Listening to Paul Batalden

Attendees enjoyed many treats at the 2012 International Forum on Quality Improvement and Safety in Paris. Inspiring keynote speeches. Impressive poster presentations as far as the eye could see. Croissants and macaroons around every corner. 

Few treats, though, compared to sitting and listening to Dartmouth professor--and improvement legend--Paul Batalden share his lessons and wisdom at a student lunch session on Thursday. He offered up Improving Health Care: A One-page Book, a book he developed "to open the topic [of health care improvement], not close it." Students, professors, and other improvement gurus (such as Don Berwick) followed along with interest.

"We get so many signals every day about the broken health care system," Batalden said. "The habit we've developed is to ignore them. We have to change that. We've got to figure out a way to make improving a simpler proposition. We have to move from where we are to where we need to be."

As a writer in the room, it was hard not to just write down every word out of Paul's mouth and hit "Submit" on this blog post. It would have been much easier and much better. For example:

"My sense is that the only thing powerful enough to overcome a habit, the only way to overpower that is with community and hospitality," he said. "And that's not tea and crumpits. Find some way to create a local group with curiosity. We didn't set out to create the IHI. We started with a group of people we knew and trusted, and became a community of curiousity."

Anyone who has met Paul has something positive to say about the interaction. He's warm, generous, brilliant, and anxious to share what he knows, which is an awful lot. But it's not how much he knows; it's how he shares it. He tells stories that engage every set of eyes in the room. 

"I remember this visit to one of the parts suppliers at Toyota. They were talking about the employee suggestion system ..." he started at one point on Thursday.

Then another: 

"I remember one time taking care of an 11-year-old boy who developed pancreatitis ..." 

The richness and the lessons of each story stick with you long after he moves on to the next one. And when you think about them later in the day, they mean even more.

The teaching--and the conversation--lasted only 45 minutes, but it's hard to imagine a better way to spend three-quarters of an hour. It was a treat that will last much, much longer.


- Mike Briddon, Managing Editor, IHI Open School

Follow @IHIOpenSchool on Twitter for news and updates from Paris!

Bringing Learning Home from D.C.

Four students—one from Bellin College in Green Bay, WI, and three from Eastern Virginia Medical School (EVMS) in Norfolk—went to the 13^th Annual International Summit on Improving Patient Care in the Office Practice and the Community in Washington, D.C., with hopes of bringing home valuable lessons to their respective communities. The Bellin student was seeking inspiration and some new ideas for her Chapter. The EVMS students were seeking information for Health Outreach Partnership for EVMS Students (HOPES), their student-led free clinic. Here are their experiences:

Kimberly Herman, 4^th year nursing student, Bellin College

I decided to attend the conference with the hope that I could bring back useful information and proven techniques to assist with the quality improvement initiatives that our Bellin College Open School Chapter has undertaken at area hospitals in Green Bay. Having attended the IHI National Forum in Orlando this past December, I was interested in seeing how quality improvement and patient centered care could translate to office and community settings.

I was not disappointed.

It was inspirational to see all of the people in health care that are devoted and actively working to improve the quality, safety, and experience of patients. (I think that too often health care is seen by the public as a business with its focus on making money instead of caring for people, families, and communities.) I attended sessions on interprofessional communication, individualized care, and the use of e-visits and social media as a way to reach out to patients in different ways. This sort of interaction looked into correcting misinformation, informing patients, providing more individualized information, and offering support for a patient during the course of treatment.

From these sessions, I left with realistic and useful ways of helping to provide safe, appropriate, high-quality care in future day-to-day interactions with patients—and several valuable lessons for my Chapter!

ChengXi Wang, medical student, Eastern Virginia Medical School

My primary goal in attending this conference was to gain insight into models of primary care, which I would then share with the EVMS community. Specifically, I wanted to see successful examples of how care can be coordinated across the various health professions and in community-based settings.

I found everything I was looking for—and more.

I learned about the tiers of influence in health care and realized that health education in the doctor’s office just isn’t going to suffice. I saw examples of what worked, including Communities That Care and NUKA (a model of care from the Southcentral Foundation of Alaska), which will serve as frameworks for how I can do the same, albeit on a smaller scale. I learned about Kano and Lean Principles as applied to health care, and cross-training and its importance to team building. Before the last day of the conference was over, I had already sent out correspondences to members of the EVMS community as to what I learned and what we can apply. I even sent correspondences to former coworkers in the Baltimore City Public School System about several hugely applicable principles! (I taught for 5 years prior to attending medical school.) 

To HOPES, I’ve proposed that we revamp the current continuity system so that care coordinators are cross-trained and that at each visit, patients are asked: “What matters to you?” We’ll truly adopt patients as partners in their health care by having a conversation at each visit about contexts and priorities. Utilizing community resources, we’ll help patients with their own goal setting and self-management, celebrate their progress, overcome setbacks, troubleshoot obstacles, and continually re-evaluate their goals and priorities. I hope that this proposal makes its way through the PDSA cycle with results we can then share.

Krishna Aluri and Clay Nelson, medical students, Eastern Virginia Medical School

We went to the conference looking for general ideas and specific strategies for improving the quality and continuity of care in our student-run free clinic that runs on almost no budget and is administered entirely by volunteers. We found applicable and inspiring ideas in talks held by the keynote speakers, in various workshops, and in many other sessions.

Being involved in a clinic that cares for uninsured and underserved patients, we were especially interested in improving continuity of care and ideas for helping patients overcome some of the barriers that they face in receiving and making use of health care. We were inspired by Maureen Bisognano’s discussion of Health Leads and social advocacy (one of our goals and necessities for helping patients), as well as by Dr. Donald Berwick’s explanation of the Health Impact Pyramid— something that we learned to address in the care of patients before I had ever heard of the pyramid itself. In these talks, we learned the importance of assessing each patient’s understanding of their illness and their barriers to care as well as using patient-specific goals, and models for continuity of care to bypass the barriers and get better health care outcomes.

From the learning labs, we took away ideas and goals that included greater automation in our upcoming use of an EMR (such as triggers for e.g. diabetic patients—described by one participant as an IT reminder system for patient care) and the standardization of care using an EMR to achieve specific goals (important for us since the HOPES clinic has continuously changing clinical teams of volunteer students and attendings). Related to social advocacy and continuity of care, we were glad to hear how other clinics and teams improve care coordination by having specific tasks for pre-visit, visit, and follow-up patient encounters that are carried out by a diverse and integrated clinical team (the follow-up, we learned, may have the most significant impact on compliance with treatment plans). Using examples from clinics in underserved areas of the US and abroad, another session showed us how to improve our continuity of care using only limited resources.

In other sessions, we heard about the importance of matching patient materials and education efforts to their health literacy level (which the HOPES clinic and other EVMS programs already strive to do), as well as how to go about assessing barriers and challenges that are keeping patients from reaching their own goals and the goals that their care teams have for them. Along with this, we learned how to study and improve our operations at the clinic by using PDSA cycles to study our efficiency.

We also gained insight into the health care system as it applies to us as a students and future physicians. We were intrigued by comments on sustainable health care and on eliminating the waste in US health care—two major ideas that will affect us as physicians. (Victor Montori’s discussion of patient-centered care was one of our favorite talks.)

Overall, the conference gave us insight into the future of health care implementation that is better designed to meet the needs of the patient population. As a result, we believe we will be able to deliver better patient-centered care and are better equipped to face future health care challenges.

Duke Students Share Three Lessons from the 13th Annual International Summit

As first-year medical students, we spend almost all our time reviewing material related to human health, disease, and the management of illness. This foundation is necessary for practicing medicine.

But we want go above and beyond “necessary and sufficient.” We want to work together with our patients, colleagues, and communities to provide the highest quality, safest, and most effective care—every single time. The skills needed to achieve this goal are lacking in the traditional medical school curriculum.

This is where IHI and IHI Open School come in.

From March 18-20, we attended IHI’s 13^th Annual International Summit on Improving Patient Care in the Office Practice and the Community in Washington, D.C., and were blown away by the advances being made in building systems where each person has the health care that best fits her/him. We walked away with three major themes:

1. For care to be optimal for each unique person, health care must operate in a people-centered fashion. That means considering an individual’s economic and psychosocial circumstances. We learned, for instance, about different case management models that take these factors into account and in which health professionals work with a panel of patients to help them manage chronic illnesses. Work from other countries (Canada, England, Scotland) was particularly revealing in illustrating how different cultures approach these problems, and how, often times, we in the US can be narrow-minded in our thinking of how health care functions and the interactions it can have with other community institutions. On the other end of the spectrum, from large government driven programs, we heard practical advice from leading US solo/small practice physicians in how they achieve high quality care in their relatively resource-limited settings. Seeing how their passion for quality was intertwined with relationships they had formed with their patients over decades was extremely inspiring.

2. We learned that the pace of research on how to improve care is increasing. We live in an era of active research and increasing knowledge on best practices for improvement gaps, such as chronic disease management and avoidable hospital readmissions. As future health care professionals, we need to remain aware of these advances (they may be just as important to our future practice as a drug discovery) and possibly consider becoming involved in health services research ourselves. The panels on the Triple Aim and PDSA were particularly good at illustrating how quality improvement work occurs.

3. Technology provides the backbone to improvement. The process of incorporating technology is cumbersome—both in terms of time and resources. We heard from hospital systems that are using Meaningful Use regulations as a jumping board to achieve higher quality of care. We also learned about the use of mobile apps for individuals to better manage illness. Electronic health records, databases, patient portals, and other technology advances, when used meaningfully, allow health providers and patients to achieve better results. Examples of health data in action from overseas (England, Scotland) offer exciting ideas for how we can also meaningfully use similar data here.

In all, IHI’s 13^th Annual International Summit reminded us once again of the tremendous challenges, but more importantly, exciting opportunities we—as only beginners in our medical journey—will face as we enter the health care field. It is an exciting time. We look forward to staying informed and continuing to work with IHI to build on the great improvement work already being done.

Parastou Fatemi, Medical Student, Duke University School of Medicine and President, Duke IHI Open School Chapter

Marisa Dowling, Medical Student, Duke University School of Medicine and Vice President, Duke IHI Open School Chapter

Welcome New IHI Open School Regional Leaders!

Regional Chapter Leaders, which are selected after a region comprises at least 25 Chapters, serve as intermediaries between the IHI Open School team and local IHI Open School Chapters. They form the backbone of the Chapter network and help foster the growth of the IHI Open School community. We are thrilled to have them join our team and are immensely grateful for their contributions! Feel free to drop them a line and say hello. They’d love to hear from you!

United Kingdom IHI Open School Regional Leader  

Hi, my name is Andy Carson-Stevens. I’m thrilled to be the new Regional Leader in the United Kingdom. The IHI Open School has played a huge part in my professional life. As a medical student in 2008, I convened the Wales Chapter as a student program allied to the 1000 Lives Campaign in Wales. During an internship at IHI in 2009, I realized the power of the IHI Open School network, and co-founded the first student-led global patient safety campaign to encourage the spread and implementation of the WHO
 

Surgical Safety Checklist. To our surprise, thousands of students got involved in the “Check a Box. Save a Life.” Campaign! Through academic scholarships awarded by the IHI Open School, I’ve been fortunate to attend IHI learning events such as the National and International Forum, and in 2010, I attended the Student Quality Leadership Academy. I’m now honored to be the lead author on a new course for the growing IHI Open School catalog. The IHI Open School has given me a family of friends to share and learn with from across the world - I look forward to learning with you!

Starting this August, I will be a primary care physician trainee and a Lecturer at the Institute of Primary Care and Public Health, Cardiff University. You can reach me at andypcs@gmail.com.

United States Midwest IHI Open School Regional Leader

My name is Lakshman Swamy, and I am an MD/MBA student in my final year at Wright State University in Dayton, OH. I'm excited to serve as the Midwest Regional Leader this year! My goal is to create a stronger network between our Chapters—new and established—and to promote more interdisciplinary communication as well.

I'm also looking forward to spending the next few months at the Center for Clinical Excellence  at Brigham and Women's Hospital in Boston. I'll be getting started on regional events by working closely with the IHI Open School staff while I'm there, as well. Feel free to drop me a line anytime to share your ideas or talk about Chapter programming. You can reach me at lswamy@gmail.com. Looking forward to a great year!

United States West Coast IHI Open School Regional Leader

I’m Jessica Schwartz, and I just moved to Denver a few months ago from San Antonio, Texas, where I attended Trinity University’s Masters in Healthcare Administration program and led San Antonio’s IHI Open School Chapter.  I am completing my Administrative Fellowship at Children’s Hospital Colorado from January to December 2012, and I’m really excited to continue my involvement in IHI! 

As the Regional Leader of the West Coast, I hope to shine a light on the great work these local Chapters are doing, foster collaboration in and between Chapters, and organize at least one regional event. Please contact me with any ideas, suggestions, or comments.  I look forward to working with the Chapters in my region, other Regional Leaders, and the IHI Open School staff to really make some positive change.  You can reach me at Jessica.Schwartz@childrenscolorado.org.

End of Life Care: Does it ever get easier?

May 9, 2011 was the first day of my third year of medical school, first day on the cardiology inpatient service, and the first day I met Ms. W, my first patient. Ms. W was a 77 year old woman with COPD, right-sided heart failure, pulmonary hypertension, and was in the ICU for ARDS due to spontaneous hemorrhage of unknown etiology. Because taking care of Ms. W would be challenging and overwhelming, my senior resident and I walked into Ms. W’s room together for introductions.

I naively expected to see a charming elderly lady who was just a little short of breath. However, one could argue that formal introductions were not needed because Ms. W likely never even knew we had walked into her room—she was on a ventilator and thus was heavily sedated. Nevertheless, Ms. W was very much present. Her gray hair was pulled back in a high loose ponytail, her hands were warm and her head bobbed up and down with each breath. She would inconsistently raise her eyebrows at the sound of her name and her tongue would slide towards whichever side her body was turned on. Despite the lack of any form of acknowledgment at our first meeting, Ms. W made a significant impression on me because just fifteen years earlier, my grandmother, who was 77 years old, was also in the ICU heavily sedated and dependent on a ventilator.

I worked diligently to take care of Ms. W. Every morning, I cheerfully greeted her, carefully checked her heart and lung sounds, confirmed the presence or absence of distal pulses, monitored the position of her endotracheal tube, checked every inch of her skin for signs of rash or pressure ulcer, and recorded her ventilator settings. As part of my morning ritual, I crossed my fingers before picking up her record book of ventilator settings hoping to see a positive trend towards recovery over time. I zealously poured over books and primary literature to understand the complicated management of her cardiac, respiratory, and renal disturbances. Perhaps it was selfishly motivated, but I felt committed to Ms. W. I strongly believed that if I could heal Ms. W, I could make up for my lack of understanding and inability to help my grandmother fifteen years earlier.

As the days passed, there were no signs of improvement and there were plenty of subtle hints that even a modest amount of recovery was unlikely. Managing her fluid status with changes in either direction only made things worse. Family meetings were initiated. I stood in the shadows as difficult conversations uncovered internal family tensions between honoring Ms. W’s understood wishes and managing Mr. W’s feelings of loss. With each passing day left without a decision about our next steps, Ms. W steadily and slowly declined. Her ventilator settings started to uptick towards the need for more aggressive support, her kidney function was slipping, and the color of her feet became mottled. It was finally decided that it was time to let Ms. W go. Because Ms. W was my very first patient, my senior resident insisted that I join the family as they said good-bye.

The family, hospital chaplain, senior resident, and I all gathered into Ms. W’s room. Slowly, one by one, the beeping and whirring of the machines helping Ms. W stay alive were shut off. The endotracheal tube was removed and the only sounds left were short exhales of air and muffled sobs from Ms. W’s family. The sight of Ms. W’s family quietly and lovingly saying good-bye to her instantly transported me back to my grandmother’s hospital bed. Without consciously being aware of my own thoughts, I too began to sob as little bits and pieces of the past and present intermingled. I was not there when my grandmother passed away. But, simply transposing my father and mother’s faces onto Ms. W’s daughters felt all too real.

In just moments, after a few sputtering coughs, Ms. W stopped breathing. As I stood alone in my corner of the room shifting in and out of my own thoughts, I remembered that it was my father’s birthday--an overwhelming coincidence that made things too personal. With this realization, I said my good-byes to Ms. W and her family and then stepped out of the room rushing to find some privacy. All of the bathrooms were occupied, so I dashed into an empty family waiting room. I closed the door. I grabbed a box of tissues in one hand and held onto my cell phone with the other as I began to cry and wail. While I rationally and clinically understood the importance of discontinuing aggressive treatment for Ms. W, I could not resist feeling like I had failed her, and by association, failed my grandmother.

After gathering some composure, I loosened my grip on my cell phone and called my mother. She was away in China, but I ignored the inconvenient time difference because I needed to hear her warm and comforting voice. She explained and described how hard it was for us to let go of my grandmother. My mother assured me that it was the right thing to do and it was not a failure. My grandmother never wanted to be in the ICU and we had already disrespected those wishes for 200 days. She was ready and as honorable children, my parents had to let her go. Hearing the words that I myself have advocated for in regards to end of life care while working in the area of quality improvement of health care delivery, I calmed down and regained my strength.

My month on cardiology was only the beginning of a year of dramatic change and growth. By the end of my cardiology month, my clinical knowledge had increased exponentially. But, I can’t confidently say that I achieved similar emotional maturity. Ms. W was only the first of a total of four patients I lost that month (I have since lost another three while on surgery and lost my dog whom I was medically managing remotely as she succumbed to mesothelioma). On one hand, I have learned to harden my heart, for self-protection reasons, as I have not shed another tear for my patients. But, on the other hand, my great exposure to death has not made leaving the hospital when I had an unstable patient or losing patients any easier. Of all of my patients, the faces and narratives of the patients I have lost are those that I remember most vividly. The clinical courses and what I could have done differently, to some extent, haunt me. Consequently, the feelings of failure are always hovering and have shaped all of my future difficult patient experiences. Selfishly, I am drawn to more aggressive and alternative treatments despite promised or lack of promised outcomes.

Will my beliefs and instinctual emotions ever align? As I continue in my training, perhaps I will achieve a better balance between the science of medicine and the humanistic relationships with my patients enough to step away from my own selfish discomfort with failure. Will more experience become the evidence I can depend upon when making future clinical decisions? Because death and dying are fundamental aspects of medicine, for the sake of my patients and my own well-being, I certainly do hope that time and experience will foster the strength to be my patients’ guide through difficult times. Of all things, this is the best medicine that I can provide.

Remembering the Match Day Madness

Joshua Liao, BA, BS

Editor’s note: Joshua Liao, a fourth year medical student at Baylor College of Medicine, participated in Match Day this past Friday, where he found out that he will begin his Internal Medicine Residency this July at Brigham & Women’s Hospital in Boston, MA.

Most students have heard about the raw emotions—from elation to disappointment to contentment—on display during Match Day. As several leaders shared remarks in the minutes before envelopes were passed out last Friday, this became absolutely true for me. I felt the nervousness rising inside my chest, and I couldn’t take my eyes off the Match Board, the enormous vehicle my school uses for “job notification.” At Baylor, each student’s name is printed on the board with a corresponding envelope stapled beneath. The board is then covered by wrapping paper and parked behind the speakers until the appointed time.

Eventually, the envelopes were unveiled, and the seconds after I opened mine were a blur. I remember clenching my fist in gratitude before my loved ones mobbed me with congratulations. Behind me, shouts of joy mixed with epic, celebratory music. On the outside, I sensed my lips drawing into a wide, irresistible grin. Inside, I was absolutely ecstatic. I had matched into an absolutely amazing internal medicine residency.

After percolating in the feeling for several moments, I phoned my parents (who live in China) and then moved into the courtyard, congratulating my classmates and seeking out key mentors to thank them for their help and encouragement. Photos were taken, but I forget how many. There were many more hugs and handshakes. By the end of the event, I was exhausted and content.

Now, even just days after the Match festivities, I am struck by several important lessons about the whole process:

First, the moment can pass quickly. Plenty of people warned me about the intense emotions, but none told me how rapidly the whole thing would move. It felt like only seconds between the speeches and the paper being torn away from the board. I moved through the crowd to the board and removed my envelope, all without fully realizing it was happening. Seconds later, I was hugging my friends and family, and the uncertainty and nervousness had suddenly given way to relief and joy. The moment was like the first seconds after a dive into a cold pool; I felt the weight of my own feelings before I even realized them.

Second, the event can be as much the reinforcement of the past as it is the beginning of the future. Most know and think of Match Day as the beginning of new chapters in our lives, and in many ways, they are right. But as I embraced, laughed, and exchanged the good news with classmates, I realized how the moment seemed to strengthen my feelings toward them and my desire to stay in close touch going forward. Along my path around the courtyard, I ran into friends with whom I’d shared long study sessions, call nights, difficult cases, and extracurricular activities. I was able to enjoy a few moments with my closest friends from my medical school class. I found myself not only congratulating many of them, but also hoping sincerely that we would continue to stay in touch—in person, for those who’d be in the same city as me; via regular phone or webchat meetings for the others. Ultimately, I knew well in advance that Match Day would be a time to look ahead to residency. But I didn’t know it would stir such a strong sense of camaraderie and the desire to intentionally preserve my meaningful medical school friendships through demanding residency schedules. The thought felt warm against my chest.

Third, and most importantly, Match Day can be a powerful reminder of all the friends, family, and mentors who helped shape us. Some say that no man is an island, and that idea was never truer for me than during Friday’s celebrations. The notification paper only listed my name and the program’s name, but I remembered all the thoughtful letters of recommendation, advice, and input that contributed to that pairing. Several loved ones, friends, and mentors were present, and I was able to look them in the eyes and share from my deep gratitude. I owe long, thankful phone calls or letters to those who were not in attendance. Regardless, they were all in my thoughts almost immediately after I opened my envelope, where they have continued to linger in the hours and days following.

So for now, I will bask in the moment, thankful for the supporters and friends who journeyed through medical school with me. I will replay the moment from Match Day in my mind a few more times, to remember the anticipation and aftermath of it. But after a few days of this, I must stop. I have many letters of appreciation to write.

Where did you get matched? Leave a comment below and let us know where you’ll be starting your residency.

Enjoying the Milieu of Matching: Reflections from a First Year Intern

The fourth year of medical school is a rather strange mix. You spend much of the months of November to January travelling all over, living completely out of a suitcase, and wearing the same dark suit for days on end. This is followed by whatever method you might choose for ranking the places that you would like to complete residency. Some people make endless lists of pros/cons, others continue to research every possible detail about programs, hospitals, cities, and the like. All of this leads up to filling out the rank list with NRMP (National Resident Matching Program), checking it a few (possibly a dozen) times, submitting the list, and waiting for almost a month.

Then comes Match Week – probably one of the most unusual ways ever to find out about one’s first job (or at least the first as an MD/DO).

The second week of March is filled with a roller-coaster of emotions for fourth-year medical students across the country. There’s the universal anxiety about receiving the email from NRMP on Monday morning – “Did I match?” – followed by a week of anticipation. Medical schools seem to handle Match Day in one of two main ways. Most medical schools convene students (often for the first time in many months) to celebrate the achievements of the class. Some schools (like mine) have students announce where they will spend the next 3-7+ years in training one-by-one in front of a crowd of classmates, families, and friends. Other schools (so I’m told) have students open their match letters all at once, allowing for a bit more private experience. In both situations, the primary motive is to celebrate the achievement of students completing the four years of medical school now embarking on the next part of their training.

As I look back on my own Match Day, I’d encourage those of you reading this to make sure you take the chance to celebrate. Take a little time to reflect on what you have accomplished and to enjoy a day with the people with whom you have worked throughout medical school. In addition, celebrate with attendings, faculty, and mentors alike. Match Day, for many students, will be one of the very last times that you spend with your classmates. Some classes decide to celebrate on the morning before Match Day with a makeshift “tailgate” (caution: rumor has it this can be dangerous), while others host parties afterwards for students and faculty. In whichever way you choose, take the time to enjoy your individual and collective accomplishments. The next few weeks and months will be filled with final rotations, travels to find a new place to live, and hopefully at least a little time to relax. Graduation will find most people in the midst of life changes, marriages, babies, moving, and that day will come and go rather quickly. Take the time on Match Day to realize what you’ve accomplished and to re-connect with the people who were alongside you on the lengthy journey from the anatomy lab, through the classroom, and onto the wards. It’s an exciting week; make the most of it. Good luck!!

- Ross W. Hilliard, MD, Internal Medicine Intern, Rhode Island Hospital and The Miriam Hospital, Brown University/Lifespan