In hospitals, comprehensive blood tests of inpatients are commonplace — way too common, in some cases. The Society for Hospital Medicine says repetitive blood tests are often unwarranted and can lead to harm in several ways — causing anemia, lost staff time, and significant costs. Matthew Cerasale, MD, a resident in the Henry Ford Health System and IHI Open School learner, decided to try to improve his own practice of ordering regular blood tests as part of a quality improvement elective. He then expanded his project to improve test ordering in four general medicine units at the hospital. Below, he describes his experience and offers advice for other health students taking on QI projects.
Matt Cerasale, MD, presenting his quality improvement project at IHI's 26th Annual National Forum.
OS: How did you first
become interested in QI?
MC: I first became interested in QI during a Quality
Improvement and Hospital Medicine elective during my residency. It was the
first time I had received any focused teaching on QI, and really the first time
I was able to get a grasp of what was really involved with health care QI.
OS: How did you come
up with the idea for your project? What was the problem, and did your project
MC: The idea for my project initially started as a personal
improvement project from the QI elective, during which I had to pick something
to improve in my own practice. The Choosing
Wisely campaign seemed like a good starting point, so I selected one of the
five points from the Society of Hospital Medicine list. The specific point I
chose was about reducing unnecessary laboratory testing for clinically stable
inpatients. During my personal project, I was able to evaluate my own
laboratory ordering workflow and identify problematic areas through a root
cause analysis. For example, I learned there was no clear feedback or
determination of appropriateness of my ordering practices. As a possible
solution to this problem in my workflow, I changed my daily ordering practice
to include writing out each laboratory order in my patient progress note linked
to a specific problem. My laboratory ordering practices changed significantly
with the intervention, as my number of daily orders dropped. With this initial
success, I decided to expand the intervention to a broader population of
physicians in my institution, and their laboratory orders decreased as well.
OS: How did you
identify a faculty sponsor or mentor, and how did they help you succeed?
MC: I was lucky enough to be paired with an excellent
faculty mentor during the QI elective, Dr. Chase Coffey, currently at Cedars
Sinai in Los Angeles. He served as my QI teacher and project coach. He really
pushed me during the initial phases of the project to get a solid understanding
of what the problem was and what ways it could be addressed. My other project
mentor, Dr. David Paje of Henry Ford Hospital in Detroit, has aided me in
previous projects and fit in perfectly to help me expand this project. He got
me in touch with additional resources within the hospital that were essential
for project growth.
OS: What was the
biggest surprise in doing the project?
MC: The biggest surprise during the project was
understanding how big a simple problem actually was, and how many people it affected.
Laboratory orders are a seemingly simple problem. But by investigating them at
the ground level, I saw how much nursing time, technician time, lab expense,
and potential patient harm was occurring.
OS: What was the most
gratifying part of the doing the project?
MC: The most gratifying part of the project was seeing how
focused time and effort really can make a difference in patient care in a
timely fashion. I had previous experience with clinical research where you
would find a significant outcome, but its direct effect on patients either was
not clear or would not be seen for some time. QI work let me see how quickly
health care delivery can be improved.
OS: What did you
learn from working on an interprofessional team?
MC: Working with other healthcare professionals who were not
physicians allowed me to get a better grasp of everyone’s role in patient care.
I also had the opportunity to meet personnel I would have not otherwise
encountered, if I was not on the project.
OS: If you had the
chance to start your project all over again today, what would you do
MC: I would do nothing differently at the onset. I learned
so much, and the initial phases went so well, that I can’t think of anything to
change. During my third PDSA cycle, I would have made the design more QI-oriented,
rather than setting it up as strict research design with a control. I feel I
lost the opportunity to impact more physicians, and it limited my ability to
give continued feedback during the intervention.
OS: How will the
improvements you made be sustained over time?
MC: Sustaining the effect of the improvement over time will
be difficult. My project encourages changes in ordering and documentation
practices, which takes a large amount of buy-in from the target audience of physicians.
I believe with the next PDSA cycle, which will include a stronger feedback
mechanism, there will be a more easily sustainable result.
OS: What were some
key lessons from your experience that you want to share with other QI learners?
MC: Take the time to really understand the problem, identify
who the key stakeholders are, and form a strong team to help the project along.
Getting a broad understanding of the problem and all of the people it affected
were essential to making the project work and making it meaningful. Building a
strong team allowed me to form relationships with people in different
departments, who had skills very different from my own and could make major
contributions to the final project.
OS: How, if at all,
has this experience changed your outlook on your career?
MC: My QI experience both through my QI elective and
completion of my project did change my outlook on my career. I knew I wanted to
do hospital medicine, but I didn’t know how I would supplement it with other
interests. After becoming involved in QI work, I had a clear idea of what I
wanted to do and how to use QI to be a more productive physician in my hospital
and the health care system as a whole.