Dec 27, 2020

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!

Aug 14, 2020

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

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.