IHI Open School: Why is Quality Improvement important in Healthcare!

IHI Open School: Why is Quality Improvement important in Healthcare!

Why is Quality Improvement important in Healthcare!

Why is Quality Improvement important in Healthcare!

Being a former student of Dr. Lucian Leape at Harvard School of Public Health, I understood under-utilization and over-utilization of health services but did not expect to have a first hand experience of both at the same time.

Last week, my husband was diagnosed with ureteral lithiasis (renal stones) with bilateral renal calcifications and obstructive renal nephropathy which led to our tryst with one of the great healthcare systems of the world.

We work in different cities of the US and meet only on the weekends when my husband visits home in Jersey City. During the weekdays, he stays at Madison, WI. One fine Friday morning, I received a call from him. His voice was shaky as if in deep pain. He had experienced a sudden onset excruciating pain in left lumbar region. (It was a déjà vu. I have had 2 similar calls from him in the past- one in 2006, for right sided pain that was suggestive of appendicitis for which he had an emergency appendicectomy and another even further back for renal colic.) He is a very tolerant man and the fact that he never ever complains about a pain that is not due to an emergency condition made me worry. This time, his symptoms were suggestive of renal colic because of possible obstructive stone in the left kidney. I advised him to go to the Emergency for pain medication and further work up. He was given some strong iv pain medication(probably morphine family), the name of which was not mentioned in discharge summary. In fact, it should not be called a discharge summary as it was merely a prescription. His routine investigations and X-Ray was done. But, all he was told was that he had microscopic hematuria and he had a renal stone. No reports were given with discharge. Wasn’t there a need to know detailed findings, as in what was the size and location of the stone and whether it was affecting the renal organs in any way? I was surprised that no investigations were handed to him for future follow ups. All they cared to do was hand off a prescription asking to follow up with his PCP (who was in Jersey City) after 3 days.

His pain improved by the evening and he flew back to home with some discomfort. We spent a restful weekend. Monday morning, he took a flight to Madison for work, hoping that the coming week would be uneventful. To our dismay, the pain occurred again while he was in transit, this time making an even grand appearance. He was trembling in pain and had an episode of vomiting. Fortunately, the flight was about to land in Cleveland. All passengers were requested to remain in their seats because of this emergency. When the flight landed, the ambulance was waiting for him by the runway. He was rushed to the emergency soon after landing. (Great job! I must tell Dr. Atul Gawande that once again aviation industry beat health care in quality and efficiency.)

I received another call from him when he was in emergency room. Alas! If only I could be there to save him some trouble! Since, he did not have any previous medical records apart from the discharge prescription, all routine investigations were repeated and a CT Scan was done. I asked him to insist on receiving the reports at discharge this time. Thankfully, upon insisting he was given all reports but the CT Scan film. He improved by the evening and returned to home instead of taking a connecting flight to Madison. I rushed from office to the airport to pick up my dear husband who was still in pain.

Next day, I took him to our Primary Care Physician (PCP) for specialist referral. Thanks to the over-engineered system that specialist referral was not an easy task. One has to go through a gatekeeper.

The PCP asked for the CT Scan and XRay film. Guess what! We did not have it. The credit goes to the emergency room protocol where it is not considered necessary to provide all reports to the patient upon discharge. The PCP repeated URM and found some leukocytes. An antibiotic cover should have been prescribed earlier at the emergency but for some reason they didn’t. Probably they believed in ‘Eminence Based Medicine’ more than ‘Evidence Based Medicine’.

My husband had to take a flight to India in 3 days to attend a family function for which he had been waiting for a long time. Hence, we requested for an earlier referral to confirm if he was fit to fly. The PCP asked us to come for a follow up visit after 3 days while he would check if a specialist appointment was available. We showed up at the health center for the scheduled follow-up visit, (the same day that he had his long distance flight). To our dismay, the referral could not be arranged due to scheduling conflicts (under-utilization). The PCP ordered for a repeat CT scan. It was extremely difficult to get same day appointment for CT Scan from the OPD. Hence, we were asked to go to the emergency.

When we went to the emergency, I provided the entire history and reason for the visit to the registrar. Since we were referred to the ER for CT Scan while my husband was stable (as it was a very long wait before we could get a scan done from OPD and we needed it before his flight in the evening), we were willing to pay the extra copay for the scan. After an hour long process for registration and yet another hour of wait, I was finally able to speak to the Emergency room doctor on duty. Despite explaining everything to her, she had ordered unnecessary blood investigations and iv infusion just for the sake of following ER protocol (over-utilization). Another hour passed and no one showed up for next steps. After a couple of reminders, a nurse came with iv line equipments.

This was the limit. My husband was up and about and all we needed was a CT scan to see how his kidneys and the stone were doing in order to be able to decide whether he was fit for a long distance flight same evening. I had to step forward to stop the nurse from repeating those unnecessary procedures. Fortunately, I was a physician myself and was able to control some of the process to some extent. I am wondering what would the patient journey be like for people with non medical background. In our case, had I not stepped forward, there would have been unnecessary pricks, infusion and observation (over-utilization). Not to mention the side effect of missing the flight.

Finally, we got his scan done and were able to get a cd for the CT Scan report upon special request. Fortunately, the kidneys that were swollen earlier had reverted back to normal and the size of stone had decreased from 4mm to 3mm. There was another non-obstructive stone identified in the right kidney. Frustrated, my husband took his flight to India hoping to recover soon and praying for no more ER visits. However, he would still need a couple of follow ups, a specialist referral and investigations to find the etiology for prevention in the future.

This short experience was long enough to reach a conclusion that healthcare needs quality improvement. There are a couple of things that could have made this experience smoother and are the potential areas for healthcare quality improvement.

1. Whenever, a patient is discharged from ER, s/he should be given a complete history of stay along with all investigations report.

2. For radiological investigations, if actual film can’t be given, cd consisting of scan images should be handed to the patient.

3. Ideally, the EMRs and HIS for individual hospitals should talk to each other. If not, then at least a detailed, legible description of the stay at hospital emergency room, should be provided to the patient for future reference.

4. Sometimes, instead of following protocols blindly, understanding the patient’s needs may yield better results. For example, in the incident mentioned above, there was no need of blood investigations and iv infusion. Not only would it have incurred unnecessary costs but it would have added to patient’s discomfort and recovery time.

5. On the other hand, there should be proper protocols where needed. For instance, in the case above, prophylactic antibiotics should have been prescribed when there was urinary stasis due to stone.

6. Wait-time for appointments for radiological investigations like CT Scan or MRI should be shorter.

7. Specialist consultation should be made easier. Where self referral to specialists has a disadvantage of increasing cost for health insurance companies, difficulty in referral may result in patient anguish and sometimes even worsening of conditions.

The crux of the matter is that there is a need of health care optimization where underutilization is balanced by resources saved from avoiding overutilization.

(Note: The difficulty in navigating through the health care system and high costs are one of the major reasons why people are getting attracted towards medical tourism where the marketing teams make the health care navigation easier for patients by providing good support services. But the sad part is that no matter where they go, the quality has a lot of scope for improvement.)

-Jaya Sonkar MBBS, MPH

Martin Luther King Jr. Day: Socioculturalism in Medicine

When you are born with yellow skin and black hair into a multicolored country, socioculturalism is a daily reality. Although my parents label me as an ABC (American Born Chinese) with amusement, unbeknownst to them, every day is a continuous combination of integration, negotiation, and assessment of how my decisions and actions define who I am. For example, if I choose Peking duck over sirloin steak for dinner, does that make me more Chinese? Where did this preference for a northern Chinese delicacy even stem from? My parents are from Shanghai, so my preferred protein should really be freshwater shrimp. Of the dance styles that I enjoy the most, my decision is straddled between Chinese and hip hop. When I’m seeking symptomatic relief from colds, I instinctually reach for Acetaminophen, Ibuprofen, and Phenylephrine. But, for sore throat relief specifically, my first line treatment of choice is Nin Jiom herbal lozenges and syrup. Asian Americans are predisposed to specific cancers and there is an overwhelming prevalence of Hepatitis B in the Asian American community. Because my diet is probably closer to the average American diet, what disease risk factors and predispositions do I actually have?

As illustrated above, I am socioculturally stochastic. Even the best statisticians would not be able to make any sense of this variability and extract a reliable pattern to predict my future actions. While I have never felt intimately tied to my ancestral culture, my physical appearance is a daily reminder that there is no escaping it. Despite my inability to lean one way or the other, whether I like it or not, I am American, Asian, and Chinese. Although I have traveled extensively around the world and have lived in several microcultures within the US, it wasn’t until I traveled to Ghana that I began to understand the significance and potential consequences of my blended identities within a broader context.

Wherever I walked in Ghana, people around me would whisper, mutter, scream, and shout the word, “Obroni,” which roughly translates to white person. Within days, I responded to “obroni” faster than my actual name. And after walking into an internet café, one of the most cosmopolitan buildings in the city, I quickly realized that I was in Ghana not just representing myself, but also my family, my school, my country, my ethnicity, and perhaps even all peoples of the world who have yellow skin and black hair. That’s a lot of responsibility for one person. Did I ask for this leadership role? If given the choice behind the proverbial Rawlsian veil of ignorance, would I choose Asian American physical features if I knew that my actions would forever shape how others perceived all those who merely looked like me?

This new inherent responsibility did not directly dictate my behavior while I was in Ghana. However, I do recall expending more effort describing the Asian countries I had visited, explaining why I primarily use English and not Chinese to communicate with my parents, and searching the entire city for ground pork and Tostito chips so that I could make Chinese dumplings and guacamole to share, respectively. The learning and exploration went both ways. By participating in health fairs at local churches in Ghana, I learned that measuring blood pressure on Ghanaians was slightly different from what I had grown accustomed to doing. Blood pressures tended to run higher in Ghanaians, so I had to make minor modifications in my use of the sphygmomanometer. These behaviors only seemed natural as I tried to absorb as many of the cultural nuances of Ghana. I was sure that this blatant sociocultural exchange would end as soon as I returned to the US because I’d be reunited with “my people,” people who understood me.

However, when I finally did return to the US, I realized that my sociocultural position here at Michigan is not too dissimilar from Ghana. Similarly, in Michigan, I have not only a lot to share, but also a lot to learn. I am one of a few Asian Americans in the school, one of a handful of students who attended college in the Northeast, and just one of a pair of students from Boca Raton, Florida. Just like in Ghana, my opinions and behaviors are important learning experiences from the more grandiose displays such as choreographing and performing a Chinese drum dance at the biannual Biorhythms show to more subtle mediums such as sharing cultural foods and my opinions within our small groups. Because I am unique and represent an eclectic combination of experiences and influences, that intrinsic responsibility I felt in Ghana is always with me. I am inherently a sociocultural leader, and I must confess that I spent much of this first semester struggling with those responsibilities.

It wasn’t until I took some time to reflect upon the significance of Dr. Martin Luther King Jr. Day that I resolved my inner conflict of being appointed a sociocultural leader without ever asking for such responsibilities. In 1963, Dr. Martin Luther King Jr., delivered his watershed, “I Have a Dream” speech. He described a future where the colored people of the nation could walk side by side with the white—a harmonious existence. Today, with an African American Commander in Chief, we can say that we have truly come a long way since 1963. However, I’d argue that we still have a lot more work to do before we achieve the future that Dr. King described. In regards to health equity specifically, the color of your skin is still the strongest predictor of health, not cholesterol levels, blood pressure, or hemoglobin A1c levels as one would suspect. Today, we are walking together, but I cannot say with confidence that we are talking and listening. We are not learning from each other.

Medical school admissions committees work very hard to construct a diverse class. But, we are failing at taking full advantage of this deliberate design. We cannot simple wait for required activities to engage in diversity. And even during such events, it feels like we passively wait for experiences and opinions to crash into each other to hopefully reach a blended resolution. In lectures, diversity is treated like an afterthought. We are constructing more barriers to understanding health equity when we are presented with racial, ethnic, and gender epidemiological data placed only within the biomedical context.

Yes, it is true. I physically appear different from the majority of my classmates and faculty at the medical school and carry the responsibility to speak up to share my point of view. But, I am not alone. I am not the only student with this burden of being a sociocultural leader. This is a leadership burden that is shared among all of us. We all must accept the inherent challenge to listen to others and share our experiences. We should acknowledge differences and carve out the best ways to utilize and understand those differences. That is how we will engage in diversity. That is how we will be able to better understand health equity challenges. And that is how we will together achieve Dr. King’s dream.

If not for our personal benefit, we owe it to our future patients and the greater goal of achieving equitable health care to step up to this leadership challenge instead of asking, “why me?” At the very least, as sociocultural leaders and the future leaders of medicine, we should take some time within our busy days to ask each other questions, respect disagreement, and truly listen and share.

Site Visit: Naval Hospital Pensacola

In December, Shannon visited the Naval Hospital Pensacola in Pensacola, Florida. Approximately 20 staff members came out to meet with Shannon and me, the Chapter Leader, to learn more about the opportunities available through the IHI Open School.

Among those 20 were the Faculty Advisor for the Family Medicine Residency program and four residents. These residents, along with the Faculty Advisor, are looking into ways to incorporate the IHI Open School courses into the curriculum for residents. Shannon posed this question to the faculty community via email and within a week, ten sites responded, sharing experiences and lessons learned. (Coming soon: click here to see the growing list of residency programs using the IHI Open School courses.)

Once again, the power of community in moving forward for safer, better quality care is clear in the ready assistance offered by these organizations. Naval Hospital Pensacola, excited about moving forward in 2011, will set up quarterly meetings, inviting all the staff members who attended the open house event. Using this group, we will expand our membership by holding quarterly bag lunches featuring activities and guest speakers.

The Naval Hospital Pensacola is also a Passport member, which invites them to participate in frequent calls with the larger community to learn more about the Improvement Map tool and receive improvement support from IHI faculty for the work they're doing (Click here to learn more about Passport).

- LT Laura Jensen

The Naval Hospital Pensacola recently received the Department of Defense's Patient Safety Award for Teamwork & Skill Building. Congratulations!

Dealing with Culture Shock: The Aviation and Health Care Industries

One of my favorite things to do is travel. Traveling provides me with an unmatched exhilarating feeling of adventure. Whenever I casually walk down an unknown bustling street, my senses are overloaded with new sights and smells. This kind of excitement is unbelievably addicting. My mind just races with comments. What is that brilliant green dress she’s wearing made of? Can you really eat that? Whoa, where did all of those chickens come from? Did those kids just point and laugh at me? Is his cell phone really that tiny? Why is everyone so tall?

Do I ever experience culture shock? Sure. Every new environment will take some time to adjust to, but the challenges of getting around and living outside of my comfortable apartment in Michigan is all part of the fun of traveling.

What about the culture shock of transitioning from one industry of work into another? The University of Michigan IHI Open School Chapter’s Monthly Speaker Series guest, Gary Sculli, probably does not have many positive feelings associated with his move from the airline industry into health care. Gary Sculli is currently a Program Manager at the National Center for Patient Safety in Ann Arbor, MI. He has both extensive experience as an airline pilot and is a registered nurse.

As Sculli starkly contrasted the two industries, it was clear that the airline industry and health care were two very different beasts. While it may have been difficult for me to adjust to taking cold showers while I was in Ghana, “traumatic” would be the word I’d choose to describe a move into health care from the airline industry. Here are some differences at a quick glance.

Airlines	Health Care
Team training	Hierarchical barriers
Human Factor awareness	Human Factors NOT emphasized
Standardization	Varying degrees of standardization
Checklists discipline	Expectation to complete outside functions
Formalized recurrent training	Haphazard recurrent training
FAA mandated performance checking	Absence of mandatory performance checking

Not only are there differences in work environment between the two fields, but health care is associated with higher error rates—rates that make up the harrowing statistic of up to 98,000 deaths a year due to medical errors, published in the IOM Report, To Err is Human in 1999. A recent study evaluating quality improvement in health care’s progress since the publication of To Err is Human reports the sobering fact that not much has changed. Just as many people become victims of medical error today. While a lot of improvements have been made, we still have a long way to go. According to the Joint Commission, at the root of many of the errors we see in health care are communication and organizational culture. So, what health care needs is a cultural transformation. With the likes of Gary Sculli, we are well on our way on the journey towards safer health care.

Being flexible and keeping an open mind are two important items to pack when traveling to ensure a positive experience. Gary Sculli surely did not forget to pack these on his move. He took the lemons he found in health care and made lemonade by applying effective communication and leadership strategies practiced in the airline industry to health care in order to make health care more effective and reliable. In his discussion, Sculli outlined the concept of crew resource management as a team building effort to not just strive towards eliminating error, but more importantly, how to manage error when it does occur. He also discussed different leadership styles, being a dictator or facilitator, and the health care consequences associated with each. What else is needed to make health care more reliable? Sculli illustrated the need to redesign health care to support “situational awareness,” being able to perceive, comprehend, project, make decisions, and perform actions on variation in one’s environment. Check out the University of Michigan IHI Open School website for more information on topics discussed at the Monthly Speaker Series event.

The application of many of these airline tools have been able to make some great changes in health care. With the use of checklists, many hospitals have been able to effectively standardize procedures and eliminate hospital acquired infections. Through communication training among the staff of the operating room, physicians have been shown to be more adept at soliciting feedback and taking appropriate actions, while nurses and other members of the OR team have moved away from the “hinting and hoping” strategy of declaring an error to providing feedback in a direct, concise, and specific manner.

Perhaps what I love most about traveling is that once you move past the initial jolt of shock that the differences of a new location can give you, people are really all the same. I’ve learned so much from the cultures and people I have interacted with on my travels and have adopted some of these practices into my daily life. Personally, these adopted practices have made my life better. Is health care really so different from the airline industry? They are both fields that include teams of individuals performing highly specialized skills with extreme risk and small margins of acceptable error. With the help of inspiring leaders like Gary Sculli, health care is adopting the best practices from other industries. If we keep moving in this direction, I’m sure the next culture shock health care will give is one of success that we can all be proud of.

Student Teams at the Forum

The IHI Open School team cares about maximizing the value you take away from the National Forum. This year we've incorporated student teams -- a new team-based approach, exclusively for IHI Open School attendees--into our programs. The student teams concept is our answer to a simple question: What are the habits of the world's best conference goers? How do the seasoned veterans leverage a few days' meeting into the knowledge, networking, and inspiration to fuel a year's worth of success in improving health care? It must take more than coffee.

The response has been terrific and we have 10 teams coming to the Forum! Each team is formed of 4-6 students and residents with a mix of professional and demographic factors. We'd like to thank all of you who will be participating in this unique experience. The student teams received their team assignments last week and were asked to develop their team's learning mission by making a comment at the end of this blog post. You'll be able to see what other teams are working on and hopefully find opportunities to collaborate while at the Forum. We've collected a set of best practices from other conference goers below.

How to optimize your IHI National Forum experience:

1. Active learning. With so much packed into three days, it's easy to miss a key insight in the blur of PowerPoints and plenaries. The best technique, we learned, is to think up questions well before the end of a talk. Keeping questions in mind throughout the conference, continuously searching for answers, and reflecting on daily lessons are key best practices of active learners.
   
2. Networking for collaboration. The knowledge to be gained at the Forum is world class, but it's called a meeting because that's what you're supposed to do! To make the most out of your experience, you'll want to be sure to meet the right people. You may find it difficult to find colleagues who share your interests in health care improvement at your school or institution, but student teams are designed to provide an immediate addition to your network of colleagues with common interests, and to provide a starting point for connecting with people you want to meet.
   
3. Connecting to core values. What makes the IHI National Forum so valuable is that improving health care is not just a specialty, it's a movement. Along with a list of great ideas and a stack of business cards, you leave with a sense of joy and excitement about the mission of improving health care that will carry you through the challenges of the year. The IHI Open School hopes that with the help of the student teams you will be going home at the end of the Forum energized and inspired. We hope that the Forum will be as much about learning what's new as rediscovering the core values that sparked your passions in the first place.

To our student teams: We're excited to see the results you come up with while at the Forum. Now's your chance to share your team's mission with the rest of the IHI Open School Community! Please share your team's mission in the comments section below.

See you in Orlando!

--Daniel Henderson

Gut Check: University of Michigan's Medical Error Disclosure Program

We're all familiar with the story of George Washington and the cherry tree that gave rise to the famous line, "I cannot tell a lie, father, you know I cannot tell a lie!"

What motivated him to tell the truth? Was it some sort of rumbling gut feeling that told him that it was the right thing to do? Probably the same motivating forces that led the University of Michigan Health System (UMHS) to transition to a medical error disclosure program that is fully integrated with the hospital's quality improvement and patient safety efforts in 2001.

Unfortunately, our health care world today is one in which we don't follow George Washington's leadership. Medical malpractice is guided by a "deny and defend" approach. Insurers and counsels often urge secrecy, dispute fault, deflect responsibility, and make it as slow and expensive as possible for patients to continue the already unfavorable process. As a result of this approach, it's not uncommon for medical lawsuits to take five or more years to resolve. Information about the cause of injuries is also denied to patients and families for long periods of time; and compensation is unavailable to those who most need it. Worst of all, there is little meaningful quality feedback for providers. Patients and providers are placed in adversarial positions, allowing fear to fester in between.

Turning the current, "deny and defend" approach to medical liability on its head, the current system at UMHS emphasizes full honesty and transparency between staff and patients and encourages the participation of risk management, regardless if a medical error is involved. At UMHS medical errors are identified and collected by all staff, patients, and family members. Experienced risk managers with a clinical background investigate the claims, and care quality is evaluated. The system's three guiding principles are:

1. Compensate quickly and fairly when unreasonable medical care causes injury.

2. Defend medically reasonable care vigorously.

3. Reduce patient injuries (and therefore claims) by learning from patient's experiences

Most importantly, conclusions of the investigation are shared.



We were fortunate to have Rick Boothman, UMHS Chief Risk Officer, join the University of Michigan's IHI Open School for our first Monthly Speaker Series event of the year to discuss UMHS's medical error disclosure program. Boothman's presentation was focused on the underlying principles of quality improvement that help inform the disclosure program.

Boothman's extensive experience as a trial lawyer has given him a strong and intuitive sense about cases that he can almost accurately predict if he can win a case. But, he does what he refers to as a "gut check." Would he accept this kind of care for his own mother?

The undercurrent of quality improvement has led to some great results. As reported in the Annals of Internal Medicine in a paper written by Allen Kachalia et. al., with implementation of UMHS's disclosure-with-offer program, the average monthly rate of new claims decreased from 7.03 to 4.52 per 100,000 patient encounters. The average monthly rate of lawsuits decreased from 2.13 to 0.75 per 100,000 patient encounters. The median time from claim reporting to resolution decreased from 1.36 to 0.95 years. Average monthly cost rates decreased for total liability, patient compensation, and non-compensation-related legal costs.

A system that makes patients and physicians happier...and saves money at the same time? My gut is telling me that this is a system that we should take a look at.