This is the Clinic that Will and Charlie Built...

I have officially become a groupie of the quality improvement in health care movement. Books sitting on my nightstand include: Pauline Chen's Final Exam, Super Crunchers by Ian Ayres, and How to Change the World by David Bornstein. I squealed like I had just sighted Brad Pitt when Atul Gawande's latest book, The Checklist Manifesto arrived at my door. Instead of simply saying that I need to clean my apartment, I specifically think that I need to "5S" my kitchen and desk. In order to stay fit and get rid of the belly fat I've grown since starting medical school, I am now in PDSA cycle 3 for a 30 minute exercise routine that I can reliably perform every day. The latest sign that I am a quality improvement junkie is my weekend pilgrimage to Mayo Clinic in Rochester, Minnesota.

This past weekend the AMSA Chapter at Mayo Clinic hosted a Patient Safety and Quality Care Conference at Mayo Clinic. The Mayo Clinic has not only been one of President Obama's shining examples of high quality care at low costs since he began his health reform push early last year, but has also consistently popped up during my experience at IHI as a health system that has truly embraced the IOM aim of patient-centeredness. Even though I'm buried underneath the dorsal columns of my central nervous system sequence, this was an opportunity I could not miss!



When I stepped off the plane in Rochester, I was abruptly greeted by a chilling gust of wind. But, that didn't deter me and like any good quality improvement groupie, I pressed on. From the moment my shuttle dropped me off in front of the Gonda Building and the Mayo Clinic greeters helped me out of the van, I knew I had arrived at what many say is the mecca of patient-centered care. It was difficult not to spend the weekend with my mouth agape.

Every aspect of the Mayo Clinic from its architecture and design, to the doctor-patient relationship, to Mayo's treatment of patient safety strongly embodies and reflects its mission: Mayo will provide the best care to every patient every day through integrated clinical practice, education and research. As Dr. Tom Viggiano, Dean of Mayo Medical School explained during his talk about Mayo Clinic's History, Culture and Professionalism Covenant, Mayo Clinic's mission stems from a remarkable story. A story about the work of Dr. William Worrall Mayo and his two sons, Drs. William and Charles Mayo.



Dr. William Worrall Mayo, born in England and a student of physicist John Dalton, arrived in Rochester as the Union army's examining surgeon. As his sons were growing up, William and Charles were intimately involved in their father's practice. They drove their father on patient rounds, attended medical society meetings, and even assisted their father in surgical procedures. This early exposure laid the foundations of medicine and patient care for the two brothers. Both William and Charles through consistent encouragement from their father attended medical school and both returned to Rochester to join their father's practice.

The tornado of 1883 that hit Rochester was a catalyst that led to the creation of Rochester's first hospital built in collaboration with the Sisters of Saint Francis. The Mayo family then became the physicians of the hospital and it was the brotherhood bond between William and Charles that was the first "team" that set the tone for the teamwork we see at Mayo Clinic today. As the hospital expanded and the fame of the brothers grew, it became necessary for William and Charles to pick physician partners to join the practice, expanding the team. In Dr. William Mayo's words, here is how teamwork was defined:

"As we grow in learning, we more justly appreciate our dependence upon each other. The sum-total of medical knowledge is now so great and wide-spreading that it would be futile for one man to attempt to acquire, or for any one man to assume that he has, even a good working knowledge of any large part of the whole. The very necessities of the case are driving practitioners into cooperation. The best interest of the patient is the only interest to be considered, and in order that the sick may have the benefit of advancing knowledge, union of forces is necessary."

One such recruited partner in the team that proved to be influential in shaping Mayo Clinic, was Dr. Henry Plummer. Dr. Henry Plummer's ingenuity led him to design an easy, retrievable medical record system. This system gave each patient an ID number and the mode of transport for these records was a system of pipes. Dr. Plummer's innovation acknowledged the fundamental place that medical records had in research and advancing medical knowledge and the need for shared data between physicians to deliver the best care for patients. Dr. Plummer was also instrumental in bringing the Mayo vision of integrated care into reality with the construction of the first Mayo Clinic building (built in 1914), which housed clinical medicine departments, laboratories, and administration offices all under one roof.



As the years continue, additions and innovations to the Mayo Clinic all align with the traditions that Drs. William and Charles Mayo started. There is a Mother Goose rhyme called, "This is the house that Jack built..." Each successive stanza in the rhyme gets longer and longer as odd characteristics are added to the house that Jack built. The Mayo Clinic Model of Care we know and admire today is a result of a similar layering construction.

Though, from my weekend experience at Mayo Clinic, the foundations that Drs. William and Charles Mayo created are more than just a model of care, it's a tangible culture, or even a life force that allows the Mayo Clinic to thrive. The wholly understood value that the needs of the patient come first allow the Mayo Clinic to continually push the boundaries of improvement. The weekend was primarily focused on medical errors and the developed practices and systems at the Mayo Clinic to address patient safety and quality care. We heard from Dr. Stephen Swensen, Director of Quality at Mayo Clinic, Dr. Thor Sundt who is pioneering improvements in interprofessional teamwork in the surgical setting, Dr. Paula Santrach, Chair of Clinical Practice Quality Oversight Committee, Dr. Douglas Wood, Medical Director of the Quality Academy, Dr. Bob Cima on error analysis in surgery, and many many more who volunteered their time to not only share with us their approaches to medical error management, but true to the Mayo Clinic's culture of putting the patient's needs first were also frank about areas that needed improvement. If President Obama's shining beacon of clinical excellence continues to make improvements upon "the clinic that Will and Charlie built," then the rest of us certainly have lots to learn.



I've certainly learned a lot this weekend both through the stated curriculum in the conference agenda, but also through the hidden curriculum of taking in the culture of the Mayo Clinic. I may not be able to take back to the University of Michigan Mayo's unique electronic physician and patient tracking system or redesign all of the exam rooms at Michigan so that physicians are never talking down to their patients, but I can take a plank of Mayo's culture and lay it down as my foundation so that wherever I am, I can do my best to extend the clinic that Will and Charlie built.



A big thanks to Crystal Pruitt and Crystal Shen of Mayo Medical School who organized this enlightening conference. I look forward to more great opportunities to learn about patient safety and quality improvement from the great leaders at the Mayo Clinic.

"What Do I Need to Know for My Clerkships?": A Look at the Lucian Leape Institute Report on Medical Education

In the world of medical school, spring is a time of transitions. First year medical students are returning from spring break and gearing up for the last stretch of class before summer. Second year medical students are getting ready to buckle down and study for the USMLE Step 1 board exam (good luck to all!). Third year students are on their last clerkship rotations before becoming fourth year medical students. And fourth year medical students are holding their breath as Match Day approaches (this Thursday!). Like any time of transition there are a lot of questions about the future floating around. One of the most honest and interesting questions I have heard recently was from a second year student to a resident, "What do I need to know for my third year clerkships?"

This may sound like a strange question to those outside of the world of medicine. The third year of medical school should be a logical progression from the second year, right? Not exactly. Most medical schools in the United States are structured so that the first two years are spent predominantly in lecture. The first year covers the normal physiology, anatomy, and biochemistry of the body systems and the second year delves into pathology and pathophysiology. These years are marked by long hours in class and little, if any, patient interaction. With at most a two week gap after the USMLE Step 1 exam, third year medical students are then thrown into the hospital wards to learn how to apply the basic sciences into the practice of patient care. Are these new third year medical students ready to care for patients?

The Lucian Leape Institute of the National Patient Safety Foundation says, "no." Just last week, the Lucian Leape Institute released its first of a series of reports on patient safety. The first report, titled: “Unmet Needs: Teaching Physicians to Provide Safe Patient Care,” finds that U.S. medical schools are not adequately teaching students how to provide safe patient care. Click here to read the report.

Although I have just 8 months of experience in the medical education system, I am not surprised by the conclusions of the report. A quick glance at the competencies tested in the USMLE Step 1 board exam that second year medical students ordinarily must pass before starting their third year clerkships will demonstrate the emphasis placed on the basic sciences of the body systems. While I don't disagree with the importance of understanding the basic sciences of the human body and disease processes, I agree with the Lucian Leape Institute report that there is a crucial dimension to patient care that is blatantly missing in an exam that signals that students are ready to be members of a patient care team.



The transition into a third year medical student is not easy: learning how the hospital operates, determining and establishing the medical student role on the care team, understanding and learning to anticipate the actions of the interns, residents, and attendings, and being prepared to answer any basic sciences question your attendings may ask you (a process called pimping). The third year is also an important learning opportunity. The more procedures and cases seen means a greater breadth of experience for future life-saving. Impressing your attendings is another facet to the third year of medical school. A good recommendation from attendings can go a long way in the residency application process. In the thick of all of that, medical students are probably too stressed to think about patient safety and definitely don't want to slow down the service just to ask "why?" when witnessing unsafe or needlessly complicated workflow processes. The chaos of third year makes asking questions about patient safety and quality improvement professional suicide.

So, how are medical students to learn the skills needed to deliver health care safely? The Lucian Leape Institute recommends restructuring medical education to include topics like safety science, human factors engineering, systems thinking, and the science of improvement into the basic science years of medical school. The report also recommends that medical students be given opportunities to develop interpersonal skills that include effective communication strategies for future interdisciplinary teamwork. In order to include these elements to medical training, faculty trained in patient safety and quality improvement who can model good patient safety behavior is essential. Unfortunately, most medical schools have not reached a critical capacity of faculty for training in patient safety and quality improvement to occur. Yet, from the student perspective, we can't wait another 10 years after the publication of the IOM "To Err is Human" report to reach that critical capacity.



Here at the University of Michigan, the few faculty we do have trained in patient safety and quality improvement are working hard to provide students with patient safety skills. In our first year of medical school, we've had a mandatory nurse shadowing experience and a sociocultural discussion case on medical errors to provide the first exposure to patient safety and effective teamwork. The University of Michigan also offers a second year two week elective on patient safety and a fourth year elective led by our very own, Dr. John Gosbee. At best, the University of Michigan has opportunities for students who seek to learn patient safety and quality improvement skills. This is a good start, but as the Lucian Leape Institute report would indicate, not enough. Patient safety needs to be prioritized formally from medical school through residency in order to make health care safer for all.

At the very least, concepts of patient safety and quality improvement should naturally become part of the answer to the question, "What do I need to know for my clerkships?"

Is patient safety a part of your curriculum? What do you think the best strategies are for making patient safety and quality improvement a bigger component to your health professions education and training?

Being Honest: Ducking Out from Under the Table

My adorable dog, May, has her flaws. Her bark and temper are infamous in our neighborhood. If the toy is not made of rubber, it will become an unrecognizable ball of mush within days. However, when it comes to going out to do her business, May almost never has accidents. On those rare occasions she makes a mistake, she slowly greets us with her head ducked down rather than her normal energy-filled charge when we arrive home.

We understand why these accidents happen. Most medical errors, as discussed in the IOM report, To Err is Human, are a result of poorly designed systems that do not give providers the best chance possible to care for patients in the way that they would like. May's accidents are also systems error. We only find a pool of pee in the house when we leave for a long period of time without allowing her to go out before we leave. May was not being negligent or purposefully filthy; the system she lives in simply does not allow her to successfully avoid these accidents. With these system constraints in mind, we do not blame her, but continue to work on scheduling improvements to prevent future occurrences.



Clinicians never want to intentionally harm their patients and are often emotionally impacted by a mistake. Similarly, as far as we can tell, May deeply regrets her accidents. Since she cannot use words to express her regret, she hides under the dining table and avoids eye contact as we clean up the mess until we say, "It's okay, May." Sometimes, she will even circle the "biohazard" zone slowly, as if admonishing herself. May's actions demonstrate her acknowledgment of the accident and we accept her apology--a courteous exchange that occurs between people all the time.

Medical malpractice is one of the few bipartisan goals of the current health reform battle. However, how to reform this messy process that is hard on all participants (physicians, hospitals, patients and families, and insurers) emotionally and financially is not as clear. Focusing on how to minimize costly lawsuits through caps on financial damages awarded to patients further complicates the fundamental courtesies that should occur when a mistake happens: acknowledgment, understanding, acceptance, and forgiveness.

In a paper published in the NEJM in 2006, then Senators Hilary Clinton and Barack Obama discuss how to improve patient safety and the medical liability climate through open communication between physicians and patients. The paper cites that the most important factor in people's decisions to file lawsuits is not negligence, but ineffective communication between patients and providers: lawsuits occur when "unexpected adverse outcomes are met with a lack of empathy from physicians and a perceived or actual withholding of essential information."



For those of you who are Grey's Anatomy fans (click here to read a Grey's Anatomy Obsession confessional), episode 13 of season 6 titled, "State of Love and Trust," touches specifically on medical liability reform and being honest with patients. A patient, later discovered to have a form of cytochrome P450 that unexpectedly allows her to metabolize anesthesia faster than normal, wakes up from anesthesiology in the middle of her bowel surgery and is traumatized by the violence of surgery and the panicked yelling from the surgical team. Emotionally disturbed by the experience, the patient wishes to press charges against the hospital. Dr. Shepherd, interim Chief of Surgery, is deep in thought about the threat of a lawsuit on his first day as Chief, when Dr. Miranda Bailey talks to him about open communication between physicians and patients in situations of medical error (see clip above). By apologizing to the patient, Dr. Shepherd is acknowledging the mistake and the patient's concerns, is providing the patient with the opportunity to understand and accept the mistake, and is working with the patient to reach an agreement that allows both sides to accept the mistake and attempt to reach forgiveness.

As then Senators Clinton and Obama explain in the paper, open communication allows for improvements in patient safety. The proposed National Medical Error Disclosure and Compensation (MEDiC) Bill was based on model disclosure programs such as those in place at the University of Michigan Health System (Go Blue!) and the Veterans Affairs system. These programs have given both patients and physicians protection while successfully reducing administrative and legal costs for providers, insurers, and hospitals. Surveys from these successful programs have also showed greater trust in and satisfaction with health care providers. On the cost side, the disclosure programs have resulted in the filing of fewer malpractice suits, a reduction in litigation costs, accelerated provision of compensation to patients, and increases in the numbers of patients who are compensated.

It is a remarkable feat that the University of Michigan Health System has reduced litigation costs from $3 million to $1 million in four years with its disclosure program. Though isn't it ironic that at the heart of the solution to such a complex problem are the basic principles of being honest and communicating openly with patients?

Telling patients the truth at times may be harder, but it is the most respectful thing to do. My dog, May, would bark in agreement.

Understanding the Incomplete Medical Diagnosis

*names and some details have been changed to maintain and protect privacy*

If multiple sclerosis was an anatomy review item, I can just imagine Dr. Zeller pointing at the spinal cord and asking me, “Eva, what is the clinical presentation of multiple sclerosis?” After overcoming the anxiety of being “pimped,” my response would probably include symptoms such as: muscle weakness, difficulty in moving, difficulty with balance, visual problems, fatigue, and pain. Before meeting my patient volunteer, Casey, that’s how I characterized multiple sclerosis. The mental image in my head also included a wheelchair. This snapshot of multiple sclerosis is the medical mold that physicians give to their patients upon diagnosis, which I used to think was complete and scientifically correct.

After almost six months with Casey, I now understand that this sort of medical mold is incomplete. This medical mold is analogous to giving an unknowing sculptor a headless cast of Michaelangelo’s David and telling him that this represented Michaelangelo’s complete masterpiece. What was missing in the medical mold of multiple sclerosis (MS)?

What was missing was Casey. Her empowering and encouraging relationship with Dr. Osuco, the optometrist who made her initial diagnosis; the negative recommendations she received from physicians that told her to quit nursing school because she had MS; her steady and rapid inability to walk up flights of stairs; the finality and fear she felt when researching more information about her condition; the shame of losing the ability to spell simple words; the unbearable embarrassment of urinary incontinence; the feeling of helplessness as her right side got weaker; the difficulties of maintaining a treatment regimen that seemed to fundamentally change her personality; starting every date with “I have MS”; shopping for life insurance plans along with her elderly mother; the loss of friends because they just couldn’t handle it; designing a plan for “when things get to that point”; doctor shopping and coming across the kind and comprehensive care that Dr. Richardson provides; temporarily losing hearing in her right ear and worrying about its implications on her MS; letting go of managing the disease on her own and instead working with Dr. Richardson's team; navigating how others view her given her very normal appearance but serious condition, trying not to mention her occupation as a nurse unless it means better care for her and her family; meeting other MS patients at varying degrees of disease progression who are all fighting and living quality lives; negotiating the risks and benefits of a high-risk drug that drastically improves quality of life but can cause a deadly brain infection; being the primary caretaker for her elderly mother who is surviving on an oxygen tank and two developmentally challenged foster children; working as a nurse nearly full time; her strong beliefs to advocate for quality and patient-centered care; and lighting up the room with her warm smile. That is the complete picture of MS.

How can we as future physicians learn how to see the complete picture of a disease? We need to be aware that our list of symptoms is only a subset of factors that can instigate tremendous challenges and change on another life, learn how to talk to patients about their values and greatest concerns, and integrate those values and concerns with the treatment plan. By laying a foundation of trust and building a strong partnership with patients, we can begin to cross the gap between the stigma that we create and the reality of illness in an individual. My experience with Casey has taught me these important lessons and I hope to never forget them as I continue in my training.

Many thanks.

Implementing the Safe Surgery Checklist in New Delhi, India

This year we started a Global Health Initiative within the Harvard IHI Open School Chapter. We aim to make quality improvement and patient safety truly global. Last year one of the members of the Harvard Open School Chapter, Shabnam Hafiz, introduced the Safe Surgery Checklist at three hospitals in Pakistan. Building upon this momentum and furthering the cause of global patient safety I decided to implement the checklist at hospitals in New Delhi, India during the winter break. As I work on spreading the checklist, I will be sharing my experiences with the readers of this blog. I hope you will find the posts interesting and insightful.

In implementing the checklist, I wanted to do it in a manner that could be replicated by other people wishing to create change, sometimes without significant access to the top leadership at a hospital. I wanted to conduct an experiment in bottom-up change.

One of my physician friends was working as a Resident at a government hospital in Delhi. I got in touch with him when I reached Delhi, and over a cup of coffee I explained the surgical safety checklist to him. He offered to set up an appointment for me to meet with the head of surgery at his hospital to discuss the checklist. Two days after that, I went to the hospital and in a five minute meeting explained the checklist to the Chief of Surgery. She was ready to implement it and remembered having read the journal article. I then met with other surgeons at the hospital, and also the Chief of Anesthesiology. Everyone was ok with the idea and it was decided that I would hold a trial run of the checklist in the OT the next day.

The next day I reached the OR early and explained the checklist to the OR nurses and clarified their doubts. Then I ran the checklist in two OR’s. As this was the first time even for me, I felt a little rushed in the first case and did not feel that the process was as effective as it should have been. In the second case I tried to get some nurses to take over from me, but they were a bit hesitant. In the third case another nurse did volunteer to run the checklist.

What was amazing was that on the very first day we managed to identify gaps in care. One of the questions on the checklist asks ‘Has the site been marked’, it turned out that it was not a routine procedure to mark the incision site preoperatively at this facility; the senior surgeon noted this deficiency and told the surgeons to carry it out for future surgeries. A discussion with the anaesthsiologist revealed that mostly preoperative antibiotics were given in the ward, and the gap between the administration of the antibiotic and the skin incision possibly exceeded 60 minutes in most cases.

After the OR trail run I approached the Administrative Head for his permission to hold a formal presentation to explain the significance of the checklist and to show the videos. He was very supportive and the presentation will be held next week during which I hope to train other people in implementing the checklist.

Suggestions, comments and feedback welcome. Watch this space for updates.

New year, new courses

Happy new year, everyone!

I know you're probably still recovering from last night's celebrations. But I wanted you to know that the IHI Open School just published three brand-new quality improvement courses. The courses will be required for our basic certificate of completion. And like all our online courses, they're free for students -- you just need to register with IHI.org.

Here's a quick snapshot of our latest offerings:

Quality Improvement 104 ("Putting It All Together: How Quality Improvement Works in Real Health Care Settings"): The first three IHI Open School quality improvement courses introduced you to the fundamentals of improving health care. In this course, you're going to see how two real organizations actually used these methodologies to improve an important aspect of patient care. You'll start by learning the four phases of an improvement project's "life cycle": innovation, pilot, implementation, and spread. Next, you'll delve deeper into the theory of spreading change - both the foundational work by sociologist Everett Rogers, and IHI's Framework for Spread.

Quality Improvement 105 ("The Human Side of Quality Improvement"): If you want to improve a complex system, you'll probably have to convince the people around you to do things differently. But a change that seems sensible and beneficial to you may feel threatening to others. In this course, you'll learn why culture change is crucial to the success of many improvement projects. You'll discover the most common reasons people resist change, and then you'll practice responding in a way that mitigates that resistance. You'll also learn how new ideas typically spread through a population, and what you can do to help different parts of a population adopt a change. Finally, you'll learn different ways to motivate people -- and which methods are most likely to be effective in your setting.

Quality Improvement 106 ("Level 100 Tools"): This practical course will teach you to create and use three essential tools for improvement: PDSA (Plan-Do-Study-Act) templates, measurement planning forms, and run charts. Working through step-by-step tutorials that put you right in the middle of health care scenarios, you'll learn how to plan a series of tests, collect data, graph your results, and interpret what your graph is trying to tell you. This course is fully hands-on, so get ready to practice what you learn along the way. (Note: You'll need Microsoft Word and Excel to make the most of this course.)

Ready to get started? Drop by our learning management page.

The Task Is Upon You

Inspired by the words of Sekou Andrews and Dr. Don Berwick:

Protect our bodies with health nourish our souls with purpose.
Pour knowledge into our minds passion in our hearts.
Expect efficacy and improvement as its currency.

You asked us to reflect.
True desire faces unmet needs with apprehensive tensions
Reflections question reality with rude awakenings sending shivers of concern with Goosebumps of guilt.
What kind of system have we built?

You asked us to envision.
Doubts of broken foundations, shaky pillars, left with bridges that don’t connect.
Our patients we fail to protect.
Commitment and dedication advancing medical knowledge
Measuring its quality brings discrepancy to surface.
Pores sweat, mistaken assumptions composed of salty ignorance
Sincere passions lost through convections leave us cold.
Bold conversations expose realities of a system unjust.
Wake up my good friends, this system has rust.

You asked us to change.
Analyze criticize fundamentals of our fruit.
Bitter a taste of past disgrace transforms into sweet prudent pursuit.
Evolutionary regeneration stimulated by a gravitational force
Demand higher expectations elevate us to greater strengths
Scale up, costs down, aim times three.
Sprint to lead map improvement goals of being complication free.

Our school is one open world a challenge knocks.
Revolutionaries unlock by developing keys that makes us
Better fit to learn, better fit to teach, better fit to reach
Out to our patients, communities, and colleagues.
Declare legitimacy, demand transparency, institute policy.
Strapped with tools ideas for change.
Courage in our hearts and energy to proceed.
United together, we shall achieve.