Feb 6, 2017

Building bridges at ISQua 2016 in Tokyo

Rainbow Bridge, Tokyo
“The older I get, the more clearly I remember things that never happened.”
 Mark Twain

I try and distill my three main action items after conferences as soon as I get back home, so that I can commit them to memory, or at least to paper. This report on The International Society for Quality in Health Care (ISQua) 2016 conference, as you can see, took a little longer to write! I would like to think that it was because I was still basking in the warmth of Japanese hospitality, or was busy networking with all the fabulous people I met at ISQua for months afterwards.

Why memorialize just three things, given that I learnt tons of new information over a span of 5 days at ISQua Tokyo? The rule of three says that messages or action items in threes are more likely to be remembered. Examples that come to mind are the Three Musketeers, Goldilocks and the Three Bears, Three Little Pigs, and Three Billy Goats Gruff. Messages such as Stop, Drop and Roll (fire safety), and Faster, Higher, Stronger (the Olympic motto) follow the same principle.

So here are my three action items from the 2016 ISQua conference - better late than never…

(1) Check out Charles Vincent and RenĂ© Amalberti’s open access book. ‘Safer Healthcare - Strategies for the Real World’.
The book refocuses our attention on patient safety from the lens of the patient's environment - instead of focusing solely on healthcare professionals and hospitals. The authors urge us to think in terms of the management of risk over time over the course of the patient’s journey. This includes contexts other than the inpatient setting – outpatient care, nursing homes, the home environment, and the patient’s community. As a primary care pediatrician, I especially appreciated the book's attention to risks in outpatient settings, an area that has relatively recently been attended to in the world of patient safety. 

(2) Involve health professions students and trainees in reducing overuse of medical care.
Wendy Levinson, Chair of Choosing Wisely Canada, spoke about involving medical students in reducing overuse. Too much health care is harmful to patients and the healthcare system. More is not always better. So why is it so hard to change clinical practice? It starts with medical education. A fundamental problem with the culture of medical education is that trainee doctors are rarely challenged for over-ordering tests and are more likely to be criticized for not ordering them. About 20 countries so far are involved in the Choosing Wisely campaign. Dr. Levinson urged us to encourage students and trainees to question overuse and to have them consider if a test, treatment or procedure will change the patient’s clinical course and if there are less invasive options. Dr. Levinson’s session ended with this video parody of Pharell Williams' song, Happy.

(3) Discuss supplier-driven variation when I talk to clinicians about the problem of healthcare costs.
David Goodman’s plenary talk on variation covered supply-sensitive care. This is when the supply of a service or resource has a major influence on utilization. Dr. Goodman showed us how variation in care is frequently due to differences in local capacity. In areas where there are more hospital beds per capita, patients are more likely to be admitted to the hospital. In areas where more CT scanners are available, patients are likely to receive more CT scans. Even though patients may receive less numbers of procedures or tests in areas where there are fewer medical resources, there is no evidence to show that these patients live shorter or less healthy lives compared to patients in higher-spending higher-utilizing areas! This is further compounded by perverse payment incentives that ensure that capacity is maximized.

Improvement Science Panel
With 1200 attendees representing 60 countries, ISQua 2016 allowed me to make new friends and catch up with old ones. The panel on Improvement Science that I facilitated was international and diverse, with quality and safety researchers from six countries. I also led a seminar with experts from Australia, Ireland and Japan on designing education to change quality outcomes.

Between sessions I found some time to enjoy the amazing food and culture of Japan, and even bought a kimono! Arigato gozaimasu ISQua and Tokyo for an amazing and memorable learning and cultural experience.

- Ulfat Shaikh

Sep 12, 2016

You must be this tall to ride the process geek bus

On a pleasant December morning in Florida, 200 or so clinicians and health care administrators attending the IHI National Forum disembarked a bus at Universal Orlando. 

At least one of them (yours truly) suffered from a longstanding and deep fear of roller coasters. What followed next was a day devoid of Doctor Doom's Fearfall or The Incredible Hulk Coaster, but nonetheless a thrill ride. These eager individuals were treated to a backstage look at how Universal Orlando keeps thrill ride junkies safe and their parents who stay on the ground taking pictures reassured - a day only a process geek could love.

Universal Orlando employs about 15,000 people and welcomes anywhere between 20,000-60,000 visitors a day. Despite its high volume and complex operations, the resort has an enviable safety record, not only for its visitors but also for the hundreds of actors and stunt people it employs.

The goal of our day was to identify examples of safety and reliability in a high performance non-healthcare industry that could be applied to healthcare, and to develop ideas for improving safety in own work environment. We started off the morning in a conference room learning about safety principles at Universal Orlando.

Then we were whisked off to see The Eighth Voyage of Sindbad stunt show. The story-line and script were nothing to write home about, but the show’s redeeming feature was a bunch of wild stunts and the grand finale, where a stunt person is set on fire and high dives into a water-filled pit. Spoiler alert ... amidst explosive pyrotechnics, Sindbad rescues the beautiful Princess Amoura from the evil witch Miseria, and all ends well.

A backstage look at the show and a Q&A session with the stunt people helped us learn how Universal Orlando designs stunts, how transitions and hand-offs occur there, what systems monitor the cast, how continuity is ensured if the cast changes, how the resort communicates changes in plan and errors, and their process for handling hazardous equipment.

Reliability is the probability of a product consistently performing its expected function without failure. With about three shows a day since the early 1990’s, The Eighth Voyage of Sindbad certainly demonstrates Six Sigma level performance with very few adverse events and high reliability.

In their book ‘Managing the Unexpected’, Weick and Sutcliffe describe five characteristics of high-reliability organizations (HROs) such as nuclear power plants, air traffic control, commercial aviation, and aircraft carriers. These are organizations that could have failed many times with catastrophic consequences but have not. This becomes especially important in complex, dynamic organizations that deal with uncertainty and make decisions under pressure, sometimes with inadequate information, in high-risk situations. This sure sounds like a hospital, right?

Here are my notes on features of HROs that I spotted at Universal Orlando:
  1. Sensitivity to operations: Focus on situational awareness - constant awareness of the state of the system and processes to identify risks. Through the Job Safety Analysis process, situations are graded on a risk assessment matrix based on their level of hazard. Standardize processes to avoid variability. Design high-risk situations such as stunts to be highly reliable. Stunt people attend a fight call before each show, a brief rehearsal where they practice their moves.
  2. Reluctance to simplify interpretations: Solid root cause analysis practices when failure occurs. Safety teams review error information monthly. Use of a decision matrix to determine if an error is due to personal accountability or system problems. Entire park and each stunt is under constant video surveillance. Embrace complexity.
  3. Deference to expertise: Listen to experts at the front lines. Front line workers have firsthand knowledge of problems. Rely on knowledge, not on position. Former stunt people run the safety program at Universal Orlando. Encourage front line workers to promptly call out problems and near misses. Reward reporting - Safety Bucks are awarded to staff members who report safety hazards and these coupons can be used to buy meals at the staff grill. Meet with competitors regularly (in this case, Disney, Sea World, and Busch Gardens) to discuss and learn about safety issues.
  4. Preoccupation with failure: Focus more on failures rather than successes. Pay attention to early signs of failure such as close calls and near misses, and use these deviations to improve processes quickly. Universal Orlando has a humorous safety video, Safety Man, that all staff watch when they are hired, that stars their Chief Safety Officer in a superhero costume, tights and all. Believe that “danger is in the routine” - repetitive and familiar tasks can lead to complacency and mistakes.
  5. Commitment to resilience: Continually devote resources to corrective action plans, dealing with stress, and quickly recovering from errors. Nurture resilience. Keep the focus on learning and growing from failures.
In essence, HROs foster "mindfulness" - alertness, flexibility, and adaptability.

If you are headed to the Institute for Healthcare Improvement Annual National Forum this December, check out the Universal Orlando learning visit or one of their other Forum excursions.

- Ulfat Shaikh (@Ulfat_Shaikh)

Apr 17, 2016

Our blue and gold stars! Celebrating graduates of the 1st UC Davis Training Program in Health System Improvement

"Give a man a fish and you feed him for a day. Teach a man to fish and you feed him for a lifetime".

Depending on who and what you read, this quote has been attributed to Lao Tsu, Maimonides, the Bible, the Chinese, the Native American, my colleague Scott, and even to the Italians!

Regardless of the quote’s origins, it brings home the importance of promoting self-sufficiency to sustain change.  

On March 16 this year, 32 physicians, nurses, students, trainees, and staff graduated in the inaugural class of the UC Davis Training Program in Health System Improvement.

With the Class of 2016
The program is a way to learn about the science and art of improvement. As you might imagine, these are invaluable skills in our current health care environment.

The program teaches skills to enable learners to implement, evaluate and sustain population-level improvement initiatives. Our objectives are to increase learners’ ability to understand and apply tools and strategies to improve health systems, participate in teams to implement changes, and contribute to organizational change management efforts.

We used a blended learning style. A selection of online courses from the Institute for Healthcare Improvement Open School complemented interactive in-person learning at the 2-day intensive course on March 15 and 16.

A big hit at this year’s training was the Ball Toss Game where teams of participants formed a circle. Their goal was to toss a tennis ball to another team members – but not to the person right next to them – without dropping the ball. The game teaches participants how to reduce cycle time and to eliminate dropped balls (i.e., defects) using trial and error.

The Ball Toss Game in progress
Players stop at the end of each turn to assess their last performance and to tweak their next move based on their experience. They learn that they need to change process and system if they want true improvement. They find that getting closer to each other and communicating expectations in advance helps the team improve flow and less likely to drop the ball. They self-organize and discover that smaller teams do faster and better. And they also realize that a little fun and is a great way to build team spirit.

The Ball Toss Game is very physical. So it works well right after lunch or at the end of the day when energy levels are at a low-point.

Blue and Gold certificates of completion (UC Davis school spirit!) were awarded to 32 graduates at the 6th Annual UC Davis Quality Forum on the afternoon of March 16. We asked graduates what was the most surprising thing that they learnt from the training. Here are some responses: 
  • "I was surprised to learn that we have so many resources to help our efforts in our health system."
  • "How much financial waste can be avoided through quality improvement and streamlining processes."
  • "The significant reduction in preventable deaths since the initial Institute of Medicine report".
  • "The multitude of different tools (DMAIC, PDSA, etc.) that do essentially the same thing but with a slight twist."
  • "The amount of detail and research that should/is involved in quality improvement."

- Ulfat Shaikh (@Ulfat_Shaikh)

Jan 10, 2016

It’s all about that buzz! Running a tweet chat at the IHI National Forum

With the Don of healthcare improvement
(Don Berwick, of course)
The Institute for Healthcare Improvement's 27th National Forum last month was a standout event for many reasons. A learning expedition at Universal Orlando to learn about safety and reliability strategies (more about that in my next post), Magic Johnson talking about his HIV/AIDS advocacy work, running into old friends, and making some new ones.

One memorable experience was facilitating a buzz session on delivering high value care along with two fellow Californians - Lisa Schilling, Kaiser Permanente’s VP for Healthcare Performance Improvement, and Anna Roth, CEO of Contra Costa Health Services.

Part of IHI’s effort to increase interaction at their learning events, buzz sessions are “designed to stimulate thinking and draw on the collective experience of the audience”. We ran two buzz sessions titled, ‘Thriving in a Value-Based Environment’, and were blown away by the interest they generated. We had about 300 health system leaders, clinicians, policymakers and researchers at each of the two sessions.

With Anna and Lisa at our session
How do you generate a lively buzz, yet keep the conversation manageable and in a format where we could memorialize the discussion? About 10 minutes before our first session started, Lisa, who certainty cannot be accused of lacking spontaneity, suggested the idea of a facilitating a Twitter chat. Not wanting to appear uncool, I decided to play along. So Lisa came up with a hashtag on the fly (#27ForumValue) and added it to our slides, and were in business.

The brave souls at UC Davis Health System’s public affairs department have been working hard to get our faculty members to use social media in our work. Thanks to their Twitter 101 workshop, which I had attended a few months prior, I was all set to go. A few months prior, the American Academy of Pediatrics had even added me to their list of “tweetiatricians” – a cute little term for pediatricians who tweet.

The goal of our session was to identify approaches that health systems can take to thrive as they deliver high-value care. We began each session with an overall introduction to the topic and our plans for capturing the discussion. I led a segment on engaging front-line clinicians and staff in improvement efforts, Anna led one on ambulatory care redesign, and Lisa handled co-design / co-production with patients and families. We provided question prompts after each of these three sections, and the audience divided up onto groups of 10 to discuss each issue. 

Our audience then got to report out their key ideas verbally or by joining our chat. I honestly enjoyed the added connection with our audience that Twitter brought to our session, and cannot wait to host another tweet chat at our 6th Annual UC Davis Quality Forum coming up in a couple of months.

- Ulfat Shaikh (@Ulfat_Shaikh)

Dec 8, 2015

Surviving the School of Hard Knocks

I recently visited the National Archives in Washington D.C., which happened to be running the exhibit, ‘Spirited Republic: Alcohol in American History’. The exhibit delves into the history of alcohol in American society. It offers a look at the evolution of the Federal government’s policies, including how the government regulated, prohibited - and at one point even promoted - alcohol.

A couple of highlights that healthcare folks might find intriguing: A "gold cure" was one of the most popular treatments for alcoholics (or “dipsomaniacs” as they were called back then) during the late 19th century. You can also view a prescription for whiskey for I. F. Johnson, dated January 3, 1924. During Prohibition the Volstead Act allowed for medicinal use of alcoholic drinks by patients who obtained a prescription from a licensed physician. Whiskey was touted as the new wonder-drug, used in the treatment of conditions as varied as tuberculosis, anemia, pneumonia, and high blood pressure. Adults could obtain an ounce of whisky every few hours at a cost of $3 (equal to $40 today) with their prescription.

A 1918 quote by Governor Hanley of Indiana caught my eye. 'Why I hate the liquor traffic' states, "I hate the Liquor Traffic for the almshouses it peoples – for the prisons it fills – for the insanity it causes – for its countless graves in potters fields. I hate it for the grief it causes womankind, and for the shadow it throws upon the lives of children – its monstrous injustice to blameless little ones."

My visit to the National Archives was actually lunchtime detour from the American Academy of Pediatrics National Conference. A key Conference theme was identifying toxic stress in children and promoting resilience. Did you know that adverse childhood experiences (such as parental drug or alcohol addiction, child maltreatment, or exposure to domestic violence) increase the chances of physical and mental health issues in children that can persist into adulthood? The higher the number of negative experiences a child has, the greater the likelihood of these physical and mental health problems. A rough childhood even raises the risk of premature death in adulthood through changes in the genome, hypothalamus-pituitary-adrenal axis, and immune system.

The Adverse Childhood Experience (ACE) Study offers 10 questions that can help healthcare providers assess toxic stress. One of these questions screens for people in the child’s home with problem drinking, alcoholism, and drug abuse.

The HOPE, or Health Outcomes of Positive Experiences study, shows that emotional connections built during infancy (through activities such as reading together), childhood (providing opportunities to play, taking time to talk, and family dinners), and adolescence (developing safe and nurturing relationships with adults outside of the home, such as grandparents or teachers) build resilience. These connections buffer children against the storms of unsafe or unstable environments. They help children learn social and emotional competence, and build the experience of resilience.

So what is the one new thing I want to try out to help high-risk families in my practice build emotional connection and resilience? The HOPE study had many suggestions for clinicians, but one struck me as particularly intriguing and unique. Asking parents during clinical visits, “What are you most proud of about your child?” As a pediatrician and a mom, that question gave me pause – both professionally and personally.

To quote the great Dr. Seuss in The Lorax, “Unless someone like you cares a whole awful lot, Nothing is going to get better. It's not."

- Ulfat Shaikh