What role can students play in improving care? Justin Slade, fourth-year medical student at Boston University School of Medicine and former Open School Chapter Leader, recently appeared on WIHI to share his experience in health care quality improvement. As a first-year medical student, he worked on a project that helped improve care for sickle cell patients at Boston Medical Center. Below, he explains how students can help accelerate improvement.
Open School: What role can students play in improving the quality of health care?
JS: I think many of the perceived barriers to student involvement in quality improvement can actually be translated into advantages in our work.
We enter medical or other health profession schools with a limited understanding of hospital processes, a small professional network, and little to no influence in the health care setting. Students may not know much about hospital processes, but that means that they bring a fresh set of eyes to the table. A student is resistant to normalization of deviation because at first quite literally nothing about being in a hospital feels normal to us. With this comes the fact that we are also less likely to trust our initial assumptions, and instead turn more quickly to data-driven evidence to guide us in our work.
OS: How did you get interested in quality improvement?
JS: I think a lot of my interest in quality improvement can be attributed to what was going on in the world at the time I entered medical school. It was at the height of the 2012 presidential election season, the Affordable Care Act was in the spotlight, and it didn’t seem like I could go a day without reading about the immense challenges that we faced as a nation with regards to health care delivery.
I was also a fan of Atul Gawande, who had just published The Checklist Manifesto, and was really inspired by the stories he told about people working to find solutions to many of these challenges in health care. From this I realized that I wanted to work toward improving systems of care and creating a better medical environment to spend my future career in. The only problem was that despite my awareness of quality improvement, I had little to no idea how to get involved in or carry out this work.
A few weeks into my first year, I joined the BU Open School Chapter and met Dr. James Moses, Faculty Advisor for the Open School and Medical Director of Quality Improvement at Boston Medical Center. He became a mentor to me, and I expressed that I was interested in doing a quality improvement project. James suggested focusing on care for patients with sickle cell disease, a population that many hospitals have struggled to provide high-quality, effective care for over the years.
The Open School Practicum
helped me to find a mentor and acquire a foundation of quality improvement knowledge in order to run PDSA cycles and develop run charts so that I could test if our changes were leading to improvement.
OS: What are the challenges of providing care for patients with sickle cell disease?
Sickle cell disease is a genetic condition that causes severe pain during crises, which occur when normal-shaped blood cells become sickle-shaped and block small arteries. Patients suffering from a crisis often end up in the emergency room, and then hospitalized.
This places a huge burden on patients and adds to the cost of our health care system — but it doesn’t have to work this way. Patients and providers can manage the disease more effectively in the outpatient setting to avoid these emergency visits. We learned that doctors had a low rate of follow-up with these patients after they were discharged from the hospital. Patients were not attending their follow-up appointments in many cases. My first task was to explore what was causing this lapse in care to happen and to propose some solutions that might fix the problem.
OS: How did you learn what was causing the problem?
At first, I thought the issue was that the appointments were scheduled, but patients weren’t coming in. After examining some records, however, it turned out that scheduling the appointments was the larger issue. It wasn’t happening consistently: less than 50 percent of patients discharged had an appointment scheduled within 28 days and a significant number left the hospital with no appointment scheduled at all.
I also found that the further out a patient’s appointment was from the hospitalization, the less likely they were to attend this scheduled visit. Upon discovering this, we decided that although patients’ attendance at visits was an issue, we first needed to focus on improving appointment scheduling.
OS: What happened when you decided to improve the scheduling of visits?
I brought our data to the outpatient provider group that worked with these patients. Some were supportive, but others were resistant at first. One of the providers worried that I planned to publish the data in order to reveal a system that wasn’t working very effectively. I explained that our goal was to help improve the coordination of care for these patients, and that there was absolutely no intention to make anyone look bad. I also spoke with providers from the inpatient service and the emergency department.
From these discussions I learned that house staff were having a hard time scheduling follow-up appointments because physicians’ schedules were too packed. Our group decided to try having the outpatient providers set aside appointment slots for post-discharge follow-up. It also turned out that the process for making appointments was quite cumbersome for the residents. They would be trying to schedule these follow-up appointments through a general hospital hotline with several automated prompts and were often placed on hold for a long time before reaching someone. In response to this, we established a direct line for residents to reach the outpatient office administrator to schedule follow-up appointments for these patients.
OS: What was the result of these changes?
We implemented these changes over the course of about six months and the results were staggering. After our interventions, between 80 and 90 percent of patients were leaving the hospital with follow-up appointments scheduled for within 28 days. More importantly, attendance at follow-up appointments within 28 days doubled. This is really great for these patients because there’s evidence from other settings that shows patients with sickle cell disease have lower hospital readmission rates if they attend timely follow-up appointments.
OS: What are some of the lessons you learned from this experience?
The most important lesson was that students can add a lot of value to quality improvement teams. I’ve also learned that students and many other people working in health systems have been improving processes for years, yet they just don’t happen call this “quality improvement.” I used to work in an organic chemistry lab, using the scientific method to optimize reactions, and not once did I refer to this as quality improvement — but it was. I’ve learned that many of my peers in the Open School have had similar experiences in their past work.
Finally, I think it’s important that we’re able to be more hands-on as students. In my free time I would join rounds at the hospital in order to see firsthand where the system was breaking down. Not everyone can do this later on in their careers when they have more responsibilities. Being able to act as the “boots on the ground” in order to improve delivery of care is an amazing experience, and one that I hope students continue to seek out in order to create a better future for both ourselves and our patients.