Statistics in baseball and medicine

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

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

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

Lessons from Bo Schembechler

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

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

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

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

1960s: Coronary Bypass Surgery (vein grafts)

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

1980s: Internal mammary artery grafts, statins, diet

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

2000s: BiV pacers, hemoperfusion

Taken directly from Dr. Kim Eagle's slides

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

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

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

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

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

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

IHI Open School at the General Assembly of the IFMSA

Dear all,

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Project Fives Alive: Two Days of Energizing Inspiration

Karni QI Team

In typical last-minute Eva fashion, two years ago, I decided to defer from medical school for a year to work at the Institute for Healthcare Improvement (IHI). IHI can be best described as a fast-paced social change organization that operates like a cross between a think tank and consulting firm that focuses on improving the delivery of health care through spreading systems redesign tools and interventions all around the world, including Ghana. As much as possible, IHI practices what it preaches. In addition to encouraging health care systems and health care professionals to employ the model of improvement to make the delivery of health care more efficient, reliable, and effective, all of IHI’s own work is continuously evaluated for improvement. After living and breathing quality improvement for a year, the transition to medical school, where the focus sometimes felt like mindless memorization of volumes of facts, was difficult.

My main motivation for coming to Ghana this summer to work on clinical quality and management research was to return to the field of quality improvement of health care. For the most part, my research has been very fulfilling as I have delved into answering the questions: what kinds of improvements can be made at the level of a district hospital to improve maternal health and how can those improvements be made? Since data is the backbone and currency of quality improvement, sometimes answering my objective questions has been frustrating because I continuously run into underdeveloped data and information systems. On the days that I felt particularly beat by data available to me, I’d wonder how IHI functions in Ghana.


Lambussie QI Meeting

IHI has three developing countries programs: Ghana, South Africa, and Malawi. In Ghana, Project Fives Alive, a partnership with the National Catholic Health Service (NCHS) and Ghana Health Service (GHS) is working towards reducing under five mortality through quality improvement. While I was working at IHI, the CEO, Don Berwick, made a short visit to Ghana and collected the most inspiring stories. Thanks to Nana Twum-Danso, Project Fives Alive director and Ernest Kanyoke, Project Fives Alive Project Officer, I had the opportunity to be inspired too.


Piina QI Team

Last week, I traveled to Wa in the upper west region of Ghana to join Project Fives Alive on two days of quality improvement (QI) meetings at various health centers and CHPS zones. It was a difficult journey up to Wa from Kumasi, but those troubles immediately melted away when I met Ernest. If it were possible to anthropomorphize quality improvement, Ernest would be the perfect model. He is brimming with energy and is whole-heartedly committed to quality improvement in his work and his everyday life. Upon arrival, when my hotel reservation was not processed correctly, Ernest immediately evaluated that this was due to a problem in hand-offs and he said he wished had time to help by first collecting data on how often this occurs. At the very least, seeing Ernest carry around a flip chart and colored markers conjured up feelings of comfort. IHI truly is flourishing in Ghana.


Lambussie Health Center

Because I arrived in Wa around 2:30AM and had to be up and ready for site visits at 7AM, Thursday’s meetings were tough. Immediately after Ernest’s more than deserved introduction of myself to the QI teams, I’d invariably fall asleep. I am still so ashamed that in response to the amazing work that these health centers are doing to reduce neonatal deaths, all I could give them was an inattentive, silent, sleeping Eva. Thankfully, even while sleeping, I think my brain was still alert and I gathered some truly remarkable accounts of the QI work being done by midlevel providers (midwives, community health nurses, and local support staff) to drastically improve the processes that can reduce neonatal mortality.


Samoa QI Team

For example, in Samoa, the two CHPS Zones have greatly improved their skilled delivery rate by making small changes to make delivering at a health center attractive for mothers. These changes include offering traditional porridge to the women after delivery. This small change does not just represent a inventive adaptation of traditional practices, but also sends the message that the health care staff cares about the well-being of the mother and that the health centers are welcome institutions. In Karni, the QI team discussed the progress of their intervention to reach out to women and develop a pregnancy plan to increase their skilled delivery rates, which are at a laudable 90+% and a very effective mosquito net distribution program that has reduced their rates of malaria admissions.


Karni QI Meeting

What impressed me the most was not the outstanding results and outcomes that these health centers can celebrate, but the dynamics of the QI meeting itself. The health center staff have no formal training in statistics, yet after just a few learning sessions, are very data driven. Midwives and community health nurses take turns contributing to and facilitating the QI meeting to discuss and evaluate the rates of first trimester registrants for prenatal care and improving postnatal care follow-up visits. During the meeting, their various registers (the raw data), are always open right in front of them and they reference the data throughout the meeting. The connection between data and the individual patient success narratives they are experiencing is strong and solid. I can’t say that even providers in the US have made this connection. The foundations of QI have been laid for these teams and with that, I believe that they can take on any health care delivery challenge.


Exuberant Ernest Working His Magic

All of this progress, however, could not have been possible without the skillful facilitation of the project officers. The project officers not only have a deep understanding of the individual process and quality measures and interventions that each health center is undertaking, but are also experts at managing relationships. Project Fives Alive is a partnership with the NCHS and GHS are extremely important agencies to work with for the success of its work. The project officer has mobilized and empowered all of the necessary stakeholders to participate in the shared goal of reducing under five mortality. A representative from the GHS district health office traveled with us and was present at every QI meeting. All levels of staff were asked to open their registers and discuss and interpret the data. And then together, the QI team would set aims and deadlines to meet before the next QI meeting. My own research experience has proven that this is no easy task. Building confidence and a positive attitude among the providers is on an entirely higher level. The hospitals that I visited were still struggling with just making sure all of the necessary stakeholders that would work together to improve maternal mortality were all available on the same day at the same time to just discuss maternal deaths. These project officers, like Ernest, have just the right combination of encouragement and persistence to have led the QI teams to where they are now.


Run-chart at Piina

The four sites that I visited were extremely resource deprived in comparison to the district hospitals that I have spent most of my time working with—most of the health centers do not have electricity! Yet, despite these resource challenges, look how far a statement like, “let’s take a look at the data” can go. The run charts and meeting minutes posted on the wall is really the only technology I saw that these facilities were using to achieve their results. It’s phenomenal. The next waves of the project are to expand and replicate the work being done in the northern regions to the rest of Ghana. This kind of exposure to QI has so much potential that I know whenever I have the opportunity to return to Ghana, the health care delivery system in Ghana will be positively unrecognizable.


The Fearless Issah

My site visits and time spent with the Project Fives Alive team was the perfect burst of inspiration that I needed as I begin to undertake my last small project before I have to return to Michigan. Perhaps it was Issah’s adroit driving skills that powered us through sometimes as much as 300km of dirt roads to reach these communities, but after just two days with Ernest (and his highly marketable energy if only extractable) and the community QI teams, I’m excited for my own project with the confidence that QI works successfully in resource-poor settings like Ghana. With more opportunities for these community teams to share, evaluate, and celebrate their work and even greater individual engagement with data, the results that Project Fives Alive will produce I think will exceed the already achieved success. Three cheers for Project Fives Alive!

Thank you again to Nana Twum-Danso and Ernest Kanyoke for this amazing opportunity to join you all for two days. I look forward to following Project Fives Alive as it continues to grow and spread.

For more information about IHI and Project Fives Alive, here are some relevant links:
Project Fives Alive Website
Fives Alive Project Description
On the Ground Account When IHI's Jane Visited Ghana

For more blog posts about my summer in Ghana, visit "Eva Ghana Wild"

Taking Care: Join us at the IHI National Forum in December!

Join us at the 22nd Annual IHI National Forum on Quality Improvement in Health Care. This year's keynote speakers include IHI's President & CEO, Maureen Bisognano, writer and performer, Jenny Allen, and Washington Post reporter, T.R. Reid. With over 125 sessions to choose from, you'll have plenty of new skills to learn! Join 5,999 other health professionals who are passionate about quality improvement and patient safety. Check out the list of opportunities for students and faculty below:

• Apply for a student or faculty scholarship (50-75% scholarships).
• Use the Student Track to guide your session selection.
• Submit a student poster.
• Connect with other students in the Forum Students' Facebook Group.
• Is this your first conference? Review the Student Forum Survival Guide!

We look forward to seeing you in Orlando!

Is There a Spike in Medication Errors in July?

An interesting article was published in the Journal of General Internal Medicine last month which connects the rise in medication errors in July to the start of new medical residents.
4 Click here to read the full article.

• What's your reaction to the article?
• Has this article or topic come up in conversation on your campus or at your organization?
• What can Chapters do?

Please share your thoughts in the comment section below! How did others react to the article? Read more:

• National Public Radio story


• KevinMD's blog posting


• American Academy of Family Physician's reaction


• American Medical News article