Coming Together for Improvement

This past August, three IHI Open School Chapter Leaders and I attended a state-wide interprofessional education (IPE) summit in South Dakota, the third conference in the country focused on this topic, and the first to be state-wide. We felt that the conference, designed to fuel conversations across our state on the importance of implementing IPE opportunities in our health science curricula and practicing health systems, was an incredible opportunity to contribute to our health systems both as students and IHI leaders. From the beginning, IHI has focused on the importance of patient quality and safety from a team-based approach, something that is often lost in a health professional curriculum. 

During the summit, groups from a variety of disciplines and backgrounds came together to discuss the successes and difficulties they have faced while implementing different types of IPE learning experiences. For example, thanks to the tireless efforts of leaders across the state, “Interprofessional Day” is now held every fall on the University of South Dakota’s campus. During this important day, nursing, pharmacy, physician assistant, physical therapy, occupational therapy, and medical students come together in interdisciplinary teams to work on patient case studies while learning team-building skills and cultivating professional relationships. This year, the University of South Dakota is also working to design an interdisciplinary elective course focused on simulation education. 

At the same time, challenges still arise as we continue to work towards finding better ways to communicate our ideas and progress. As current students, we were able to offer some great insight into these projects, and help facilitate ways to improve upon these current endeavors across the state. 

As IHI Chapter Leaders, throughout the day, we were very excited about the number of health care professionals who spoke to us about the importance of IHI, in particular the IHI Open School courses and events we organized for health professional students. The IPE summit was a fantastic way for us to share the importance of IHI, both with those who have worked closely with us in the past and those who want to get more involved with IHI in the future. 

Overall, it was an incredible day. Each of us were very thankful for the opportunity to be a part of the IPE summit, and look forward to working towards many of the goals discussed throughout the day. There are countless people across the state who realize the importance of team-based learning for health care
professionals. As they are working towards implementing these ideas into curricula and professional education opportunities, we are excited as IHI student leaders to help bring these goals to fruition.

--Rebekka Sneed is a second year medical student at USD Sanford School of Medicine and the IHI Open School SD Chapter President. This blog was also featured on the National IHI Open School blog on 10/8/13.

Never-Always: Part 1

The month of March always features an emphasis on patient safety by the National Patient Safety Foundation and this year’s theme is National Patient Safety Awareness Week 2013:

7 Days of Recognition, 365 Days Committed to Safe Care. This annual lifting up of the ancient Primum non nocere concept (latin for “First do no harm”) reminds us of our fundamental obligation. Check it out on the link below.

http://www.npsf.org

Now you can actually translate and in fact summarize the profound implications of Primum non nocere with 2 words – “Never-Always”. Dr. Bruce Pitts, our Sanford Health Chief Medical Officer, has recently coined this weighty calling with a very simple but poignant definition of what our care should/could be, “Some things never happen and some things always happen”. You could say that safety is “Never” and quality is “Always” or reverse them, for they are imminently interchangeable. Never-Always simply works as a call to greatness in healthcare…like always wash your hands, always reconcile the medication list, always do a timeout, always get your influenza shot or never do not wash your hands, never do not reconcile the med list, never do not do a timeout and never do not get an influenza shot. Now add your own Never-Always ideas….the list is very long indeed.

As Dr. Pitts reminds us, “Articulating greatness in terms of ‘never’ and ‘always’ provides clarity and direction…By the standards of ‘never’ and ‘always,’ no health care institution in the nation or the world has yet achieved greatness. The new high ground is unoccupied.” Indeed this is a daunting challenge to our industry and represents a very steep slope up Mount Complexity. To accomplish this will require all of us climbing together, in order to ever hope of occupying this ground? This is why the IHI Open School matters!

So why does Never-Always so resonate and what is its connection to our South Dakota IHI Open School Chapter? The answer it seems may lie, not outside of us, such as a required course to pass or a mandatory benchmark to meet, but rather within us, as raised by Daniel Pink in his book Drive. Pink exposes the literature of intrinsic motivation and shows us that we humans are internally motivated by three major drivers - Purpose, Mastery, and Autonomy.

Check out Drive and strongly consider it as your next read. Here’s the link: http://www.danpink.com/books/drive

Intrinsic motivation is far more powerful than any extrinsic motivator, like a test or a benchmark.  Those individuals and organizations, per Pink, that tap into this rich bank of human capital can achieve extraordinary things. It’s really what pulled us all into medicine…not? So let’s apply Pink’s observations to Dr. Pitts’ notion of Never Always and then work it out as our chapter’s response to National Patient Safety Awareness Week, or maybe as our personal driver toward great contributions to medicine.

• Never Always restores the patient to the reason for why we exist –  and that is true Purpose
• Never-Always revolutionizes our work around the new science – or the science of the human caring for the human. In other words it challenges us to conquer ourselves and that is true Mastery
• Never-Always engages the frontline imagination with joy and meaning – or in other words “I matter and  my work (and my learning) matters…I can make a difference” and that is true Autonomy

Try pondering  Never-Always as the motivator in your corner of the health care world and ask yourself a few questions. What things would you never want to happen or you would always want to happen in your setting? Better yet, ask yourself this, ”What would I want never to happen or always want to happen, to myself or the person most precious to me, if I/they were a patient?” Next, begin to connect the IHI Open School modules (achieved that Core Certificate yet?) and our chapter’s event opportunities, to this notion of Never-Always. This is a fantastic way to begin to master the new science of the human caring for the human and to reach for purpose and autonomy.

Every once in a while we run into words which capture the essence of things and upon which we can hang everything that matters. To that extent we owe a thank you to Dr. Pitts for articulating what greatness in healthcare can look like…Never-Always. I close with his challenge, “We…have concluded that we have no choice but to lead the industry’s march toward greatness.  We begin here by authoring it.” Could the South Dakota IHI Open School Chapter begin to lead the industry in interdisciplinary learning, and in some way help to author it? You bet we can, but it will require all of us to climb Mount Complexity…students, deans, faculty, frontline care givers, and healthcare systems. Our chapter is perfectly positioned, given the extraordinary accomplishments of just the past two years. We can achieve great things, because everyone of us just naturally brings the drive toward overarching Purpose, the drive to Master our discipline…and the drive toward Autonomy, or that I matter in the vast sea of American medicine…because I matter to the patient.

--Wendell Hoffman, MD, FACP is the Faculty Advisor for the SD IHI Open School Chapter, Patient Safety Officer for the Sanford Health Sioux Falls Region, a Clinical Professor of Medicine for the Sanford School of Medicine and a practicing Infectious Disease physician with Sanford Clinic.

If you would like to contact Dr. Hoffman with questions or comments, you can email him at Wendell.Hoffman@sanfordhealth.org

The Tenets of Professionalism

I have often heard the legal profession described as the “second oldest profession” and with the “oldest profession” being an inappropriate topic area for this blog, apparently that would put the medical profession as the “third oldest” profession.  Whether or not either the medical or legal profession can lay claim to precedence to an “older” title is probably irrelevant but the key is both professions have been around for thousands of years; while much has changed, their basis hasn’t.  For the medical profession, this basis is probably best summed up by the famous quote from Dr. Mayo, “The best interest of the patient is the only interest to be considered”.

It may be fairly obvious but by choosing to be trained in one of the medical disciplines, you have “joined” a profession!  Based on the discipline, professionals may voice different oaths, but in the end, we all have committed to several basic behaviors:  confidentiality of the information we have received from those we will serve, clear and effective communication with both the patient and others that will be assisting us in serving the patient, being respectful of those we serve and modeling respect for ourselves and the profession that we represent by our words and actions, and finally actually being available when called upon to take care of our patients or clients.  In the complex world of today’s medicine, in order to meet the “best interests” of the patient, being professional also means that the concept of team needs to be promoted as well.

One of the other major concepts of a profession is that professionals are self-regulating.  This is sometimes thought as merely a personal obligation, but in many instances this can also be peer-to-peer or group obligations.  Essentially, all of us require the skills to provide and receive feedback, especially from our peers, so that the feedback is constructive. 

For the last several years, I have been involved in the Patient Advocacy Reporting System (PARS) created by Vanderbilt University.  The program was developed from research that showed that there was a direct correlation between patient complaints and medical malpractice suits.  The program has been enormously successful because it uses peer messengers to make physicians aware of patient complaints that have been received about them.  Vanderbilt’s research has shown that when physicians receive peer feedback, they are more likely than not (70%+) to act upon the information and bring their focus back to patients and consequently the amount of patient complaints decline (as does the risk of lawsuits).

The success of the PARS program is directly related to professionalism.  The recognition by our peers that the profession is worth self-regulation and that they can play a part by providing feedback about issues that are important to both patients and physicians.  The recognition by the physicians receiving the message and feedback reflects that our peers have a common basis to discuss the feedback with them and that they should take the time to listen to their peers about how to improve their own professionalism.

Being part of a profession is an honored path that we should all recognize and take responsibility for by making the profession better than when we first joined.

--David Danielson, JD, CPA, is Senior Vice President of Clinical Risk Management at Sanford Health, is an Assistant Professor of Internal Medicine at the USD Sanford School of Medicine and is a member of the National Patient Safety Foundation's Board of Governors

Reflections on 100,000 strong for our patients

Recently, I have come to agree with Dr. Berwick, viewing the IHI Open School as not just a movement, but a revolution started by students who are motivated to change the culture of care in the systems where we work.  We are finding that in order to make the changes we need to achieve higher quality care at a lower cost, we must transform entire systems of care.  100,000 students and residents signed-on to the IHI Open School is an incredible number and is certainly a huge milestone!  These students are entering their respective health professions as natural leaders in quality and safety.  In many ways, they have now become the experts in their systems.  But our patients need us more than ever.  We need more students to sign-on.  The systems are not changing quickly enough and we require a small army to teach others how to develop safer, more effective, patient-centered care that is timely, efficient, and equitable.  This means teaching the science of quality, safety, teamwork, and communication.  We must do this together.  And it must be multi-disciplinary.  Health care delivery is increasingly complex.  Patients are confused, vulnerable, and are being harmed more than we would like to admit. 

The IHI Open School is the absolute best way for us to come together, connecting with students of all disciplines in our local chapters, advocating for IHI Open School courses to be integrated into the curriculum at our schools, teaching other health care providers about these important topics, and engaging in dialogue with students and faculty around the world through the IHI Open School chapter network.  I originally thought of the IHI Open School as a motivator, an entity designed to encourage students to complete courses on their own time and develop the skills they need.  However, after four years of existence, it is now becoming an integrator.  The concepts we learn through IHI Open School are the threads that connect all health disciplines.  Every student in every health discipline should have these skills.  Application of these skills has solved many complex problems and will continue to solve problems and improve patient care on a larger scale.

So let’s bring 100,000 more students to the IHI Open School. 100 years ago, Dr. William James Mayo stated in his commencement address at Rush Medical College in Chicago, “The best interest of the patient is the only interest to be considered, and in order that the sick may have the benefit of advancing knowledge, a union of forces is necessary.”  Indeed, our union of forces is the IHI Open School. 

 

--Ryan Miller is a 3^rd year medical student at the Sanford School of Medicine and Chapter President for the South Dakota IHI Chapter

Doctor is Spelled T.E.A.M.

I am a first year medical student who has come to this point in my life via a different path compared to most other medical students. As a college and high school basketball coach for eight years, I learned to study performance as if it were a science. The most interesting part of athletic coaching to me was not who could develop the most complex or innovative strategy, but who could get their individual players to execute their roles within the team strategy as close to perfection as possible. I am coming into medical school from a background of studying players to learn how to help them perform to their highest capability.

Understanding how to assist individuals to reach their capacity translates to medicine, and to every other field. The problem that I find interesting is not how to find new information, but how to use the existing information better. As a coach, my job was to find new ways to help each athlete get to a place where he does his job flawlessly. As a student, my day is now currently filled with gathering information. There is so much to learn, I feel as though I may never quite grasp things with as much detail as I would like. But, I know eventually I will be as prepared as I need to be - just as those before me have been. So, in thinking about becoming a doctor someday, I now think about how I will ever be able to keep things straight and not make any mistakes. Because I know if I do make a mistake, the consequences will be much more severe than a low test score. That brings me back to the same question that I faced in coaching. How can I get the most out of what I have? How do I consider all the data and tendencies that we will learn, and not leave anything out? So far, I think we have learned about maybe twenty drugs - and I struggle to keep them separate. How will I be able to do the same, when that number is in the hundreds or more?

The answer, I think, is to realize that a complete knowledge of medicine is too complex for me. I am going to need help from other people. In order to be able to rely on others in the future, I need to start working on doing so now. The time to cultivate professional, trusting relationships is not when disaster strikes and I can't quite remember the correct sequence of remedies I need to apply. It is the days and months before that time. Thus when it all comes crashing down, I know I will be able to trust those around me to help achieve the best outcome.

This idea is the ultimate lesson in being part of a team. That is what makes athletics so valuable, and is hopefully the lesson that we will start to learn as we begin our medical careers. Learning how, not just to work with other people, but to rely on them and allow them to rely on you. Of course the knowledge is important. Of course it is my responsibility to know it all myself as well as I possibly can. This is not an excuse to be lazy and rely on others to get you by. This is just understanding that more can be achieved when people work together. Being a great teammate is a skill that needs to be cultivated. It takes some humility to ask for help or to ask for other ideas. The time to start working on those skills is before you actually need to use them.

 --Scott Stevens is a first year medical student at the Sanford School of Medicine

A Season of Renewal

It’s the season of renewal at the University of South Dakota Sanford School of Medicine.   Our former senior medical students have moved on to residencies to complete their transformation from student to colleague.  Men and women who were college students a few short months ago are now medical students.   They bring with them their enthusiasm, aspirations and hope for the future.  

Our new students will find a medical school that is undergoing its own process of renewal and transformation.   In 2012, USD SSOM was rated in the top ten schools in the nation in rural medicine and in family medicine and was named one of the top ten most popular medical schools in the country by US News and World Report.    Our graduates have enviably high rates of passing national boards and high median board scores, and the school recently passed accreditation with flying colors.  Despite this great foundation, changes are afoot because we recognize that the curriculum of the past will not adequately train physicians of the future.   .   

Soon, students will notice fewer lectures and more interactive small group sessions.  Basic science courses will be coordinated with each other to provide a more vivid and memorable picture of the function of the human body.   Clinical work will be more clinic-centered, because the outpatient setting is where most diagnoses are made and where 75% of visits in the U.S. occur.  More time will be set aside for electives and this will occur earlier in the curriculum to allow students to gain more experience in an area of interest before they have to choose a specialty.   Our new Frontier and Rural Medicine (F.A.R.M.) program will allow a select group of students to spend significant time in a rural community of less than 10,000 people.

This is a lot of change and we are not alone.   Virtually every medical school in the country is overhauling its curriculum right now.   In part this is in response to the recent Carnegie report that pointed out that the structure of medical education had not changed in more than a century.   Medical education has simply not kept up with educational theory.   Long-term memory is created when learning is interactive, uses multiple modalities, is repetitive, and is directly related to patient care.  Clearly, it is time for us to change.  But how do we know that we are creating a better system?   The answer is that USD SSOM is uniquely positioned because the Carnegie report cited the Avera Sacred Heart Yankton campus of USD SSOM as a national model for educational reform.   This means that the school has experience in delivering the modern clinical curriculum and has the outcome data to show that students who go through this curriculum are highly successful as measured in many ways including performance and test scores.   Only a small handful of schools in the country have this experience.   Another major asset in this process is the high quality of the teaching faculty in the school.   It is difficult to ask basic scientists and clinicians to change the way they teach, yet they are not only willing to do so but they are also highly engaged in creating the new model.   The best systems (and the best people) are those that are flexible and responsive to changing needs.   The communities and health systems are strong supporters of medical education, and we will continue to rely on these important partners.   Our final important asset is the students themselves, who provide critical input and advice to us at every stage of the process.  

The new curriculum must be responsive to the medical needs of South Dakota and the nation.   It is always important for physicians to provide excellent care in a face to face environment.   However, there is an increasing need for physicians to step back and consider the health of populations.   The modern physician should insist that the quality of care be measured and improved, leading the effort rather than resisting it.  Medical school needs to provide the tools for young physicians to do this.   Many diseases now are related to behaviors and social factors that are not going to be influenced by medications or tests.   Modern physicians need the tools to motivate behavioral change.  Physicians also need to be competent to practice in an increasingly multi-cultural world.   Finally, and perhaps most importantly, physicians need to adhere to the highest standards of professionalism.   These are tall orders, but they can be accomplished.

One of the things I like best about academic medicine is the variety and change that is inherent in it. We have the privilege of working closely with some of the best minds and some of the nicest people in the country.   Building on this foundation, we share our new students’ sense of optimism and look forward to the future.

--Mary Nettleman, MD, MS, MACP is Vice President for Health Affairs and Dean of the University of South Dakota Sanford School of Medicine

June 28, 2012--A Day in History

June 28, 2012…..will this become a landmark date within the history of our country?  Perhaps not, but as I pause to collect a few thoughts for Unum Vox, it is hard to take one’s eyes off of CNN, or the explosion within the blogosphere, over today’s Supreme Court ruling relative to the PPACA (Patient Protection and Affordable Care Act).  Without a doubt this is a critical moment in our country’s lurching, ponderous journey towards universally accessible, affordable, safe and reliable health care.  Rest assured, the political debate will only escalate, pundits will continue to pontificate, but a stake has now been placed firmly in the ground, and any effort to diminish, augment, or change our approach to health care reform will have to travel through this historic piece of health care legislation, or at least be measured by/compared to it.

Regardless of an individual’s political or philosophical persuasion, the PPACA pushes this country in several positive ways.  In fact, many laudable accomplishments can already be attributed to it.  The misfortune of severe illness no longer renders an individual uninsurable.  “Pre-existing illness” will disappear from the insurance industry’s lexicon.  Young adults will continue to be able to access the benefits of family coverage rates until age 26.  Through exchanges, employer based plans, and expanded Medicaid coverage we should be able to approach fully accessible health care for 95% of all citizens, and simultaneously remove a long standing embarrassment for this country amidst the roll call of nations within the developed world (even many countries considered to be “third world”).

Admittedly, this piece of legislation was/is far from perfect.  Much of the “tough medicine” true reform requires was side-stepped by our political leaders.  Sustainability is only possible within the context of affordability, and most will agree that the measures taken within the PPACA fall far short of dealing with the difficult decisions needed to take control of the inexorable climb of health care costs.  Until we hard-wire care that is fully cost conscious, and high value, this effort will collapse under its own weight.

However, I take great solace and daily inspiration from two critical observations by Dr. Donald Berwick, past director of CMS, and founder of IHI.  First, he likened the journey towards high quality, safe and reliable health care to a car trip, and he stated that the health care community (i.e. not Congress) drives that car.  Secondly, he opined the following:  “the key to improvement is coverage, and the key to coverage is improvement.”  In other words, we will never produce high value, high quality care for our country until everyone has access to that care.  Likewise, unless we produce care that is of the highest quality, universal coverage will be unsustainable.

As for me, I choose to be greatly encouraged today.  The keys are in OUR hands. 

--Tom Braithwaite, M.D., FACP is Chief Quality Officer at Sanford Health in Sioux Falls