Feb 8, 2020

Next Generation of Quality in Children's Health Care

Just returned from the Children's Hospital Association Next Generation of Quality in Children's Health Care Design Workshop in Dallas earlier this week. This meeting convened about 50 thought leaders in pediatric quality from across the country to identify a framework and implementation strategies for the next generation of quality in children's health care.

Here is a distillation of my notes from the meeting:

(1) Health disparities and the positive difference that quality improvement makes: An example is the glaring difference between steadily improving outcomes for cystic fibrosis versus the dismal and variable outcomes for sickle cell disease, largely due to funding for systematic quality improvement in cystic fibrosis.
David Nichols, American Board of Pediatrics


(2) Balanced quality portfolios: Following the publication of the Institute of Medicine report, 'To Err is Human', significant attention and resources have been dedicated over the past two decades to patient safety. Increased attention over the next decade needs to be paid to the other five domains of quality - timeliness, effectiveness, efficiency, equity, patient-centered care.

(3) Patient and family partnerships: Deepen patient and family engagement – get patient advocates onto your teams, integrate them into decision-making to set priorities, engage them meaningfully in quality improvement and co-designing care, provide easier access to medical information, leverage feedback and innovations from online patient networks, and increase the use of patient data collected at home from wearable technology.

(4) Learning health systems: Integrate improvement science, quality improvement, and clinical operations, so that new learning and research is translated to change in local clinical practice without delay.

(5) Standardization: Standardized clinical pathways help us implement evidence-based care, reduce variation in care, and get to shared mental models. Developing and updating clinical pathways takes lots of resources and time, and so using publicly-available robust pathways, with attention to our local context, helps us get to clinically effective care faster.

(6) Outside the hospital walls: Move from the concept of "children's hospitals" to "children's health systems". There has been significant attention paid over the past two decades to improving care in inpatient settings. Increased attention over the next decade needs to be paid to quality improvement in ambulatory specialty care, primary care and community settings, as well as social determinants of health.

I graduated from pediatric residency a year before the IOM report, 'Crossing the Quality Chasm' was released. Since then, I have witnessed the amazing progress in quality that children's hospitals have made. Significant strides have been made in improving patient outcomes, collecting and using health data, team-based care, and training in improvement methods.

We need to look back with pride at all these accomplishment, yet pay attention to ensuring that our priorities for the next generation of quality are aligned with current population and health care needs of our children and their families.

Apr 6, 2019

Want to volunteer on an emergency medical response team? Read this before you rush in

“Paradise is burning”. A colleague uttered these words as we stepped into a smoky Northern California afternoon in November last year. The Camp Fire, the most destructive and deadliest wildfire in California history, was still being contained. Ultimately the fire ended up killing at least 80 people, burning more than 150,000 acres, and destroying over 14,000 homes.

I emerged from the hospital building to see familiar landmarks in Sacramento, 90 miles away from the Camp Fire, blurred by the smoke. A family of 4 adults and 3 children walked into the hospital in N-95 masks. I was startled at this post-apocalyptic vision and was also heartbroken because I knew that the smoke that I was breathing in was people’s lives, homes, hopes, and dreams.

The air quality was rated 337 in Sacramento, reflecting particulate air matter on a scale from 0-500. I read that these levels were worse than readings from cities known for their dismal air quality such as Shanghai, China and Delhi, India. There were public health warnings to stay indoors and UC Davis and my neighborhood public schools were closed.

Emergency response teams worked non-stop. Victims of the Camp Fire were transported to my hospital in Sacramento, the closest level I trauma center to the site. I was on service in the newborn nursery that week and knew that several colleagues were volunteering in shelters to help.

Given that it is only a matter of time before the next disaster strikes again, I wanted to learn how clinicians could poise themselves to help out. I spoke to physicians and nurses with experience in volunteering in natural disasters internationally and nationally, and also looked at the literature around volunteering. This is what I learned:

(1) Don't just show up at the disaster site hoping you can help
Smoke and ash in the air at the Camp Fire Medical Shelter
(Photo courtesy Michael Piela) 
When Hurricane Katrina hit in New Orleans, Dr. Douglas Gross from UC Davis wanted to help. He travelled there with a small church group, but came back feeling that he was not all that helpful. Having done disaster relief work for years, Gross has strong feelings about volunteer teams. He feels that sometimes they can be helpful, but all too often, they may do more harm than good. Gross said that a positive aspect of the experience was that his group traveled to New Orleans with their own supplies, which many of the other groups that that rushed in to help did not have. 

Dr. Elizabeth Magnan from UC Davis, who helped out at the Camp Fire, felt that just showing up at the disaster site may be more problematic than helpful. If you just show up to volunteer you usually do not come in with arrangements for where you will stay and what you will eat or drink. The relief organization has to now take care of you and you become a liability instead of an asset. If you do not bring your own supplies, you end up using other people’s supplies. You can put a strain on already limited resources and end up not functioning very effectively.

(2) If you think you want to volunteer in the future, contact a known disaster relief organization now
Camp fire shelter readying patients for transport (Photo courtesy Michael Piela)
Michael Piela strongly recommends that interested clinicians register in advance with a disaster relief organization. Piela is a registered nurse and emergency medical technician with years of experience providing medical services during local, state, and national disasters through the American Red Cross and the Santa Barbara County Medical Reserve Corps. The organization you decide to volunteer with will review your professional license, credentials, experience, and vaccine records. Piela recommends joining your local American Red Cross division and taking one of their courses to learn how to assist in a crisis. Or you can join a Federal Emergency Management Agency (FEMA)-sponsored Community Emergency Response Team to get trained on disaster preparedness. 

Gross shared that after his experience after Hurricane Katrina, he joined the federal Disaster Medical Assistance Team (DMAT), part of the National Disaster Medical System. He says that through DMAT he functions as a temporary federal employee when he is deployed, trains once a month, and works with a well setup disaster relief team of about 60 people which includes pharmacists, respiratory therapists, paramedics, veterinarians and provides communication facilities. Other options for organizations to work with are American Red Cross Disaster Action Teams or a State Medical Assistance Team.

(3) Be realistic about what you can do to help
Splinting a Broken Arm with Cardboard
(Photo courtesy Douglas Gross)
You will be working in an austere medical setting with limited resources. You may be restricted to basic first aid supplies, such as bandages and over-the-counter medications, and may not have access to intravenous fluids, prescription medications, X-rays or medical transportation. Medical equipment that needs electricity may be difficult to run. If there are power outages, you may end up using an emergency generator. You may not be able to recharge your mobile phone or laptop.

Assess what skills you have for the particular situation. Do people need trauma surgeons, mental health professionals, or primary-care physicians? Some of the medical problems that Magnan, Piela and Gross took care of were breathing issues due to asthma or smoke, chronic conditions worsened by stress, outbreaks of diarrhea due to lack of running water, injuries, rashes, uncontrolled diabetes, and people’s prescription medicine being lost in the disaster. Acknowledge the limitations of your expertise.

(4) Take care of yourself
Patient Care at Shelter Dealing with a Norovirus Outbreak
(photo courtesy Michael Piela)
A big part of disaster training is keeping yourself safe. Magnan recounts a Norovirus outbreak that also struck several clinicians at a shelter that she volunteered at. You will likely be working very hard in shifts that are 12 hours or longer which can take a toll on your physical and mental health. Make sure that you are able to meet your personal needs. You may be sleeping at a Red Cross site or in someone’s home. 

If you are on the roster of a disaster relief organization, plan for potential absences from your regular workplace in advance. Since you may be on call for the disaster relief organization certain times of the year, make arrangements ahead of time for coverage. Develop a network of colleagues at your job who can step in to help you. Check if the organization you are working with covers liability insurance.

(5) Be flexible and humble
Modifying Used Water Bottles as Spacers for
Asthma Treatment (Photo courtesy Douglas Gross)
It is quite possible that at your regular job you are a highly-respected clinician or a master surgeon. But realize that you may not be in charge any more at a disaster relief site. Understand that your new environment may be chaotic and you will need to be flexible, humble, a good team player, and have the resilience to deal with whatever is thrown at you. You will very likely need to make independent decisions fast, have a positive attitude, bury any pecking-order mentality you might have, and be really resourceful. 

The disaster site may not really need the skill set you were trained for in medical or nursing school. Gross recalls modifying used water bottles to work as spacers to deliver asthma breathing treatments. He and his team helped build latrines in Haiti, because that was the need at hand. Go with the attitude that you will do whatever is needed to help.

"Men anpil, chay pa lou" [Many hands make the burden light] – Haitian Creole proverb

Nov 8, 2018

Please Don’t Hide the Forceps


This intriguing story of the Chamberlen family makes the case for sharing what has worked for us in healthcare improvement. Back in 17th century England, the Chamberlen family bucked the trend. Although most babies in those days were delivered by female midwives, the Chamberlen men were well-known for generations for their obstetric skills.

William Chamberlen arrived in England from France and worked as a pharmacist. His family was famous in the midwifery world for their ability to deliver babies safely. William’s son, Peter, attended the childbirths of the wives of King James I and King Charles I. The Chamberlen family was known for their skills in safely delivering babies who presented in the breech position. Back then babies in the breech position frequently died, and their poor mothers also died with them in child birth. The family was also well-known for their skills in managing difficult and obstructed labor. This was especially timely given the prevalence of vitamin D deficiency rickets back then, which caused pelvic deformities in women and subsequent problems with childbirth.

Peter Chamberlen
Turns out that the Chamberlen family’s success came from their proprietary obstetric forceps, variations of which are used to this day in difficult births. The family designed these forceps and subsequently kept them top-secret. They transported the forceps to the mother’s bedside stored in a large highly decorative wooden box, personally transported by the Chamberlens in a special carriage. The expectant mother was blindfolded to prevent her from seeing the box’s contents, the birth was conducted under blankets, and no one except the Chamberlens were allowed to enter the birthing room.

The Chamberlen obstetric instruments
The story ends with a sordid twist when the Chamberlen's obstetric instruments, including five pairs of obstetric forceps, were discovered hidden under the floorboards of the attic of their family home in 1813. After Peter Chamberlen died, his wife, Ann, stowed them away there for over a century. The instruments are now with the Royal College of Obstetricians and Gynaecologists in London.

I’ve spent the better part of the last decade working in health care quality and deeply appreciate communities of practices or quality improvement collaboratives in healthcare. According to one definition, “Communities of practice are groups of people who share a concern or a passion for something they do and learn how to do it better as they interact regularly.” Communities of practice can exist face-to-face in physical settings (hospital wards, outpatient clinics) or virtually (online discussion boards, virtual learning collaboratives).

Regardless of the setting, my work as well as those of others has shown that the special sauce in communities of practice in healthcare is the clinician champion – someone who is a passionate advocate for advancing the cause, and believes in sharing and collaborative learning. How do we identify clinical champions? It’s more than expertise. Look for these behaviors - Someone who makes connections between different people, is an enthusiastic cheerleader for the innovation, has the resourcefulness to find and mobilize resources, is savvy about navigating socio-political environments, effectively communicates a compelling vision, gets things done despite resistance or inertia, and is not afraid of sharing what worked or did not work for them. Realize that these are not necessarily the loudest people in the room.

So please don’t hide the forceps. Share your work generously. Imagine how many babies and moms a Chamberlen clinical champion might have saved.

Leave a comment - How do you share what has worked or not worked for you in your healthcare work?