Student Quality Leadership Academy

After two days of an intense conference, and then a busy week, I’m finally getting a chance to reflect on all I learned at the IHI conference I attended June 17-18.

From near (I live in Brookline, MA, and hopped on a bus over) and far (Iowa, Kansas, California, and even Great Britain and Portugal), about 55 students gathered in a conference room in Cambridge, Massachusetts, for the first IHI Open School Student Quality Leadership Academy. What was especially interesting at first was not just where everyone was from physically but rather the areas each was studying. As a medical student, I see nurses and pharmacists only as clinical co-workers, and I rarely speak with anyone with an MBA or studying administration. Our extracurriculars at school, despite valiant attempts, are also for the most part made up only of medical students, even many IHI Open School Chapters. But here, students studying public health, dentistry, pharmacy, nursing, and even engineering, were just fellow students working on health care quality and safety.

Our presenters were at the tops of their fields – leadership, communication, conflict resolution – though they occasionally seemed to forget that not everyone around them was part of the Harvard system!

The topics were focused on leadership and were not specific to quality improvement or even medicine, which was a surprise as I expected more hospital-specific tales. But the idea was one of more general leadership, and we were lead through “Leading Change” and “Managing Conflict,” skills which could be applied to any part of life. Some of the ideas were quite theoretical – what are the stages people progress through (or don’t progress through) as they experience transition during major changes. “Difficult Conversations,” where we looked at cases of mistakes in hospitals, was more clinical.

One of my favorite sessions, however, combined the two. We read a case study of a hospital struggling with high mortality in their cardiovascular surgery department. The person who was tapped to make change was an internist (one strike – not a surgeon) and a woman (another strike – all the surgeons were men). We discussed what someone in that position might do in order to make change happen.

And then, to our surprise, the facilitator told us that this woman, who we thought was a case study, was in the room! Dr. Justine Carr got up and told us how, without any staff except a shared administrative assistant, without any budget, without any actual power over the surgeons, she was able to get a fragmented group to work together and decrease mortality. It was an impressive story on its own, and hearing it from the leader herself made it even better, and the fact that the change she effected saved lives-—and continues to save lives-—motivated us to go do something.

Now all we have to do is go back to our institutions and try to do the same thing!

Eva Ghana Wild

Wo kƆ he? = Where are you going?

To celebrate my last summer, I am going to Ghana! It'd be a shame to let Emily's ingenious blog title go to waste, so here's an offshoot blog: "Eva Ghana Wild."

I fly out in just two days to spend my summer doing clinical quality and management research on maternal mortality at six district hospitals in and around Kumasi. With cans of bug spray packed, I think I'm ready! This is my first trip to Ghana and my first time venturing out to Africa, so stay tuned here for pictures, impressions, and hopefully not too many vignettes about embarrassing myself!

Psst...if you are in Ghana this summer, let me know!

Quick 10 Minute Lesson

What motivates us? Perhaps with $100 in my pocket, I'd willingly bite into a chocolate covered grasshopper. But, money can't be the only motivator for our actions and behaviors. This short video highlighting Dan Pink's ideas on motivation sheds important light on P4P, joy in work, management, leadership, and so much more! What do y'all think of the video?

HT: Xi Wang

Shooting for "Sensemaking" in Health Care

Despite my lackluster sports careers in tennis and Ultimate Frisbee, I am a huge sports enthusiast. In college, I was introduced to basketball. My hometown team, the Miami Heat had just fought their way to the 2006 NBA Finals. Like any good fan, my eyes were glued to the TV every game against the Dallas Mavericks. I gasped at every missed shot, held my breath during every free throw shot, and cheered for every point scored. The Miami Heat's journey to the championship was epic and I have been enamored with them ever since.

However, since winning the NBA Championship in 2006, the Miami Heat have really tried my devotion to them. In the 2006-2007 season, my team was riddled with injuries and inopportune player absences. Shaq had promised us a repeat championship, but the end result was far from that. The Miami Heat instead became the first defending champion since 1957 to get swept out of the playoffs in the first round following a championship season. Disaster only continued in the next season with major roster shake-ups. The Heat made history again by ending the season with the worst record in NBA history: 15 wins and 67 losses. When the Miami Heat came to Boston that year, they set another new record: the fewest made baskets in a game (17). I left the game with the feeling that I should have worn green and that it was time for me to switch my allegiance to the Boston Celtics, the team of my new home.

But, things began to turn around in the next year. The Miami Heat began rebuilding the team around superstar Dwyane Wade and the new talent joining the Heat gave them new energy. This year, they are seeded 5 in the Eastern Conference and face the Boston Celtics in the first round of the NBA Playoffs. However, their tumultuous journey to Game 5 (today) serves as a reminder of how unstable my beloved Miami Heat are. While watching Game 4 last Saturday, I could not help but think of the work of Karl Weick, Rensis Likert Distinguished University Professor of Organizational Behavior at the University of Michigan Business School. Thankfully, on Saturday, the Miami Heat, down 3-0 in the best of seven series against the Celtics, beat the Celtics 101-92 to force a Game 5 (today).

As much as I love the Miami Heat and have faith in Wade's athletic prowress, I am not hopeful about tonight's game. Using Weick's own words, the Miami Heat are not a high-reliability organization, an organization that operates under very trying conditions all the time and still manages to have fewer than their fair share of accidents, but should be.

The conventional way of thinking paints organizations as stable and secure structures or institutions. Referencing and extrapolating from the intelligent design movement and the watchmaker's analogy, the conventional organization is one that was carefully designed and left to operate and survive against all subtle and radical changes. However, Weick believes that organizations are alive and dynamic. At all times, they "chat, dissemble, disguise, mobilize, and galumph." In an ever-changing reality, these dynamic organizations possess the ability to change, anticipate, react and adapt to the unpredictable and unexpected.

It's not difficult to see the Miami Heat as such a dynamic organization. Each player is a member of the organization and in the game, they are acting, communicating, and reacting to whatever play the opponent team throws their way. So, why is the error rate or number of losses so great? How did the Miami Heat slump so low after winning the NBA Championship? Looking back at my abridged account of the Miami Heat's recent past, you will notice significant unpredictable changes made to the organization: injuries, roster changes, coaching changes...and those are just changes within the organization itself. Every opposing team experiences such changes and brings those with them to the game. These are external changes. For organizations like the Miami Heat, as Weick describes, "when the unpredictable happens, and the world as we know it unravels, we are all the more likely to become so paralyzed that we cannot survive the experience."

In my own unqualified opinion, the Miami Heat have been operating as a flawed and rigid organization. Its world-view relies heavily on Dwyane Wade and his ability to carry the entire team to victory. When the Miami Heat won the NBA championship in 2006, it was Wade who scored a series of clutch points to edge the Miami Heat past the Dallas Mavericks. The writing was on the wall, so to speak, in regards to Miami's rigid reliance on Wade. In the following season, Wade briefly injured his wrist and then seriously injured his shoulder. In the season where the Miami Heat dropped to its lowest point, Wade was obviously rusty from his injuries. Who charged the Miami Heat forward to win Game 4 and stay in the playoffs this season? Dwyane Wade. He scored 46 points alone. Of course, Wade has had the help and support of his teammates, but not enough since the NBA championship line-up to really call the Miami Heat a team. The Miami Heat since the 2006 championship has been a one man show. Taking a look at tonight's game, what do the Celtics have to do to overcome the Heat? Study and adapt to one man and according to news reports, they did just that. The Celtics spent three times more time than usual watching film to prep for tonight's game. If I was a betting woman, my money would not be on the Miami Heat to win tonight.

What can the Miami Heat do to become a high-reliability organization? It needs to develop its, as Karl Weick calls it, sensemaking abilities. Sensemaking is the process through which the complex and unpredictable world is given order, within which people can orient themselves, find purpose, and take effective action. This sensemaking is achieved through two other Weick concepts called mindfulness: the ability to react to even very weak signs that some kind of change or danger is approaching and the ability to take strong, decisive action based on these signals, and galumph: purposeful playfulness and innovation that provides organizations the opportunity to test different possibilities and scenarios. For the Miami Heat, the team's reliance on Wade immediately following the championship season was a weak signal that should have been corrected immediately, rather than seen as a sure-fire formula for success. New players and innovative starting line combinations were tried. Miami just needs to be even more creative. With this unflinching commitment to reliability coupled with increased innovation, the Miami Heat will see improvement. I am confident in my team.

Stepping back from my NBA playoffs fervor of excitement, what do basketball and sensemaking have to do with health care? Like the Miami Heat, health care is an organization that has yet to achieve the status of being a high-reliability organization. Health care has similar rigid organizational flaws. There is an over reliance on individual performance, weak signals of variation and danger are not taken seriously, and there is great need for innovation and system redesign. If health care can make improvements in sensemaking, it too can reach the season playoffs and become champions. Basketball fans hold their heads up high when their team becomes a high-reliability organization and performs well. But in health care, the stakes are higher. Our patients depend on us to make health care more reliable because it means they can live another day. The health care playoffs are happening right now, and it’s about time we all pitch in and start shooting for sensemaking in health care.

For a more eloquent explanation of sensemaking and its application to health care, read Don Berwick's IHI National Forum Speech, "Escape Fire".

An Evening of Thanks

I have a little over a month left of my first of year of medical school...an unbelievable fact. One of the highlights of my year has been the Family Centered Experience program. I have written about the program in previous posts here and here. Closing up our year, all first year med students were asked to work in small groups and create an interpretive project using untraditional media to express our understanding of what we have learned from our patient volunteers. Tonight, all of our interpretive projects were on display and we spent the evening with our classmates and patient volunteers experiencing the reinterpretation of the struggles and triumphs of a life with illness.

Interpretive projects included poems, works of art, mixed media art pieces, cookbooks, original pieces of music, interpretive dance pieces, a children's book, and much more. Since pictures are worth a thousand words....enjoy!












To our patient volunteers, thank you so much for a memorable year!

If you had the opportunity to creatively express the patient experience with illness, what would you create?

Join Us On April 5th!

IHI Open School hosts a call with the Picker Institute/Gold Foundation Grant Program

Join us on April 5, 2010 from 12 - 1 PM EST. The Picker Institute/Gold Foundation Challenge Grant Program provides annual grants for integrating innovative patient-centered care projects into resident physician training. Three recipients from the 2009 – 2010 Challenge Grant Program cycle will present their projects on this free call facilitated by David Leach, MD, former executive director of the Accreditation Council for Graduate Medical Education (ACGME). Learn more about their projects. Participating sites include Beth Israel Deaconess Medical Center, William Beaumont Hospital, and Children’s Mercy Hospital. Register now for the call!

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.