Quality Improvement in Healthcare Episode 1: Institute for Healthcare Improvement

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Erik: And we're here. This is the Baylor College of Medicine Resonance podcast, I am your host Erik Anderson and I’m here with some other people if you want to introduce yourself.

Adam: Hello I’m Adam Floyd I’m an MS3 here at Baylor College Medicine.

Jinna: Hi I’m Jinna, a current MS4 at Baylor.

Parth: Hi I’m Parth, I’m currently a researcher student at Baylor, I guess I’m technically a second year.

Raj: Hi everyone my name is roger eddie, I'm a third year medical student.

Erik: Cool, and thanks to you all for being here. So to give a quick introduction, everybody that just introduced themselves as part of the Baylor College of Medicine student org: The Institute for Healthcare Improvement (IHI). And we have in collaboration with them, we're about to bring you a mini-series on quality improvement in medicine. We're going to have a lot of great speakers that you know we'll talk about later, but we're going to just kind of do a real quick introductory episode on what healthcare improvement is and quality improvement and a little bit about what the org is. So Adam, do you want to take it away?

Adam: Sure thing. So first up we just wanted to explain a little bit about what IHI is to that end. Raj what is nationwide IHI?

Raj: Sure Adam, that's a big question but I’ll give it a shot. So the IHI, or the Institute for Healthcare Improvement is a national non-profit advocacy education organization dedicated to quality improvement, patient safety, and high value or value-based care. Or since we love acronyms so much in medicine healthcare: QIPS and HVC or VBC. Their vision is that everyone has the best care and health possible and their mission is to improve health and health care worldwide. A lot of the work is focused on improving patient population health outcomes while also reducing medical overuse, waste, and cost, which we often see go hand in hand organizationally. IHI started officially in 1991, although its efforts started as grant funded programs in the late 1980s. One of the key people involved in IHI was their founding president and CEO um Donald Berwick who is a pediatrician, public health expert, and health policy expert, and as well as a health care administrator over at Harvard. He’s kind of been the main leader of this organization's vision. One of the main aspects of IHI that is really relevant to medical students or health professional students is that they have something called the open school, which is a collection of over 30 online courses on various topics in a lot of these areas that we talked about. A lot of which comes from the intersection of biomedicine healthcare with the management sciences and industrial engineering. Focusing on efficiency and process improvement and aspects like that, that are not necessarily strictly the clinical and basic sciences that we learn in our health professions curriculums typically. Finishing that they also run a series of lectures and webinars, courses, podcasts, resources. They publish reports and white papers, they hold several conferences throughout the year um they have some certifications that people can add to their CV and all that in these areas to really gain education and improve their expertise. Two aspects that I really like about the IHI personally are that one, they're really interprofessional and interdisciplinary. So they're all about that teamwork and collaboration, e.g. how we can use our collective knowledge and expertise and resources to really improve health care worldwide. And the second aspect is that worldwide component actually. Even though they do a lot of work in the U.S. they also have a global focus. For example one of their big meetings every year is actually an Africa forum where they focus on improving healthcare across the continent there and improving health systems collaboratively governments. So there are a lot of really cool aspects of IHI I think are really interesting for health professional students.

Adam: That's awesome, thanks Raj. And I mean to go off of that you know very detailed explanation, very good explanation, we also have an IHI branch here at BCM. The BCM IHI Open School, I believe you mentioned. So IHI here at Baylor is kind of a one stop shop organization for all things quality improvement and patient safety. Our mission here at BCM is to educate students about the importance of quality improvement patient safety, equip students with tools and skills in QI and NPS in their future careers, and engage students in improving health outcomes. So really IHI at Baylor includes members with a variety of specialty and research interests but it's all tied together by a desire to make measurable improvements in health care. Our activities here range from workshops to electives to mentorship and research initiatives. Even to the organization of a yearly research conference. So, like Erik mentioned, the Resonance podcast team has been gracious enough to help us put on this quality improvement mini-series. Really this is a way to showcase the quality improvement work being done here at Baylor College of Medicine, kind of advertise opportunities to students on the part of you know great faculty and residents who are you know doing big things in quality improvement and patient safety. A little bit about what quality improvement and patient safety are—patient safety is just reducing or preventing harm to patients, quality improvement is just systemic improvements that lead to measurable improvement in healthcare delivery often measured in terms of efficiency, reproducibility, value, etc. QI work is done here by students, residents, faculty, all in a variety of different specialties, with different research interests, with different backgrounds they all want to improve healthcare. 

Erik: Adam can I jump in real quick?

Adam: Yeah please comment.

Erik: As somebody, you know that's not in the org that's just had a little bit of quality improvement classes, you know experience at Baylor, it really is kind of a foundational thing for our profession. As you were saying it's like it's already sort of built into our code of do no harm and trying to basically maximize that, that I don't know, axiom if I want to sound pretentious. You know that that core belief and fundamental belief for us as a profession. So it's really important, and so I think it's great that you guys like,  we have a student org that's sort of around to try to teach students how to basically be better doctors. How can we how can we improve everything, and then yeah you can basically apply that to anything, as a lot of the faculty talk about in the interviews.

Adam: Yeah and one of the great things about QI is that quality improvement work is one of the quickest ways to make a tangible change as a medical student. So most of us are familiar with you know bench research or clinical research. I know you're doing your PhD right now and that's a you know four or five, six year process. A lot of QI projects can be done really in you know weeks to months where you just you go in you see kind of a need you make a small you know one small discrete change and then you measure what happens. And so you know even as a MS1 or MS2 you can go ahead and get started with that pretty quickly. And yeah, at this point I wanted to kick it over to Parth who's going to talk about maybe why we're doing this series and who we are going to be talking to and that kind of thing.

Parth: Yeah so like Adam said as an organization we're kind of committed to spreading the word on and getting people involved in quality improvement and patient safety research, and just generally knowing about like education. But we're doing this series to give a platform to and kind of shine a spotlight on Texas Medical Center (TMC) faculty that are currently engaged in quality improvement and patient safety research you know. I found that when I came to med school I myself didn't really know much about quality improvement or patient safety. I knew what bench research was, I kind of knew what clinical research was, but even then not really. And I didn't know at all about you know the IHI or the QIPS movement or anything like that. And so we're hoping that by doing this series and by finding you know actual researchers who are doing research in the space and who are making great strides in this space. And giving them a platform and spreading the word on their research we can you know sort of get more students like, you know, everyone on this zoom call here into QIPS research.

Adam: I think that's what we all want, thanks Parth. Yeah and you know to that end IHI here at BCM is loosely organized into more or less four pillars as we call them colloquially. So those for us are: Mentorship, research, community engagement, and education. So to that end I just wanted to have each vice president of each pillar introduce themselves and talk a little bit about what they do and we'll go from there. So first off Jinna if you want to talk about mentorship.

Jinna: Okay so I’m VP of the mentorship pillar and so what I do is try to connect faculty and new members residents along with upperclassmen with lower classmen or just students that are new to our IHI organization. And so with these relationships the goal is to be able to have guidance in quality improvement and learn about new projects that are going on or finding a niche in QI.

Adam: That's awesome, that's awesome. And I know you've helped out you know a lot of younger students including myself find you know mentors within the QI world and so thank you for that. So the next pillar would be research and Parth has been working on a really great kind of research matching program. So Parth if you could speak both to your pillar and then to that program that would be great. 

Parth: Yeah so I'll start with the general pillar first. So I guess kind of as I alluded to before there's a lot of great QIPS research happening at um the TMC, I mean we're the world's largest medical center, and so we just have a lot of medical care being delivered which gives us the opportunity to study a lot of delivery of medical care. And so most of that research is not being done by students, it's being done by MDs, by PhDs, and I guess Erik some of it I’m sure MD/PhDs as well as you know a whole host of other degree holders and then researchers. But most of it isn't being done by students, and so first of all we want to kind of give more students the opportunity to get involved in this kind of research and to do that as a pillar we kind of try to scope out and see what research is being done and then we try to make students aware of it. We try to give some of it a platform and to that end like Adam mentioned we host a yearly QI TMC conference where researchers can go and present their work. And lastly we're in the process of setting up I guess a research matching system, that's what we're operationally calling it for now. But basically what we want to do is we want to reach out to faculty and kind of ask them, hey what projects are you working on and would you like or would you be willing to have students come in and help you with these projects. Then we want to take that list of projects we found and reach out to students and say, hey are you guys interested in this space and if you are would you be interested in getting involved in any of these research projects that we've found that are currently happening. And through this we well, first of all we hope to get more people involved in and thinking about QIPS research, but kind of secondly we just hope to take a lot of the kind of chance out of finding a good research venture and how to find a good research project. I mean I think so many of these sorts of processes are you know kind of probabilistic where you might end up being like a really good researcher or you might be really interested in research but unless you just kind of happen to find the right mentor with the, or the right pi with the right project at the right time, you might not be able to end up doing any research. And that's hard if you kind of come to Baylor without any connections you know if you're not from the area for example. And so we're hoping that we can all kind of you know come together, we've been at the school for two, three or four years now, we're hoping we can kind of come together and put our heads together and help create a project or a program to take some of the chance and the guesswork out of finding a research venture. 

Adam: That's awesome Parth, yeah I really resonate with what you're saying about kind of taking the chance aspect out of finding research projects. I think us as medical students and you know even all the way up to the you know residents, fellow, faculty level can speak to the fact that it can be hard to find a good research project sometimes even though you have you know an abundance or willingness and you have the skills. So thank you for that. Next I wanted to kick it over to our vice president of community engagement Raj Reddy and see what he had to say both about community engagement and some new initiatives he's been heading up during COVID times and recently.

Raj: Sure thanks Adam, so hi everyone my name is Raj I’m the new vice president of community engagement for IHI chapter at Baylor. So actually this isn't a completely new venture for us and we haven't really had a community engagement portion of our chapter before so this is kind of a really novel experiment they're trying to do. But essentially this is kind of our venture into public health quality improvement, which essentially has a lot of the same principles as regular quality improvement that we think about, but deals more specifically with kind of the social determinants of health and how they affect our patients health care and access to care. As well as kind of the additional component of being especially resource strapped in the public health field and really having to use resources and personnel wisely to ensure that we're serving our population the best. And so essentially we've been trying to with this role we've been trying to take a lot of things we've been doing in our IHI chapter but really go out into the community and really try to improve the actual health of our patients in the Houston and Harris county communities. And so essentially that involves working with a lot of our publicly funded community agencies as well as our charitable nonprofits that really fund, for example clinics or health education or other initiatives like that, for patients here in Houston and Harris county. And so actually our work in this area is kind of derived from the IHI national recover hope campaign which ran for a couple years but ended officially this previous year although the work is still ongoing, but specifically focused on substance use disorders and reducing the prevalence, as well as the disparities and the negative outcomes we're seeing with those issues over the last several years, specifically in the opioid crisis but not exclusively opioids and also the full range of substance disorders. And so with that program we actually under our previous presidents started a seminar on motivational interviewing with a focus on using that technique for substance use disorders with patients. And kind of from that seminar, which we're still conducting as a chapter today, we've kind of branched into this whole area of community engagement and how it can really bring again, how we can really bring a lot of those QIPS HVC techniques into the community arena. So in this area I do have some overlap with the research pillar under parth as well as our education pillar under Anje, and which you can ties back into our folk library perspective on QI work because a lot of QI efforts whether they're at an individual hospital or clinic or across an entire health system still involve a research component. We still need to collect data, analyze it, and see whether or not it's working and then revise our plan if necessary. And that's basically the essentials of a PDSI cycle that we do at IHI and QI all the time. And so that's one component, but also the education pillars like I mentioned before, we're still considering our MI, motivation interviewing, seminar we're also seeing other areas that might be particularly underserved or neglected in in current health professions curriculum. Like, for example end of life care, how to fill out an advanced directive, how to fill out a psychiatric advance directive for patients with serious mental illness. Those sort of aspects that still have a very clear connection to improving health care outcomes but may not be in our traditional curriculum already.

Adam: Well thanks Raj I really appreciate that. As someone who's been to the motivational interviewing workshop a couple times at this point I can attest to the fact that it's served me, well you know on the wards. It's just good overall information to have as both a you know medical student and a human being, and i'm excited to see what we continue to do with the community engagement wing of IHI. So next I want to talk about our pillar of education. My name is Adam Floyd and I'm one of the co-presidents of IHI and I’m standing in for Anje Batra who's our VP of education, he wasn't able to be here today. But just briefly about our education wing, Raj already mentioned the motivational interviewing workshop, we do have several workshops that are aimed at really all levels of medical students’ education. We have motivational interviewing, plan do study act cycles, root cause analysis, handoffs, process mappings, and several others. Additionally, we do have several electives, both pre-clinical and clinical electives. Most of these, both the electives and the workshops are you know interactive. They have a practical component and we try to leave attendees with action items that they can use you know either on the wards or in life in the near future. One thing I wanted to talk about, we kind of brought up what is our most important or maybe our most useful workshop for an MS1, and in my opinion I think that might be motivational interviewing. Though I'm a huge fan of all our workshops, motivational interviewing because as an MS1 I so often found it difficult to have conversations with patients about substance abuse or weight loss or really any of those touchy topics where you're trying to lead a patient into, you know a direction that you know is evidence-based and will improve their health care. So motivational interviewing gives you a set of tools to do that. Another question I wanted to bring up, or another statement I guess, is what is the most useful on rotations, or what's a workshop that you've used on rotations? And for me that would be the handoff workshop. So handoffs are kind of transferring care from one provider to another, and we do have a handoff workshop where we work on doing that in an evidence-based fashion, and under that framework I’ve, on wards several times caught little details that later helped me with my differential or patient management that I would not have otherwise caught. So like I said we do have those workshops. We have several electives and then as Parth mentioned we have a QI research conference every year where we have about 90 researchers come in really from all over Texas to present their QI work, and so I think that's a great opportunity for medical students both to network and to you know show off the great work they've been doing over the course of the year. So those would be our four pillars like I said, mentorship, research, community engagement, and education. So thank you so much to the VPs for talking briefly about each of those.

Erik: Yeah, no that was great, especially again as like I said somebody that doesn't know quite as much about all this as obviously all you do, the mini-series in general helped me learn a lot about this and all the workshops you just talked about. I mean it really does serve as a great resource to just better yourself generally as a physician, or a physician in training, because they're all just skills that you're going to need to be really good at. Handing off, you need to be really good at handing a patient off because like you said a lot of errors can happen there, so it's great. 

Adam: Yeah, yeah definitely and you kind of you kind of touched on it earlier that all of us come into medical school wanting to you know follow the Hippocratic oath wanting to prevent error, wanting to provide benefit, that kind of thing, and quality improvement is just kind of intrinsic in that. So one thing Anoosha, my co-president, likes to say is that we're all interested in QI, some of us just don't know it by that name yet. And so i'm a big fan of QI work here at Baylor.

Erik: Definitely yeah it's like you can apply it to anything, just it seems to me, and correct me if I'm wrong, it's just a way of thinking about something. Like breaking it down into a discreet amount of steps and then deciding like, is this where the error is happening, and if not..or if yes then we need to improve something here.

Adam: Exactly and that, what you just mentioned, that is our process mapping workshop. That's what we do. So yeah there are you know a variety of tools, it's kind of like learning to use Microsoft word or Excel or some kind of you know statistical analysis software. We all know kind of what we want to do we're just looking to give people the tools to you know kind of codify that and write it up and make it a discrete project.

Erik: That's great, well thank you so much everybody for talking about the org and kind of all the details. It's a great mini-series so I'm excited we're gonna tee it off now.

Adam: Thank you so much Erik for the opportunity, for giving us this platform. We're big fans of the podcast and what you're doing so thank you for that.

Erik: Without further ado here we go 

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