Systems-Based Practice

“Appropriately use system resources and assist patients in accessing health care that is safe, effective, patient-centered, timely, efficient and equitable.”

Before medical school, I had experience in biomedical product development, translational clinical research, and more theoretical computational modeling. All of these avenues of work developed technology or results that could have some sort of potential to reach clinical use. At the time, I had no appreciation of how that would happen. Who decides which devices are used in the OR? What level of data is required to change clinical practice from one medicine to another? What determines if a hospital will participate in a clinical trial or not? These are difficult questions that even today I still don’t have complete answers to, but my clinical rotations have provided insight into the complexity of medical decision making and the systems-based approach required to produce change in day-to-day processes in a hospital.

My third and fourth year project in HSIQ, Health Systems Informatics and Quality Improvement, provided significant insight into how difficult it can be to modify established systems in the hospital setting. As a quality improvement project, our goal was to identify a population or specific process in the hospital that was amendable with the most benefit for the least invasive change. Our intervention focused on the pediatric population, and through meetings with Dr. Bapat, a neonatologist at Nationwide Children’s Hospital, we aimed to address post-operative temperature management of NICU patients that has largely gone on unrecognized. Through many months of QI meetings and iterations in our project, we eventually discovered that temperature measurement in PACU patients could be optimized, with the goal to lead to the early identification of patients that requiring additional warming, thereby reducing hypothermia rates. 

The process was standardized and adopted in the PACU by using the same temperature monitoring guidelines utilized by the NICU. By using evidence-based practice guidelines and uniform equipment already utilized by staff in the NICU, the intervention was more easily adopted by staff, and if any issues were to arise, they would be able to communicate with their knowledgeable NICU staff colleagues. The new protocol was communicated through daily morning meetings with the staff, and our intervention was revisited in monthly QI meetings. We provided reminders of the intervention by hanging these flyers through the PACU: Keep me Warm_Flyer

Despite the eventual success of the project in terms of its ease of application, we encountered several barriers that caused delays in our intervention planning and rollout. One such delay early on was that the original data analyst assigned to this QI project left his position, and so there were months where we did not have access to data. Also, our initial intervention that was supported by the executive sponsor was deemed unworkable, so we had to go back to the drawing board. There were also delays in our rollout due to wait time for ordering/shipping of new equipment (temperature probes and cables) required for our intervention.

AHSS Poster (4)

In reflecting on this experience, after a year of planning, meetings, and delays, at the end of the day the intervention was simply to use a protocol from a different area of the hospital in a new area of the hospital. That certainly emphasizes to me the difficulty to enact serious change in a hospital, especially without strong leadership or support from supervisors higher up.

Although frustrating, this project did excite me for opportunities for QI in the future. It was satisfying to see how such a simple change could have value to patients in the future. I plan to seek out opportunities through residency to get involved in clinical research, and QI might be one of the easier ways to do that. This project empowered me with confidence that changes are possible if you notice something could be done more efficiently. That just comes with the caveat that interventions in medicine move slowly and iteratively, and it takes a team effort to ensure system-wide change.

 

 

 

Leave a Reply

Your email address will not be published. Required fields are marked *