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My Experience at IHI

By Caitlin Littlefield | Monday, August 19, 2013

Summer Immersion

A guest post from Jason W. Wilson, MD

Research Director, Assistant Professor

Emergency Medicine Residency Program

University of South Florida


Thanks to generous funding from the University of South Florida Graduate Medical Education Office, I recently attended the Institute for Healthcare Improvement (IHI) Summer Immersion course in Cambridge, Massachusetts. The course was designed as a weeklong deep dive into the function and philosophy of IHI and serves to introduce and entice participants into further involvement at IHI with an aim to create partnerships between other organizations. I can say that the program absolutely met their goals and have me returning to my home engaged and excited to enhance our improvement and safety projects within the division and across the university, hospital, and field of emergency medicine!


Prior to my participation with IHI, I did have an interest in improvement science and health services research but I did not, admittedly, know very much about the institute. In emergency medicine we are evaluated as providers on a number of metrics and our patients often face risk from inefficient systems of care and flow. Thus, I have spent time thinking about ways to improve patient care in emergency departments, focusing on triage processes, boarding times and potential sources of error generation. As a researcher, I did generate and test hypotheses but did not have a theoretical paradigm for improvement science. That has all changed after my week at IHI. I feel that I now understand the basics of recognizing and beginning to implement true scientific techniques into quality improvement and safety projects with an eye on the patient experience and the overall system impacts of potential changes. Medicine might be partially an art but quality and safety improvement can be a real science if done correctly.


One of the challenges of returning home from an experience like the IHI Summer Immersion program is bringing "takeaways" back home and keeping that motivation when changing quickly from the context of an immersion experience to the daily context and pressures of everyday work and life. I wanted to share with you some of my specific "takeaways" and motivation points from the program and demonstrate that there was real value to this course and the efforts of IHI.


When  arriving at IHI, you are put into the context of place in an office setting that feels very different from the corporate world with short cubicles and glass walls emphasizing core values of transparency and "boundrilesness" (their word and spelling). The CEO sits with fellows and young staff, the COO shares an office space and executives and senior staff intermingle with co-op students from a local college. Next, you really notice the number of young people running the organization. While there are plenty of "greytops", there are just as many millenials serving important roles in the organization. Even at the age of 35, I felt less than young (ugh!) but also confident that there are plenty of smart young people working hard to solve our challenges in health care.


Lectures were given by IHI faculty that are well published and respected in the field of improvement science and patient safety (e.g. Roger Resar, MD who developed the ventilator associated pneumonia bundle that has led to a drastic decrease in morbidity and mortality) as well as patient centered care. I got the most out of lectures in the area that I work on in improvement and learned a framework for creating, implementing, testing and disseminating tests of change.


I came away with some novel concepts such as simply getting started on small scale projects through micro tests of change - i.e. in one small patient sample or one area of the hospital or department and then scaling up through the 5Xs rule (if it works with 5 patients, 5 hospital floors, 5 areas of staff, scale up to 25, then 125, then 625, etc). I think this idea of just getting started with a test of change, grounded in a strong hypothesis with collectible quantitative data points is important - this is not the time for a perfect model, it is the time for trying a new concept. Next, when scaling up, try to get to an 80% success rate with the model. If people are doing this 80% of the time, the chances of successfully achieving higher levels of dissemination increase significantly. On the second go around you have a chance of then achieving 95% success (there are a significant number of previous studies demonstrating this relationship). I struggled at first thinking that this concept excused us having less than perfect outcomes (What hospital administrator is going to say ok to 95% success with STEMI times or stroke alert times?) but later understood that this success rate is the success of procedure implementation (i.e. following a checklist when doing a central line or bypassing the triage area and going straight to CT in a stroke alert). Even if a procedure is not followed, there is still some probability for a successful outcome (i.e. still might not get an infection with a central line even if the checklist isn't followed) and, therefore, the percent of successful outcomes when the procedure is followed 95% of the time can approach a much higher success rate.


Finally (well there is a lot more but I can't write forever) another important concept that helped my thinking came from a presentation by Robert Lloyd, PhD on measurements and the reporting of data. Namely, he reemphasized well known concepts in statistics and research of trying to stay as close to the data as possible. For example, why move to static measure such as the mean which does not emphasize the processes of variation and risks losing important information contained in "outliers" if you have the actual data available? But how do you present that data? Lloyd presented numerous examples of run charts and other techniques for doing so in a way that doesn't lose the variation or the overall "look" of the data while very much reiterating the importance of always including time in the x-axis in order to illustrate how your system is changing over time.


I know those last two paragraphs were a little deep but I wanted to show that the IHI program was able to balance broad philosophical approaches to improvement with tangible takeaways for the student during the week. The course might be over but, fortunately, there are many other opportunities to learn from IHI through their open school, the national forum in Orlando every December and (something I am considering as a next step) the deeper yearlong programs in improvement or patient safety. As you can tell, I had a great experience at the IHI course and feel ready to take my research interests in health services to the next level. Thanks again to USF GME for funding this opportunity!


If you are interested in attending the 2014 IHI Summer Immersion program please email info@ihi.org for more information.

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