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...

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

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....

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

Morning Report: 3rd Annual Patient Safety and Quality Leadership Institute

Last week, I had the privilege of participating in AMSA’s third annual Patient Safety and Quality Leadership Institute at Thomas Jefferson University in Philadelphia. Nearly 40 participants from various backgrounds converged to learn about and discuss issues surrounding patient safety. The diversity of the students ranged in years from pre-meds to residents, but also in fields from nursing through pharmacy, and of course medicine. Our host was Dr. David Nash, the Dean of the Jefferson School of Population Health, and a preeminent expert in outcomes management, medical staff development and quality-of-care improvement. Over the intensive course of three days, senior leaders of hospital systems and experts in patient safety exchanged ideas with our group on two main domains: how to structure undergraduate medical curriculum to incorporate patient safety and quality into training, and how to implement our own ideas for projects into hospital systems. Though the days were packed with lectures, discussions, and project work-shopping, the evenings were left open for socialization with my fellow students. I walked away from the weekend feeling a sense of re-invigoration, purpose and the belief that the future of medicine without considerations for patient safety and quality is a future that cannot exist at all. I’ll briefly expound on three of my takeaways for the weekend:

• Patient safety is here to stay: perhaps I’m singing to the choir as the readers of this blog most likely have similar beliefs, but to those of you who may have stumbled here accidentally, the patient safety movement is here to stay. With the work laid out by various organizations such as IHI, and leaders like Don Berwick at CMS, there is no longer the feeling that patient safety is a fad. Hospitals and hospital systems are taking a careful eye to their own operations and taking legitimate issue with these topics. The leadership at these institutions, whether they are early adopters or late-comers, will inevitably arrive at the conclusion that if they will survive as organizations, they must prioritize quality initiatives, lest punishment by government or third-party insurers. This changing environment will allow ample opportunity for any student of medicine or related fields to access leadership for traction in his or her own project.

• Grass-roots AND top-down: as Dr. David Longnecker, the Director of Health Affairs for the Association of American Colleges Medical Colleges illustrated, the movement to incorporate patient safety into medical school and residency will no longer be a matter of “if,” but of “when.” Pervasive throughout the governing bodies of GME is the impetus of change; curricular activities will have some form of training requirement for residency related to patient safety. At the University of Pennsylvania, Dr. Jennifer Myers told our institute about a specialized patient-safety longitudinal track for interested residents. Elite programs around the country, as well as the world, have adopted such a model for resident education. But this may not be enough. While curricular changes in residency may indeed force some perspectives to widen, there is an on-going need for medical schools at the undergraduate level to continue on in this mold. Models of patient safety should be integrated into medical schools throughout the country, not merely as an hour-long “special topics” lecture, but an extended module incorporating didactics and projects for practice. The essential inter-disciplinary nature of patient safety necessitates that these models should not be learned in isolation, but shared with colleagues throughout the patient care realm (i.e. nursing, public health, pharmacy).

• Take action: the best way to get involved is to... surprise! Get involved! This can range from having coffee chats with your classmates to joining your local IHI chapter to implementing your own projects at your hospital. All of the participants at this leadership institute came in with project ideas that we hoped could benefit from the exchange of ideas that this forum affords us. Having experts working with us one-on-one to define and refine our project scope and implementation plan was invaluable. Even more impressive was the ability to view the range of patient safety improvement projects around the country; the enthusiasm was palpable to say the least, with 40 minds humming away offering suggestions to each other.

I cannot express enough gratitude to Dr. Nash for enabling and providing us with such a fantastic weekend of programming. The slides for the various presenters are open to the public, should one feel like perusing through the excellent material. Future leaders of healthcare, take note: patient safety is inextricably linked to the success of your institution, start learning and practicing today!

Slides from presenters:

http://www.amsa.org/AMSA/Homepage/EducationCareerDevelopment/AMSAAcademy/PSQLI.aspx

AMSA Patient Safety Webinar:

http://www.amsa.org/AMSA/Libraries/Initiative_Docs/AMSApatientsafetywebinar.sflb.ashx

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 sense of adventure. Whenever I casually walk down an unknown bustling street, my sense 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.

News Flash!

U-M hospitals win award for being one of the nation's safest by Leapfrog! Click here to read more!

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, 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 almost 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.

Patient Centered Medical Home: An Anchor in the Ocean of Health Care?

The health care system is a ruthless and turbulent ocean. For many patients, even a regular visit to the doctor can be quite unforgiving. With patient safety, effectiveness, patient-centeredness, efficiency, timeliness, and equity concerns, health care visits can feel like navigating the ocean on a flimsy fishing boat. Now that we are transitioning into the phase of implementing and executing health reform, we must push patient-centeredness to the forefront of all our efforts to inform us on how to improve the quality of our health care system.

For example, the concept of the medical home that many say will transform health care into a more coordinated and comprehensive system isn’t just implementing electronic medical records, restructuring care teams that group physicians, nurses, physician assistants and other allied health workers together, redefining scheduling, or figuring out how to pay for these new services. The medical home needs to be a patient-centered medical home—one that actively engages the patient’s needs and concerns. Our system’s struggles with achieving patient-centered care is most evident in how health care providers deliver bad news to patients...

Read the full post at the IHI Open School Blog