Apr 26, 2015

Agents of change

Earlier this month, we held our 5th Annual UC Davis Quality Forum. In true pediatrician-style, as the Quality Forum turns five this year, let me reflect on some of our developmental milestones.

The Forum was conceived as a germ of an idea back in 2010 with the goal of enhancing the visibility of our local clinical quality improvement (QI) efforts. At that time, we thought it was a brilliant idea, of course. As 2011 grew closer, our nervousness as new parents grew and we realized that the risk of us falling flat on our faces was very real. I am glad to report that 25 whole abstracts were submitted that first year. About 60 committed people showed up. That was the year of many firsts. We started walking and talking, spreading the word to anyone who cared to listen. Learnt to follow directions from people across the health system, and understood the concept of “no”. 

The terrible twos turned out to be not so terrible after all. Now more confident toddlers, we were comfortable with exploring and showed more independence. We began to run. Brent James who leads the Advanced Training Program at Intermountain Healthcare was one of our keynote speakers. We slowly began to build higher towers, enjoyed experimenting. 

Five years old now, we speak with clarity and conviction, and tell our story using full sentences. We are flexible and can hop, skip, and can quite possibly do a figurative somersault if needed. Over the past 5 years, the Forum has experienced growth spurts, and has turned out to be a well-adjusted living and breathing product, loved by its parents, family, and friends. This year we had over 70 abstract submissions and registration was at an all-time high.

As I reflect on how far we have come in our short but feisty time on earth, I also think back to my own personal development in QI. It was 1999. I was a third year pediatric resident in the South Bronx in New York. The Institute of Medicine’s To Err is Human report was released that year. The report brought to the forefront the death toll of medical errors. Crossing the Quality Chasm followed two years later, laying out a framework for health care improvement, just as I graduated from residency and started my first job as a primary care pediatrician. I practiced in a busy teaching clinic, and was energized by my one-on-one interactions with children and their families. I learnt to be totally unfazed by new parents who brought in photos of their newborn’s stool in various shades of green.

However, as I settled into my practice, I could not help but notice that a few things we did were making our young patients and their families very unhappy. Families would spend at least half an hour, sometimes longer, in the waiting room before they were roomed. Then they would spend 15 or 20 minutes more in the exam room before they saw me or a resident. Essentially, more than half the time that they spend in our clinic added little value to their care. Perfectly delightful and happy infants who came in for well child visits, were cranky and hungry by the time we got to them. Toddlers with a fever spontaneously defervesced during their long wait, healed by the tincture of time. 

Wondering if there was a better way, I decided to spend an afternoon off hanging out in the waiting room and front office with a notepad and a pen, observing how patients signed in, checked in, were weighted and roomed. I did not know it back then, but I was actually conducting a time study and drawing a flow and value stream map. I was, in Lean or Toyota Production System terms, going to the gemba – the factory floor- for answers to system-level problems.

About 30 minutes into my time in the front office, a senior physician spotted me engaging in this activity, which suspiciously resembled goofing off. He came up to me and asked me what was going on. When I tried to explain, his response was astoundingly profound. He said to me – “If you really want to help, come back and see more patients”. Typical? Just work harder and our performance scores will improve. Rap that bad physician or nurse on the knuckles, and they will follow that central line checklist. Fire that bad apple, and our data will spontaneously get better.

I now know that if back then I had been trained in QI methods, learnt how techniques from manufacturing, the Navy, and aviation were actively spreading to health care to look at the root of problems, and to tackle issues at the level of the system, versus the level of the individual – I would have had a stronger voice, and been a more effective change agent.

I feel blessed to work at a teaching hospital. Our actions have the potential to influence the careers of tens of thousands of young people. We have an energized and activated group of students, trainees and clinicians at UC Davis that make up a large workforce of potential QI practitioners. They provide insights into system problems, identify variations in care and opportunities for improvement, and can successfully modify pathways of care. Not adequately equipping them to be effective change agents is a tragic missed opportunity. 

One of our proudest accomplishments at the UC Health System is our highly-engaged student interest group in healthcare quality. The Group is also a Chapter of the Institute for Healthcare Improvement Open School, and this allows them to network and learn from people all around the world. This group includes students in medicine, nursing, our nurse practitioner and physician assistant programs, public health, informatics, and business administration. 

A picture is worth a thousand words, and a movie is probably worth a million. So let me share a video with you that ties this all together. The video was created to capture the enthusiasm and energy that our learners bring to our health system’s efforts in quality and patient safety. What is remarkable is that the projects described here were all conducted by the featured individuals when they were students or trainees at UC Davis.

- Ulfat Shaikh

Feb 16, 2015

Personalized Medicine - Disney Style

As a pediatrician I make it part of my personal continuing education goals to keep up with the latest in children’s entertainment. Big Hero 6, Disney’s latest animated feature film, did not disappoint. It introduced me to Baymax, a potential future health care colleague I can look up to.

Baymax was inspired by a Big Hero 6 co-director’s visit to a Carnegie Mellon robotics lab that was exploring soft safe robots and developing inflatable arms to help feed, groom, and dress nursing home residents or the elderly.

Baymax, the lovable inflatable marshmallow-like robot is Hiro Hamada’s “personal health care companion”. Firmly committed to patient satisfaction, Baymax “cannot deactivate until you say you are satisfied with your care”. He instantly appears at the first sound of distress, scans for injury and illness, measures your vital signs, runs labs, provides comforting hugs, whisks your boo-boos away, and gives you a lollipop for being good.

The epitome of patient-centered care, Baymax uses a 10-point visual analog scale to ask you rate your level of pain. His single-minded devotion to promoting health is well-aligned with the Triple Aim, and makes me want to recommend him to my family and friends without hesitation. To quote Baymax, "You are my patient. Your health is my only concern."

Calm under extremely stressful conditions, his marshmallow-like appearance is intentionally meant to convey a patient-friendly, non-threatening, and approachable persona. A trait that redeems pediatricians everywhere who show up to work in costume at Halloween, or who own a large collection of Winnie-the-Pooh neckties.

Comfortable with tears, Baymax personifies physical and behavioral health integration. He pays close attention to emotional health and understands the importance of social support for those who are grieving.

Despite his heroic medical capabilities (his hands are equipped with defibrillators), Baymax does not forget preventative care. He badgers adolescents about taking better care of themselves, counsels Hiro about buckling up because seat belts save lives, affirms the role of appropriate diet and exercise in promoting longevity, and informs Hiro that he needs to wait one hour after eating before swimming.

Baymax realizes that not every problems needs pharmaceuticals. As he says to young Hiro, "You have sustained no injuries. However, your hormone and neurotransmitter levels indicate that you are experiencing mood swings, common in adolescence. Diagnosis: Puberty."

And best of all, Baymax is a flying doctor. He makes sure that he provides mobile health care and comprehensive wraparound services. A patient-centered medical home - high-quality, accessible, efficient, personalized, and huggable - Disney style.
- Ulfat Shaikh

Dec 11, 2014

Be Bold, Be Brief, Be Brilliant, Be Gone

"I didn't have the time to write a short letter, so I wrote a long one", said Mark Twain.

Marketing and communication experts know that well-crafted and memorable health communication messages are brief, high impact, and visual. Research shows that the average attention span is as little as eight seconds. Most information transmitted to the brain is visual, and images are processed several thousand times faster by the brain than text.

My medical training reinforced this concept and I was taught to let patients leave medical visits with no more than a couple of key messages, and to use visual aids to reinforce messages whenever possible.

Unfortunately this body of evidence has not translated into health professions education with much consistency. Slide presentations, too often, have too much information, minuscule fonts, distracting clip art, and are used a script instead of a visual aid.

My fears that I was doomed to die a slow and painful death brought on by millions of blue slides with small white font were allayed when I attended a refreshingly different session called 'My Hopes for Health and Health Care' at the Institute for Healthcare Improvement's 26th National Forum earlier this week in Orlando, Florida.

PechaKucha (pronounced: pe-chak-cha, Japanese for chit-chat) is a presentation style invented by two architects in Tokyo. The first PechaKucha event was held in their gallery and lounge, SuperDeluxe, in 2003, and has since gone viral across the globe. Presenters have 6 minutes and 40 seconds each to get their point across. They use 20 images, each shown for exactly 20 seconds, resulting in high impact and concise presentations whose messages stick.

Simplicity and brevity is hard. Preparing for this presentation format frequently takes much more work compared to traditional presentations.

Helen Bevan from the NHS moderated a riveting PechaKucha-style session at the IHI National Forum, a first for this meeting. Eight speakers from across the globe included a medical resident, a nursing student, physicians, health administrators, and a parent advocate. The session was fast-paced, exhilarating and inspirational.

Why stop here? Why not extend this style to presenting clinical quality improvement work? Improvers in health care frequently present their work to eclectic and diverse audiences. They have no dearth of visual materials and striking graphics to demonstrate their point. Patient stories and pictures add a strong human element to their words.

Change agents and improvers are passionate about their work and love talking about it. Slides in PechaKucha-style presentations run on automatic. A forcing function that ensures speakers end up with compact presentations, whether they want to or not.

I am convinced of this presentation style’s potential as an antidote to Death by PowerPoint. Can’t wait to try out a PechaKucha-style session at UC Davis' 5th Annual Healthcare Quality Forum on April 1, 2015. But first I need to learn how to pronounce it. This little video helped ...


- Ulfat Shaikh

Sep 28, 2014

Earth to Mars: Healthcare lessons from India

India's Mars Orbiter Mission last week was remarkable in many respects. India was the first country that successfully sent a spacecraft into Mars' orbit on its first try. The mission took only two years to accomplish from announcement to execution. However, one of Mars Orbiter Mission’s most remarkable aspects was its sticker price. The mission cost $74 million, about three quarters the amount it took to make the Hollywood movie, 'Gravity'.

Health care can learn a few lessons from India. Although healthcare in the U.S. is highly innovative, it is also highly unaffordable. Like technology and manufacturing, the healthcare industry has been experiencing offshoring for the past few years. According to the Centers for Disease Control and Prevention, about 750, 000 Americans travel abroad annually for medical care. A small, but growing number of these patients travel to foreign countries for procedures that are at least partially paid for by their U.S. health insurance plans.

The U.S. and Indian healthcare systems share several similarities. Both large democracies have private and public components to healthcare delivery and finance. Public healthcare is managed by individual states. There are significant urban-rural and socio-economic disparities in healthcare access. Noncommunicable diseases, such as cardiovascular disease and diabetes, are leading causes of death. Special interest groups actively lobby to influence healthcare policies. Medical expenses drive a significant proportion of the population into poverty each year.

There are also significant differences. Even after adjusting for clinician salaries, procedures cost five to ten percent less in Indian hospitals compared to those in the U.S. Out-of-pockets costs for healthcare are far more transparent in India. Defensive medicine is rare. However, India’s infant mortality rate is seven times higher than that of the U.S. Less than five percent of the 2 million Indians who require heart surgery actually receive it. Seventy percent of India’s 8 million blind people would see again, if they could access and afford cataract surgery. Only 36% of the population has sanitation facilities, creating significant public health hazards.

A Harvard Business Review case study of nine innovative hospitals in India, highlights their use of manufacturing and quality improvement principles to reduce costs. Eighty percent of Indians pay for medical care out-of-pocket, compared to ten percent in the US. So keeping costs low is necessary to allow more patients to utilize and pay for healthcare. Indian hospitals purchase costly equipment much less frequently than U.S. hospitals do. They send patients from spoke to hub sites to access resources, reducing equipment idle time and duplication of resources. 

Frugality is the mother of innovation. When one of these nine Indian hospital found that surgeons used only a third of standard length sutures, it ordered packages with shorter sutures. When a hospital was unable to negotiate volume discounts for disposable surgical gowns and drapes, it imported bulk fabric and manufactured its own gowns and drapes, reducing costs by less than half. Expensive single use instruments were rare. Nurses and other staff undertook routine responsibilities, allowing physicians to focus on complex issues. Hospitals developed and performed procedures that cost less. They eliminated unnecessary pre-operative testing. They chose to use cloud-based software for electronic records, rather than building individual computer systems at each hospital.

Now, Indian medical care may be coming to a hospital close to you. Narayana Hrudayalaya, one of the exemplars in the HBR case study, performs open heart surgeries in India at a price of $1500 (compared to $100,000 for the same procedure in the U.S.). Earlier this year, it opened a hospital in the Cayman Islands in partnership with Ascension Health that offers cardiac surgery, joint replacements and neurosurgery for close to half of U.S. prices. Ascension is considering duplicating the model in the U.S. following its Cayman Islands pilot - which seems like an idea worth trying.

- Ulfat Shaikh

Aug 24, 2014

Of Measures and Men

News about the Veterans Affairs (VA) scandal this summer coincided with my being in the midst of reading Daniel Pink’s ‘Drive: The Surprising Truth About What Motivates Us’. Pink’s chapter on unethical behavior seemed uncannily relevant as it described how a carrot-and-stick approach to motivation can encourage cheating, shortcuts and unethical behavior.

The VA reported that patient wait-time data had been falsified in two-thirds of its health care facilities. Organizational leadership failure, an unfocused performance measurement system, a toxic milieu, and unrealistically high goals, that placed undue pressure on staff and promoted unethical practices were cited as