Thursday, November 19, 2009

Hiding In Plain Sight: A Lesson in Human Factors Engineering

Dr. John Gosbee was our featured guest speaker this past Monday at our November Open School meeting. John is a Human Factors Engineering (HFE) and Healthcare Specialist who lectures frequently in the UM community for students and healthcare professionals and also has his own HFE healthcare consulting company with his wife. His interactive talk was an engaging introduction to a field very relevant to healthcare improvement. John gave us a brief history of HFE, including its birth as early as 1950 in the aviation field. As with the LEAN and other automotive engineering philosophies we have to wonder why it has taken so long for this insight to reach healthcare?

John’s talk challenged us to look at the poorly designed features ubiquitous in our daily lives, literally “hiding in plain sight”. I deal wi
th poorly designed features everyday without thinking too much about them: from the frustratingly enigmatic knobs on my own stove that confuse me every time I try fry an egg, to features of my car that keep me guessing each time I attempt to use them, like how I usually pop open my trunk and gas tank at least 5 times when I attempt to open the hood of my car (even Toyota isn’t perfect!)

Although initially amusing, as John next discussed the context of healthcare, these seemingly idiosyncratic details quickly became terrifying. For instance, the design features of many I
V medications and solutions commonly lead to fatal errors by nursing staff or pharmacists who misread the practically identical packages/labels.

The first exercise is pictured below- students were told to hold their breath and were handed epipens (fake ones without needles) and we were challenged to determine how to administer the drug before letting out our breath. Nearly six students were required to attempt what should be a simple task in light of the pressure of an emergency situation when an individual is going into anaphylactic shock! Personally, I misread the overwhelmingly detailed instructions and would have injected myself with epinephrine had it been a real needle...


The exercise reinforced the point that in healthcare, the more small things that build up requiring workarounds due to impractical design, the less we become able to compensate. Catastrophes result in the form of medical errors. While there are of course lessons to be learned by the engineers who design programs and tools used in healthcare to be user friendly and simple, there is a great deal of value for healthcare professionals to learn to spot these hazards. Developing an acute awareness of the design of tools utilized in the healthcare industry and an intentional mindfulness that workarounds are inefficient may alleviate further complications.

Apparently it's quite rare for a hospital or health system to employ an individual with the role of "human factors engineer" to watch out for threats posed by problematic design features. Therefore, knowing that small adjustments can lead to large, statistically significant improvements it seems crucial that we, as healthcare professionals, attempt to adopt similar mindsets.

As John explained, poor designs can be reported--for instance, the example of the insulin "pen" that he presented was one that was reported to the FDA because the numbers were reverseable depending on how the user held the pen. If US regulatory agencies receive feedback about patient safety threats it is feasible that they will be amended-at least moreso than if never reported! Relevant stakeholders are not limited to frontline caregivers; pharmacy, billing, purchasing and nursing departments all have something to gain by maintaining a critical eye to the design features of the electronic ordering systems, medical devices and other tools commonly used.

That's continuous quality improvement at its best.

Monday, November 9, 2009

A Grey's Take on To Err is Human



Hi, my name is Eva and I watch Grey’s Anatomy.

I started about three years ago with the hotly anticipated Season 2 Finale and have been addicted ever since. I have tried to stop and had hoped that a change in environment (back in school and no TV) would stop this unhealthy habit. But, I have been unsuccessful. In fact, I believe I have reached a new level of addiction.

At the end of every episode I watch, I have been able to extract a lesson to justify my time spent following the lives of the characters at Seattle Grace Hospital. I tell myself that these lessons learned will help me become a better doctor…

...But, do I feel safer or sense the improvements made whenever I interact with the health care system? As this episode of Grey's Anatomy demonstrates, tangible and measurable progress is probably still not yet within our grasp.

Once we get there, this episode should be rewritten. Seattle Grace will be a shining example of the transformation of the culture of medicine. All of the characters would not be individual heroes searching for glory, but would support each other in order to deliver better care for their patients. The Chief and hospital leadership would not bury mistakes like Mrs. Becker's death, but would take the time to identify root causes of the error and fix the system. And every single person would critically evaluate and make improvements to the complex work processes of delivering health care...

Click here to read the full post!

Wednesday, October 28, 2009

An Economics Lesson: Local Solutions



Because I now have less time to read things that don't look like textbooks and lecture notes, I've become a frequent podcast listener. Some of my favorite podcasts are This American Life, NPR's Fresh Air, IHI's podcast, and The 10th Wonder. I have about an eight minute walk to class, so a week of walking takes me through about two hour long podcasts!

After listening to two phenomenal This American Life podcasts coproduced by NPR's Planet Money team about the rising cost of health care, I've started listening to NPR's Planet Money podcast. One of the most recent NPR Planet Money podcasts is a short interview with Elinor Ostrom, the first woman to win the Nobel Prize for economics. The podcast describes her Nobel Prize winning work: qualifying the concept of The Tragedy of the Commons...

...Here's where the "IHI bells" began to ring in my head! Reforming or transforming health care probably operates on the same principle...

See the IHI Open School Blog for the full post!

Sunday, October 25, 2009

Transforming Leadership: From Individual Patients to the Community



...About two weeks ago, I flew out to LA to take refuge from the Michigan cold. LA was unseasonably chilly, so I didn't quite get the sun and warmth that I had hoped for, but I got something better.

I attended the annual Asian Pacific Americans Medical Student Association (APAMSA) National Conference and spent my three days in LA meeting other medical school students and listening to inspiring lectures and workshops. The majority of the sessions focused specifically on health issues in the Asian American population. These include the incidence of Hepatitis B, the large number of uninsured in the Korean American community, the incidence of lung cancer, health awareness and education, and cultural competency.

California has a very large and diverse Asian population. I visited the Monterey Park/Freemont/Arcadia area on my last day in LA and could have sworn I was abroad! Because of this large Asian population, Asian American specific health issues are very apparent in California and there have been several great stories of progress. We had the privilege of hearing from Assemblywoman Fiona Ma of the San Francisco area and Assemblymember Mike Eng of the Los Angeles area describe the great strides that California has made in making the Hepatitis B issue a city-wide awareness and screening campaign (Hep B Free). We also heard from Dr. Jimmy Hara, Community Benefit Lead Physician for Kaiser Permanente Southern California, Dr. Arthur Chen, Medical Director of Alameda Alliance, Captain Cynthia Macri, M.D., Special Assistant of Diversity to the Chief of Naval Operations in the US Navy, and Dr. Paul Song, Director of Clinical Quality Improvement for Vantage Oncology who have all expanded their medical careers to address large scale efforts and discussions on how to better deliver health care, increase access, and shape national health policy. To top off this list of inspiring speakers and the many not mentioned here, our conference closed with talks from Dr. Sammy Lee, the first Asian American to win an Olympic gold medal for the US and Dr. Eliza Lo Chin, president-elect of the American Medical Women's Association.

Since most of these speakers hailed from California and have done such admirable work in the state of California, I felt a little discouraged at first. My hometown in South Florida's greatest health issues are geriatric and centered around ensuring that our seniors are able to live quality lives and obtain the health care that they need easily. My second home in Boston has nearly achieved universal health care access through its individual mandate, but now struggles to iron out the financial details of managing and continuing this initiative. And my new home in Ann Arbor? Unemployment is everywhere. I have yet to gain a better understanding of the health issues in Michigan, but my guess is that access is one of the top five concerns. With significantly smaller Asian communities in these three locales, how am I supposed to take the inspiring and encouraging words from the APAMSA conference and transform them into action locally?....

See the IHI Open School Blog to read the full post!

Friday, September 25, 2009

Breaking News! Medical Students Shadowing Nurses


I just received this message from one of our Deans of Medical Education. Even though I have my first anatomy practical today, perhaps this is a sign that despite all of that, today will be a wonderful day!

Subject: New Required Educational Experience - Nurse Shadowing in M1 Year

Date: Sep 25, 2009 9:52 am

Message:

Dear M1 Class:

This year we are offering you a new required educational experience to complete during your M1 Year. You will each spend one half-day shadowing a nurse in the UM Health System.

Today’s health care delivery system challenges all health care professionals to provide care that is patient-centered, efficient, effective, safe, and timely. To meet this challenge, collaboration among members of health care teams (including, but certainly not limited to, physician and nurses) is vital. In at attempt to educate medical students on the role of nurses in the health care team as well as to foster open communication and teamwork between health professionals, this shadowing program – created originally by medical students – was run as a pilot last academic year. We hope that you enjoy the program as much as students last year did, and take something away that you can use for the rest of your careers as physicians.

We developed the following learning outcomes for the experience:

* Knowledge of what nurses bring to a health care team
* Ability to communicate effectively with a nurse
* Respect for the knowledge and skills of nurses
* Openness to learning about patient care from nurses

We will be asking you to complete a pre and a post-assessment of this experience. The post-assessment will serve as your documentation of completion of the required experience.

Sincerely,
Casey White, Ph.D., Assistant Dean for Medical Education

Little things like this that remind me why I decided to come to Michigan for med school! Do y'all have programs like this in your schools?

Tuesday, September 8, 2009

My First Patient

....With this dangerous streak of curiosity in me, I was surprised to find myself, 17 years later, walking with trepidation down the corridor towards the anatomy labs. The ultimate chance to learn was finally here. But, my steps had lost their usual spring (not just because my scrubs were too big) and rather than looking straight ahead, the scuff marks on the ground began to "fascinate" me. I couldn't contain myself when I thought about finally peeling away the skin to see how all of the different parts of our body worked together. Anatomy has a tangible tie to the practice of medicine, much more than sitting in a lecture hall learning about protein structure. So, what was I waiting for?...

See the IHI Open School Blog for the full post!

Thursday, August 20, 2009

Teaching Patient-Centeredness

See the Original Post on the IHI Open School Blog

...After just a few weeks of medical school, I'm already worrying about losing my ability to empathize with others and my future patients. During our first lecture, our professors told us that they were going to teach us the language of medicine. Will learning the language of medicine prevent me from speaking normally? Will I be as careless as my scoliosis doctor when speaking to my future patients?

Fortunately, the University of Michigan has a component of our curriculum to prevent this from happening. The program is called the Family Centered Experience. The first year medical students are grouped into pairs and each pair is assigned a patient and family managing at least one chronic disease. This could be a mother suffering from breast cancer, a father managing diabetes, or a grandfather suffering from a neurodegenerative disease. Throughout the year, we will be visiting our families and attending clinic visits with them in order to learn from the patient and their family what illness means and how it impacts the individual and family...

Wednesday, July 29, 2009

Patient-Centered Care in Rwanda

As part of the leadership team t the IHI Open School, University of Michigan Chapter, I had the opportunity during the past academic year to learn about the provision of patient-centered care. Although I was not expecting my IHI learnings to play a large influence in my summer internship in rural Rwanda, I've been quite surprised at how useful and applicable it has been.

This summer, I've been working in Rwanda with Access Project, an NGO that supports health centers in applying business and management skills to increase access to life-saving drugs and critical health services in their communities. For the past month, I've been working in a rural health center in the village of Ruhunda. I have been supporting the Titulaire, the nurse in charge of the health center, to improve efficiency and safety in several areas around the health center. I spent the first couple of weeks establishing strong, positive relationships with the staff while I observed their services. Afterwards, I begain a discussion with the Titulaire on what he, the staff, and the community believed to be the main obstacles in the provision of care at the center.

The main recommendation that I suggested focused on decreasing wait-time and improving patient flow at the health center. There were several reasons for this. First, the Titulaire mentioned that long wait time is a main complaint brought up in community discussions. In addition, my own observations at the Center confirmed that there was basically no system in place to deal with patient flow, or a process in place to ensure patients are seen on a "first come, first served" basis. The chaotic situation was what my friend Karen calls a "low hanging fruit," or an easy opportunity to make a significant and quick impact. Also, the health center is very understaffed, and this project could potentially produce much improvement with little or no additional burden on the already strained staff. And finally, and most importantly, this project improves patient safety, as there will now be a system to deal with illnesses and emergencies in a timely and efficient manner. To emphasize the severity of the situation that I observed, I was told by staff members that there are times when patients even decide to leave the health center instead of subjecting themselves to the long wait for care. This is a huge patient safety issue!

After conducting a baseline analysis for a few days, I discussed with the Titualaire my recommendations on how to improve on the current situation: I developed a simple numbering system to ensure that patients are seen on a first come, first served basis. The system also includes easily understood symbols to guide patients to the correct waiting areas, which is critical for communities with a significant illiterate population. I provided a simple template and trained him on how to create the staff task list on a weekly basis, instead of on a daily basis. This would allow the medical staff to be notified of their tasks in advance, and therefore provide them with enough preparation time in order to start seeing patients at exactly 8:00 am, when the health center opens. And finally, I discussed with the staff the results of my baseline analysis and the new system I devised with the support of the Titulaire, and asked for their input on potential problems. After a couple tweaks here and there, I'm excited to say that I've successfully implemented the new system and that I'm in the process of collecting data on how patient wait times have improved.

I feel extremely lucky to be working with Access Project, and organization that has given me the freedom to pursue this project and has encouraged and supported my work throughout my stay in Rwanda. My Access Project colleagues have provided invaluable support in helping me develop my ideas and also train the staff meembers during the practice "run through" of the new system. And because of my work in Ruhunda, I've been asked to travel to Gashora, where Access Project is building a model health center, in order to work with HR and patient flow issues. I'm so excited about this opportunity!

With that said, you may be asking how IHI has come into play during this time. IHI has provided me with the framework on how to successfully address an issue: the Model for Improvement. Being involved with the IHI Open School Chapter this past year and completing the IHI Open School online courses has also helped me develop an eye for recognizing opportunities for improvement and has trained me to be constantly aware of issues dealing with health care quality and safety. With this experience under my belt, I'm looking forward to rejoining my fellow IHI Open School colleagues in the fall, and having some great discussions about how they've been working towards improving patient safety and care this summer.

Thursday, June 4, 2009

Leadership for Results

The past two days I was fortunate to attend the IHI IMPACT (Improvement/Action) Network conference in Detroit. I was recruited by the IMPACT team to create a blog for the event so that IMPACT members (and Open School chapters) who were not present could review the materials presented by the numerous speakers.

I wanted to share the blog with you. Please feel free to comment on any of the pieces-the posts are organized in order of the speakers and panels that took place.

About the IHI IMPACT Network:
The IMPACT network is central to the strategy and concept of IHI and is a vehicle to drive change. It consists of leadership such as hospital executives and senior managers who are interested to drive system change and improvement. The program holds two meetings annually and as a “spread device”, IMPACT is about coming together and sharing knowledge locally, nationally and internationally. This week's event primarily included healthcare leaders from the Michigan community, IHI faculty and directors and other hospital CEOs from around the country.

I hope you are having a wonderful summer. Rubbing elbows with Donald Berwick and the IHI faculty has definitely gotten me very excited for our Open School activities to resume in September together!

Saturday, April 11, 2009

IHI Meeting Overview - 4/7/09

Many thanks to those of you who were able to attend the IHI Open School meeting on Tuesday night! We received very positive feedback regarding our guest speaker and the interesting discussion that followed. Here is an article passed along to us from Dr. Talsma regarding "Why 'Quality' Care is Dangerous" : http://online.wsj.com/article/SB123914878625199185.html

For those of you who indicated that you would like to be involved with future projects, I will be passing on your names and anticipated time commitments to the folks at UMHS. I will let you know what occurs in terms of the potential negotiation process that may occur. If anyone else is interested in being involved with some hands-on projects in the fall, we are working on determining the possibilities for extra-curricular involvement. Please send me your estimated time commitment per week for next fall, skills and/or interests and I will include these with my correspondence to the IPCE project administrators.

Thank you again for your support and attendance this year. We look forward to an exciting fall semester with enhanced participation and collaboration from a variety of health professions' schools!

Amy Silverstein and the IHI OS Team


Picasa SlideshowPicasa Web AlbumsFullscreen

Thursday, April 2, 2009

Next IHI Meeting -- 4/7 at 7:00pm

GENERAL IHI MEETING
TUESDAY, APRIL 7th. 6:30pm 7:00pm*
Location: Room 1680, School of Public Health (same room as previous meeting)

*Please note the time change -- due to a scheduling conflict we pushed the meeting forward by 30 minutes. Room 1680 is the Community/Organ Room located behind the glass doors in the lobby of the SPH I building.

Fellow IHI Colleagues,
Mark your calendars for the next IHI Meeting on Tuesday, April 7th at 7:00 PM in Room 1680 of the School of Public Health.

Our guest speaker, Dr. AkkeNeel Talsma, will be joining us from the School of Nursing for the final general meeting of the academic year. She plans to have an engaging and interactive discussion on her research and experience concerning "Failure to Rescue." As always, please forward this information widely to other health professions' students who are interested in patient safety and quality improvement in healthcare!

We hope to see you there!

- The IHI Open School team.

Sunday, March 15, 2009

IHI Open School Working Meeting

IHI OPEN SCHOOL WORKING MEETING
TUESDAY, MARCH 17th. 6:30pm
Location: School of Public Health, Room 2690 (this room is approximately above the Organ Room/Community Room where our last meeting was held)

Please join us next week to coordinate some exciting projects that are in the works. The focus of this meeting is to prioritize and move forward on the initiatives, and to begin to make our active presence known at the UoM. This is not intended to be a "general" meeting and will be a "working" meeting, but we hope to see everyone there!

Tuesday, March 3, 2009

IHI Update

Hi Everyone,

We’d like to update you on some IHI Open School happenings since our meeting last month. We are pursuing several exciting opportunities for active learning, on-site shadowing, and hands-on projects, as well as working to expand and improve our chapter of IHI OS. If you want to help us pursue any of these opportunities or take a leadership role in IHI OS, please contact me. Watch out for our next meeting at the end of this month.

The IHI OS Team

1) We have been in touch with the leaders of the Idealized Patient Care Experience (IPCE) project at UMHS. This is essentially UMHS’s translation of the IOM’s Crossing the Quality Chasm. It sounds like there are opportunities for IHI OS learning and contribution. We'll be meeting with their team in the next week to discuss the details.

http://sitemaker.umich.edu/jbilli/files/ipce-workingdocument-06-24-08.pdf

2) We talked to Lee Green, a family physician and member of the Michigan Institute for Clinical and Health Research (MICHR). Their focus is on clinical and translational research; Dr. Green’s research centers on the theory behind changing physician/practitioner behavior, basically how to re-train/teach experts. MICHR seems to be connected with everything IHI-related in and around UoM, and Dr. Green believes students can be involved at any level that interests them, from attending meetings to improvement projects to theoretical research.

http://www.michr.umich.edu/about/

3) We talked to Marion Udow, a leader in the Center for Healthcare Research and Transformation. They are currently involved in two pilot projects for teaching both patients and physicians about appropriate use of imaging w/ back pain (basically don’t do it!) and about sticking with medical therapy rather than cath/angio in patients with stable angina.

http://www.chrt.org/projects/delivery.html

4) We're still working on gaining entree into the School of Nursing to find students and/or faculty who are interested in engaging in the group. PLEASE HELP US! If you have any contacts at the nursing school or other helpful ideas, contact Jonathan: jdunford@umich.edu

5) We have created this blog for general dissemination of information, and are beginning a webpage. Stay tuned!

Tuesday, February 3, 2009

Chapter Meeting

This evening over 25 students, faculty, and health professionals attended the inaugural general meeting of the University of Michigan chapter of IHI. We had a great turnout from a wide variety of professions, including representatives from the medical school, dental school, school of public health, law school, and business school. During the meeting, we discussed what values were most important in providing health services to patients and how to address and reduce the incidence of medical mistakes. In addition, we listened to a couple clips from Don Berwick as he introduced the group to IHI (video) and described his requirements for a surgeon who would operate on his knee (transcript). Our next meeting will be in March - details to be announced soon. Hope to see you there!

Wednesday, January 7, 2009

Healthcare Blogs

At this evening's IHI meeting, Jonathan showed how blogging can be used as a tool to stay up-to-date with developments in the health care domain. He created a file that you can use to import these blogs into Google Reader so you can read them at your convenience: google-reader-subscriptions.xml. The list of blogs is as follows:

Health-related

Health Affairs Blog – Health policy blog that contains critiques of the Obama/McCain health plans (http://www.healthaffairs.org/blog/index.php?feed=rss2)

Health Care Industry – Explains business concepts of healthcare
(http://feeds.feedburner.com/bnet/healthcare)

Health Care Renewal – Addresses threats to health care's core values (http://hcrenewal.blogspot.com/feeds/posts/default)

Health Management Rx – Comments on health management (of course) and patient care processes of the future. (http://feeds.feedburner.com/HealthManagementRx)

Medgadget – Source of new medical innovations/inventions (http://www.medgadget.com/atom.xml)

ScienceRoll – Written by a Hungarian med student who is interested in genetics and Web 2.0 (http://feeds.feedburner.com/Scienceroll)

The Health Care Blog – Conglomeration of numerous promoters of Health 2.0 (http://www.thehealthcareblog.com/the_health_care_blog/rss.xml)

WSJ.com: Health Blog – Up-to-date information about health-related news (http://feeds.wsjonline.com/wsj/health/feed)

Not health-related

Lifehacker – Contains tips and downloads for getting things done. (http://www.lifehacker.com/index.xml)

TED Blog – A best of the best blog. Their annual conference brings together the world's most fascinating thinkers and doers, who are challenged to give the talk of their lives. (http://tedblog.typepad.com/tedblog/atom.xml)

Thursday, January 1, 2009

Welcome!

Welcome to the IHI blog website. We have created this as a portal for those who are interested in learning more about the IHI movement and as a newsletter for those within the group. We hope to use it often to communicate with members, promote opportunities for improvement, and solicit participation in IHI activities. If you have any questions, comments, or suggestions for the group, please contact IHI-support@umich.edu.