Many Ways Are There to Bake Bread?

If there was a contest out there that measured the degree to which an individual enjoyed food, my family would take the cake! My relatives in China are notoriously known as the overweight ones. My great uncle in Taiwan insists on trying a little bit of everything and can never eat the same cuisine two days in a row. It's really no surprise that a good percentage of my family decided to live in Houston, one of America's fattest cities. To make matters worse, my family's love for food extends beyond our consumption behaviors. I come from a long line of great cooks! Unfortunately, this has created a very serious problem.

I have been spoiled AND I don't really know how to cook. Living on my own this year and having to prepare every meal by myself has been tough. Someone who doesn't love food so much would be okay with eating ramen everyday. Someone with an unlimited amount of money would be okay with going out to eat everyday. Someone who has never tasted my mom's Russian influenced tomato beef stew would be okay with eating it only once or twice a year. I am not that person. So, in order to satisfy my love for food, I must cook.

Thankfully, I don't have to start from scratch. My parents, Epicurious.com, and the millions of cookbooks out there are my resources for best cooking practices. Years of cooking have taught my mom how to dice and slice meats and vegetables to extract the best flavors and cook without making a huge mess. She's done the experimenting for me. My dad is our in-house bread baking expert. If I wanted to bake a loaf of extra fluffy bread, he'd know exactly how to do it.

While I was home for the holidays, my parents asked me to cook dinner to test my few months of cooking experience. I decided to make a sausage broccoli pasta that was very well received at a pot luck. After about an hour of cooking, my mom walked into the kitchen with a crinkled nose of disgust. My sister didn't even want to touch the food and decided that leftovers would taste better. My dad ate less than usual and had an encouraging smile plastered on his face. Only my dog, May, seemed to enjoy dinner. I'll admit it tasted... different. How did this happen?

Mistake 1: I left my recipe in Boston
Mistake 2: I was too lazy to buy all of the correct ingredients so I improvised

This goes without saying, but I essentially made something entirely different. It was untested and it tasted bad. As I poured the pasta into Tupperware reserved for food that only May would eat, my dad asked me a very enlightening question: "Why didn't you use a recipe?"

Why didn't I use a recipe? I didn't have a good answer. My dad told me that even after many years of making bread, he still uses a recipe. He told me that you can make a few adjustments here and there. Add some raisins and cinnamon for raisin bread. Add an egg to make it more moist and rich. Substitute milk for water. But, there really is just one way to make bread. You will always need the basic ingredients and add them in in the same way. Each loaf will be different, but if you are making bread, your end product should look and taste like bread.

Here in the office today, we are celebrating the provisions in the stimulus bill to compare the effectiveness of different treatments for the same illness. Yet, many others see this as a recipe for health care disaster: cook book medicine is what they are calling it. Every patient is different they say. Doctors aren't robots. And what about the value of a doctor's intuition? Isn't that what makes great providers?

But, what would you say to this statistic: Clinical studies conducted by California’s RAND Corporation and other research centers consistently show that, for many medical conditions with well-defined criteria for the best treatment, only about 50 percent of the recommended care is ever delivered (1). That would be the same track record I have with my sausage broccoli pasta and that's clearly unsatisfactory. Thankfully, my pasta was not deadly. But lives are at stake in health care!

Medicine will always have a margin of variability since every patient is different and doctors are human too. But, if it is known that a patient has X disease, as a future doctor, I'd want to give that patient the most effective treatment known to treat that disease. And as a patient, I'd want to know that I'm receiving the most effective treatment available. Standardization is a scary word in the health care debate, but if you have a recipe for success, shouldn't that be shared and used widely?

I think my cooking is getting better. I will admit that I do call my parents to run through all of the necessary ingredients and any sophisticated cooking techniques at least once a week. I have also created a binder for standard dishes (so my parents don't get annoyed by my calls). Each dish has a list of ingredients, possible substitutes, important steps to remember, and plenty of room for edits. It's my binder of best practices and guidelines to ensure a happy stomach.

Comparative effectiveness research in health care can create that binder for medicine and help us prevent things from going wrong. Can you really think of a good answer to the question, "why didn't you use the best practice?"

I can't.

The New York Times on Comparative Effectiveness Research

Health Education Reform Ideas? $10,000 for your thoughts!

The stimulus bill has been all over the news. While I can't speak for the merits of the bill and its ability to rescue our ailing economy, I can report that health care has not been forgotten in the bill. The $790 billion economic stimulus package includes provisions for expanded health care coverage and allowances for health care IT. According to The Associated Press reports, the compromised stimulus bill includes "$21 billion to provide a 60% subsidy of healthcare insurance premiums for the unemployed under the COBRA program; $87 billion to help states with Medicaid, $19 billion to modernize health information technology systems; $10 billion for health research and construction of National Institutes of Health facilities." What does this mean for the Obama administration's efforts for health care reform?

Of course the health care provisions in the stimulus bill are not comprehensive. Greater access to health care and construction of health IT infrastructure are just part of the answer to better health care. For example, not mentioned in the stimulus bill are efforts to reform health education. As the next generation of health professionals, perhaps the greatest amount of change we can enact is right here on our home turf. Well, here's your chance to share your plan! The Mayo Clinic Health Policy Center and the MD Connector have partnered up to sponsor a health education reform essay contest that is open to all health professions students in the US and Canada. Over $10,000 in cash and prizes are being awarded in addition to the chance to present your plan at the 2009 Health Care Education Symposium in Rochester, MN. The submission deadline is March 16, 2009. Click here to find out more information about the competition.

To get those brain juices flowing, read this article by Parker Palmer called "A New Professional: The Aims of Education Revisited".