Agents of Change

By Ulfat Shaikh, MD, MPH, MS

We held our 5th Annual UC Davis Quality Forum last month. 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 spent 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.

QI SIG Group 2014 editedOne 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.

ShaikhUlfat Shaikh, MD, MPH, MS is director of healthcare quality at the University of California Davis School of Medicine. She blogs about health care quality improvement at Pulse.

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