A State of Flow

Hospital flow during the COVID-19 pandemic taught health systems around the country new ways to use quality improve methods to improve efficiency. We learned to how to be more nimble, how not to let perfect be the enemy of good, and how to integrate clinical operations to make the best use of resources.

Building trust with frontline health care staff, learning collaboratively with other health systems, and rapidly using from data and information to drive quality improvement were critical focus areas.

Couple of resources if you are working on tackling this complex but critical issue:

This NEJM Catalyst article summarizes what hospital flow is and why it is important to tackle flow though quality improvement methods. 

This blog post from the Institute for Healthcare Improvement shares some lessons about hospital flow during the pandemic. 

Meet an Improver: Dal Hothi

Author: Daljit Hothi, MBBS, MRCPCH, MD

Consultant Pediatric Nephrologist and Associate Medical Director for Wellbeing, Leadership & Improvement, Great Ormond Street Hospital for Children, London.

My clinical education and experience...

I am a Pediatric Nephrologist and trained predominantly in the UK, but also spent 2 years as a fellow in Toronto, Canada. I then completed an MD, with a research project focusing on the impact of hemodialysis sessions on our cardiovascular system prior to securing my consultant job. During my medical training and subsequently as a consultant I sought opportunities to advance my understanding of Clinical Governance, Quality Improvement, Safety, and Healthcare Leadership and Management.

My experience in health system improvement...

I have over 10 years of experience in Health System Improvement. I have designed, developed and delivered a number of Quality Improvement training programs, both face to face and virtually. I was the Quality Improvement theme lead for the Harvard Global Pediatric Leadership program for 3 years which gave me considerable insight on the opportunities and challenges in delivering a training program to an international audience. Over the past 3 years I have become a member of the ISQua conference faculty delivering learning labs and learning journeys with learning opportunities for everyone at beginner, intermediate and advanced level around a specific theme. I have led a number of local and national QI program and am now the QI Lead for the British Association for Pediatric Nephrologists initiating Pediatric KQUIP, a national Quality Improvement collaborative for children with kidney diseases.

Why I work in health system improvement...

The enthusiasm and drive in my medical career stems from a desire to reach perfection and a belief that there is always room for improvement. What I have subsequently realized is that change does not intimidate or frighten me, I actually thrive on it. This took to my natural place of becoming an improvement agent.

Tips for current and future health system improvers...

Over the years I have learnt that in order to translate a new idea to a sustained change in practice we have to be able to build relationships, lead and create alliances and socialize the idea for wider engagement. It is only when this is executed successfully that we are rewarded with shared narratives and new belief systems and norms of practice.

I would also like to acknowledge and normalize the fact that health system improvement is not easy. One has to develop tenacity, strategies for self-care, help build team resilience and not be frightened of failure but redirect that energy to the pursuit of continuous learning.

A personal challenge that I experienced with health care system...

A relative with dementia and malnutrition was admitted to hospital. As part of her treatment plan a decision was made to give her an albumin infusion. Unfortunately the 20% albumin was given as a bolus as opposed to a slow infusion resulting in acute pulmonary edema. The hospital failed to acknowledge that a mistake had been made and did not speak to the family about what had happened. In fact the family were given the impression that nothing unusual had happened, “there was no complication, the breathing difficulty is expected in patients receiving albumin”.

What health system improvers can do to prevent something like this from happening again...

I think healthcare improvers really need to support organizations to cultivate a culture of open, transparent dialogue with patients and their families; to design, develop and implement structures and processes for exemplary patient safety and duty of candor practices. I would like to engage, educate and empower patient to become partners in patient safety, co-designing and driving improvements alongside healthcare professionals.

Meet an Improver: Peter Lachman

Author: Peter Lachman, MD, MPH, MBBCh, FRCPCH, FCP (SA), FRCPI 

International Lead Faculty, Leadership Quality Improvement and Patient Safety, Royal College of Physicians of Ireland

Former CEO, International Society for Quality in Healthcare

As I look back over my career, I can think of many opportunities that we had to make a difference. In each of the major clinical incidents that I had to deal with the key learning was that, unless we communicate in a transparent manner, we will never achieve safety and high quality. And unless we understand and implement human factors, reliability and resilience theory we cannot be safe.

My most exciting program has been the Situation Awareness for Everyone program that I have been running over the past 7 years in the UK and now in Ireland. Here we take complex patient safety principles and translate them into day to day practice. This induces psychological safety as well as safe clinical care. All of this has been an adventure for me – constantly learning and then applying that learning to the next phase of my career.

Also, my latest program is developing young doctors to have the values, knowledge and desire to be leaders for safety quality in the future. This will make a real difference to those people who are receiving care.

My clinical education and experience...

I am from South Africa and was fortunate to have received a sound medical education. I first studied sociology and economics before deciding to follow in the medical footsteps of my father, who was a general practitioner, and my brother, who is a cardiologist.

South Africa in the Apartheid years was a challenge, especially if one was involved in student politics. I completed my training at University of the Witwatersrand, followed by house jobs in the major specialties – surgery, medicine, obstetrics and then pediatrics, as I thought I may become a general practitioner. When I started pediatrics I knew that it was to be my future specialty. After a year traveling in Europe and South America I returned to South Africa with the intent of leaving the country due to the political situation. However, I ended up going to Cape Town where I studied Pediatrics and eventually became a consultant in Neurodevelopment and Community Child Health

My experience in health system improvement...

I developed systems of care in South Africa while working there, without actually knowing that we were practicing quality and safety. For example, the first experience of a human factors failure was when a resident inadvertently gave a baby potassium chloride, and we had a highly efficient Lean system in the diarrheic ward. In those days – the 80’s and 90s’ - quality improvement and patient safety had yet to be discovered in healthcare. Yet in 1994 I was asked to go to Nottingham in the UK, as a nurse had murdered 4 babies in a hospital and they needed a fresh set of eyes. I went without the training I have now.

I found a total system failure in this rural hospital in Lincolnshire. Yet in 1994 it was not seen as that. That was the start of my improvement journey in the UK. From there I tended to follow major incidents, as when I moved to London I became head of a department and had to deal with another system failure in child protection at one of the hospitals with which we merged. In 2001 safety and quality were still in their infancy and in 2005 I was fortunate to be offered a fellowship to go to IHI for a year, which gave me the next stage of my career path, equipping me with the skills and knowledge required to make a difference.

Why I work in health system improvement...

My experience of having to manage and solve systems failures and the impact it has had on the individuals involved – the providers of care and those who received care. I believe health is a human right and safe high quality care must be a given. So this fits in with my belief system and formally over the past 16 years and previously without the specific training, I have been determined to make a difference for all in healthcare.

I started my QI journey near the beginning of the modern quality and safety movement. This has allowed me to grow with the changing views, as the evidence grew. At Great Ormond Street Hospital for Children I was fortunate to have a CEO who gave me funding and a blank sheet to make care child and family centered, safe and of a high quality. My move from there to ISQua was to enable me to spread that experience worldwide.

My advice to health system improvers...

Over the past few years, I have learnt that we should invest in people who provide care and empower the people who receive care. It is all about how we distribute power to all. We cannot have high quality care if we do not look after our staff and colleagues. This is where the values of kindness, respect, coproduction and holistic care come in.

Never lose these values and place them at the core of what you do. Never lose the reason why you came into healthcare, which was to make a difference for people. Always think of the person who one is seeing as having the same desires as you have in the quality of care – walk in their shoes. Never be satisfied with the mean and always strive to be the best. Close the quality gap. All of this requires us to be inquisitive and curious, always measuring and asking why we achieve the results that we do. Finally, learn and share that learning.

Year-end reflections on child health during 2020 and the COVID-19 pandemic

 

2020 has been a challenging year, to say the least, for those of us who work in child health. Starting with online schooling and its effects on development and mental health, to learning about the new mysterious multisystem inflammatory syndrome in children (MIS-C), to advocating for the inclusion of children in COVID vaccine trials and for schools to reopen safely, to families dealing with stress, and to disparities in education and healthcare brought on by our unprecedented reliance on technology and the internet.

Although the pandemic has posed many child health issues it has also had some unanticipated positives. We learnt that remote work is a feasible option for many occupations – at least part of the time anyway. We are learning how to be more efficient with scheduling and running meetings and conferences. We quickly figured out how to be creative with Zoom celebrations that in many instances connected people who might otherwise have never reconnected.

The pandemic highlighted the resilience and dedication of health care and public health workers. It has greatly accelerated the vaccine development process. UC Davis Health vaccinated over 4500 employees, residents, and students in just the first week of its COVID-19 vaccine roll-out. The rapid adoption of telemedicine and reimbursement for its services has increased access to care and scaled up an innovation that had a slow uptake in many areas. The pandemic is also credited for resulting in unparalleled increases in applications to medical schools, also termed the Fauci effect.

A highlight professionally was my virtual visit to the American Board of Pediatrics (ABP) as the 2020 Paul V. Miles fellow. The award honors Dr. Miles’ service as Senior Vice President for Maintenance of Certification and Quality Improvement and is given each year to a pediatrician in recognition of their work in improving the quality of care for children. My virtual visit to the ABP included presenting grand rounds at Duke University and UNC (albeit at 5 am in California!) on how to engage and sustain clinicians in quality improvement efforts, and presentations to ABP staff on using Lean improvement methods to enhance efficiency.

2020 has had a lot of memories that we could have done without. But like everything else it has been a mixed bag and has had some positives. Until this period in our collective history is behind us and we can see each other in-person, happy new year!

The best-laid schemes...

But Mouse, you are not alone, 

In proving foresight may be vain: 

The best-laid schemes of mice and men 

Go often askew,

- Robert Burns, from 'To a Mouse' (translated to English from the original Scots)

We recently held the much anticipated 10th Annual UC Davis Health Quality Forum. To give you some context, we had been planning a festive birthday bash for the past year, complete with cupcakes and streamers—and of course, the requisite panel presentations, keynote speakers, and poster session.

The festivities were all set for mid-March and then COVID-19 struck. Like other events across the globe, our event was derailed as well and we had to make some quick decisions about ways to keep our speakers and attendees safe and socially-distanced.

A Wikipedia page titled ‘List of events affected by the COVID-19 pandemic’ states, “Among the most prominent events to be affected were the 2020 Summer Olympics which has been postponed to 2021, and the Eurovision Song Contest 2020, which was cancelled entirely.” The same fate tragically befell Google I/O, San Diego Comic-Con, and Coachella.

Optimistically, the page also listed events that were modified to eliminate a live audience or held over teleconference. And so, after our plans of rescheduling our gathering to June was thwarted, we along with hundreds of other conferences planners across the world, decided to move our event to a virtual format. 

Turns out that converting an in-person conference into a virtual one is not as straightforward as one might think. What makes a conference a conference is the real-time social interaction among attendees. To help conference organizers pivot at short notice, the Association for Computing Machinery convened a task force on What Conferences Can Do to Replace Face-to-Face Meetings. The group issued a report titled, “Virtual Conferences:A Guide to Best Practices,” that talks about ways to replace face-to-face conferences with virtual ones during the COVID-19 pandemic. ACM calls this document, “a practical introduction to the brave new world of virtual conferences”.

Here are some tips from their best practices guide:

• Various parts of a virtual conference may require different media for different groups of participants. The types of media you may choose to use include video, audio, graphics and text. Playing a prerecorded video or live-casting can be combined with the audience having a live presence, so that communication goes in both directions.
• Make a nice navigation page to help attendees find sessions and people who interest them. Include meeting links, chat info, schedule, information about each session, speaker information, and attendee list in the program.
• Set up several group-chat channels, such as one that simultaneously includes all participants, and smaller session-related or specialized chat groups. Designate a person to monitor chat feeds and facilitate channels to help get conversations started.
• Increase the time set aside for virtual poster sessions, so that attendees can wander around and gather in small groups to discuss posters displayed in the virtual space.
• To increase social interaction, organize virtual lunch or coffee meetups where a senior attendee is placed in a virtual room and more junior attendees sign up to meet over a socially distanced lunch for a certain length of time. Or you could randomly assign attended to a room and have different groups for every meal.

My daughter graduated from high school this year and her in-person graduation ceremony was one of the many casualties of COVID-19. Her virtual graduation ceremony actually turned out to be fun and uplifting for the whole family. As an added bonus, we could get up from the couch to stretch our legs, get a snack or beverage, and do what we wanted without fear of embarrassing the graduate.

- Ulfat Shaikh