Quality Improvement in Healthcare Episode 5 | Transcript
Brandon: And we are here! My name is Brandon Garcia, I’m one of the hosts for the Resonance podcast and joining me today is
Anoosha: My name is Anoosha I am a fourth year medical student at Baylor College of Medicine, and I am heavily involved with the student group of the Institutes of Healthcare Improvement at Baylor which has brought you a couple of fun episodes in collaboration with Resonance to kind of share our love of quality improvement and patient safety. And so this is another episode of that!
Brandon: Awesome so glad to have you here today who do we have with us today Anoosha?
Anoosha: Yeah so today we have one of the most incredible mentors that we've ever had, Dr. Coleman who is here taking some really precious time of her very very busy schedule to be with us. Dr. Coleman has many different roles here at Baylor College of Medicine, she is a pediatric critical care physician, she served as the assistant dean of graduate medical education for the last five years, and she is a quality improvement and patient safety champion throughout the Texas Medical Center.
Brandon: Wow that's so exciting! Thank you so much Dr. Coleman for being with us today. Real quick, you mentioned before we started this session that this is your first day out of the hospital in how long?
Dr. Coleman: Thank you so much for having me Brandon and Anoosha, it's really a pleasure to be here and thanks so much for that kind introduction. So I’ve actually been on service much of the last few weeks ending of June and into early July working in the pediatric ICU and our service lines. It's obviously a very busy time in hospitals overall, and so it's actually nice to have a chance to return to some of the administrative and educational leadership work that i do. But I have to say, being at the bedside always brings a really unique and grounding perspective in trying to think about how and why we do what we do in education to really help as we train students and trainees to become physicians of tomorrow.
Anoosha: So, Dr. Coleman we mentioned you're heavily involved in medical education from the medical student to the resident to, I’m sure, even the fellow level and you're also a champion for healthcare quality and health systems science. Today in our episode we'd like to focus on your roles in quality improvement health care system science and medical education. And kind of focus there even though you do have many many roles throughout Baylor. We were curious if you could just tell us a little bit about your path to being in these roles of medical education and healthcare quality that you are today.
Dr. Coleman: Sure, thank you for that really thoughtful question. So when I think back formally to when this journey started, it was actually when I myself was in training. I as a medical student had quite a bit of interest in teamwork and how teams work together to help to make things better for patients. And even at that time in medical school, a lot of the work that I did was in the community and thinking about how what we did even as students would help our adult and pediatric patients have better health outcomes. As i transitioned into training, interestingly, I was in my residency in New York City there was obviously really a lot of work that we were doing just given the population that we served in Washington Heights and a really multicultural diverse community. There was really an opportunity to engage in work that helped us to think about what, at the time, we probably weren't calling social determinants of health and thinking about it from a health equity point of view, but really in the spirit of community pediatrics. As i transitioned into my fellowship I knew that critical care was the field that I loved for a couple of reasons. One, I appreciated the challenge of it. I also appreciated the fact that so much of the work was team based. And again just given the nature of the acuity and the breadth and depth of clinical diseases that we treat in that field, that there would be an opportunity to again think about how health and health outcomes could be impacted by thoughtful care and attention to some of the non-clinical aspects including quality and safety. As I was in my fellowship I had really great mentorship from someone who actually continues to be my mentor today, we just were in touch last week, and really had the opportunity to begin to delve into this work in a more formal way through my fellowship research project which looked at the impact of team and leadership training on patient outcomes particularly for scenarios that were infrequently encountered but high acuity when they were kind of like the ICU. As part of that work, I had the opportunity to be trained in a national program called TEAMSTEPSS which is now pretty ubiquitous, but at the time I was trained at one of only five centers in the country, that was really looking at how that program which focuses on teamwork strategies to mitigate patient safety outcomes, how that program could be integrated into their clinical work. So, from there it really took off. I realized that while team and leadership development were very critically important to health outcomes, really being able to thoughtfully and strategically make inquiry around what can we do to improve the outcome for our patients through a structured process and through a way that was intentional and team based and outcomes driven, would really be the key to helping the patients that I cared the most about. And so, I undertook a number of initiatives to really grow in my knowledge and my skills and training around the issues of quality and safety. Soon after I entered my faculty career, I had a lot of really great opportunities that I’m really thankful for that helped me to acquire a lot of on-the-job experience. I was a Director of Quality and Safety for pediatric critical care division in New York City at a large academic center that really honed my training around building a quality and safety program. How do you do morbidity and mortality in a way that doesn't feel staid and threatening and intimidating? How do you incorporate families as partners in quality and safety? How do you balance the needs of health equity in resource constrained settings? And so, in that work initially for the division and then ultimately for the department that really gave me a good foundation. And so, from there we transitioned to the Houston area and as you've shared I’ve been really grateful and just really excited about the work that I've had the privilege of doing here at Baylor College of Medicine over the past six or so years.
Anoosha: Dr. Coleman so many of those things that you've outlined could be entire episodes on their own! It's amazing how succinctly you've summarized all of these incredible projects and roles you've had in the past as a champion of quality improvement and patient safety. Thank you so much for sharing that with us.
Dr. Coleman: Certainly, thank you.
Brandon: So, you shared a bit of about the things you've done in the past, what currently is your primary focus in terms of quality improvement?
Dr. Coleman: Certainly, great question. So in the last five years, as Anoosha mentioned, I have worked with our office of graduate medical education which of course is the office that oversees the training of our almost 1500 residents and fellows here at Baylor College of Medicine across our major affiliates in a number of different specialties. And so, there is a program by the ACGME which is the council that accredits all, or many I should say, of our programs that is called the CLEAR program, clinical learning environment review program. The CLEAR program started through the ACGME in 2012 as a means through which a couple of key priorities could be accomplished. Number one, patients and families were saying it's not enough to have a doctor who understands how to do the procedure, how to do the operation, how to get the history and physical, but we need physicians who are prepared to discuss, address, interpret, and devise solutions for the challenges that we face in health care which more often than not are not just technical and clinical, but rather systems based. And so, the program really became an opportunity for clinical training to be reconsidered. What do I mean by that? So the clinical learning environment is really just that - where do trainees acquire their experience and exposure to patients and health systems? But recognizing that in the course of their clinical training, previously there was not enough emphasis nor really collaboration between affiliates or learning environments and the school or academic center that was actually sponsoring the training program. So through CLEAR, a dialogue began. A dialogue around six core areas: quality improvement/healthcare disparity, patient safety, professionalism, wellness, supervision, transitions of care - and I think that's the six, yes! And so through that work that i have been engaged in over these past five years, I've had the opportunity to partner with members of our academic institution our affiliate sites to really help operationalize and lead a collaborative network across our sites such that when trainees are going to each of these hospitals, they have a common lexicon or vernacular around the importance of quality and safety in their work, a common understanding of why transitions of care matter, common understanding around supervision, and what their role and responsibility is in that context for their patients, and really trying to elevate our collective and shared understanding around these core principles. And so in the past five years, I had the opportunity to lead that program and it was really one of the most foundational exciting and really wonderful journeys that I've been able to take professionally. Very very grateful for that opportunity. More recently, I’ve actually transitioned into another role which actually will help me to continue to do some of this work through the office of the provost in an Associate Provost role and really focusing not only on academic affairs but also Health System Science which, many people are familiar with that term, but for those who may be less so, really defines the broad scope of competencies really across the continuum of medical education that pertain to quality, safety, teamwork, health equity, partnership with families and patients to help prepare us to really be even more effective physicians. And so, I'm excited to have the opportunity to continue work in that area.
Brandon: So, correct me if I'm wrong. It sounds like a big focus of what you've been doing with this systems approach that you keep mentioning is helping physicians realize that it's not just about recognizing symptoms of a disease and diagnosing it, but also understanding like maybe like the social economic impacts of the disease and in the other aspects of care besides just sitting in the doctor's office that can help the patient. Is that kind of what you're talking about like educating physicians in that area?
Dr. Coleman: I think you've surmised that beautifully Brandon because in reality what you've said is so true. I think we typically as physicians have traditionally measured our effectiveness by what happens to our patients in terms of their outcomes and their numbers and their mortality or their morbidities, but what I think we've been called to do as clinicians in recent years, which I think is really important, is to consider our own accountability in that process. So, what roles do we need to take on to help advance the best interest of our patients? But then also, how do we need to educate differently really from the very beginning all the way through training all the way through our continuing medical education and our long-term careers so that we recognize that quality and safety isn't an add-on, but it's just like clinical medicine. It's just what we do. And so, that concept of Health System Science which really bridges the continuum evaluates individual roles and responsibilities in achieving high quality care and safe quality care for our patients, but also making sure that we understand that systems are part of that and how do we interface with systems to make sure that we have the best possible outcomes. And so yes, I think that new professional identity around what are the other factors? What's my understanding of my role? What are the impacts of social determinants? What are the impacts of areas of implicit bias? How do those factors, for example, impact the ultimate quality and safety of the care that we deliver to our patients?
Brandon: Okay that that makes a lot of sense um, and I actually really like that because I mean especially where I'm at in my training, I'm still my pre-clinicals, you know which is all the book work it's oftentimes boiling it down to - okay patient comes in, they have shortness of breath, they have you know x y and z symptoms, what's their diagnosis? It's relieving to know that eventually you get to the point where you're talking about you know well, where did this person come from? What do they really have in terms of access to care? Like do they have a community support? Do they have social work? Do they have all these other things that can help them? Because giving them a prescription isn't necessarily going to help them fight the disease without other things in place that could benefit them.
Anoosha: And Dr. Coleman we're so lucky to have someone who is so knowledgeable, experienced, but more importantly so passionate about sort of building this intrinsic motivation in learners to work in some of these very important qualities of physicians as well. So it's incredible to know that someone like yourself is so passionate about helping us become the physicians that our patients deserve and really need. So thank you so much for your work. And I'm curious a little bit more about some of the projects that you had done in your role within graduate medical education with the residents at Baylor. Would you mind sharing some examples of how you worked through the ACGME?
Dr. Coleman: Certainly, so one of the things that I just wanted to reflect on was the point that you both shared just a few moments ago as to the passion. And I think that shared passion that all of us have that's what keeps us going. I know that when I was in my pre-clinical years, yes it was fine to do anatomy, and micro, and biochem, but at the end of the day that looking ahead to being connected with the patients was what kind of kept us all going and invigorated. So in the same way, I think of that for training and thinking of how do we alight that interest in our learners so that even through the sometimes drudgery and the challenges that training can bring, that there's still that passion in that interest. And so, I think of some of the areas in which we have had great collaboration with our trainees actually with our students. So one of the areas that I just want to highlight, and honestly express profound gratitude for, is this opportunity is the chance that I was given to serve as the director of the annual Baylor College of Medicine Quality and Safety Conference beginning in October of 2018. That conference really was incepted by and led brilliantly by a core of student leaders from the IHI student interest group and I have to say when I walked into that role, I could not have found a more collaborative, professional, supportive and just really committed and dedicated team led by students for this conference. In the last year or so we have added in some of our resident leaders in quality and safety to partner with the students and the other professionals who comprise the planning committee. And I share that really as an example of a success story the conference is in its seventh year this year. It was postponed due to the ongoing health pandemic, but will be convened next spring. But that being said, we had almost a third more abstracts this year 30 more abstracts than we've had in previous years. The quality just keeps getting better and better, and this is an activity that is not only regional but also now national and brings in many of our health system partners to see the quality of work in terms of inquiry and thoughtful QI projects that are being done across the system. Another area that I just really want to extend credit and gratitude for their contributions is through the house staff quality and safety council that started in GME. We started it about five years ago when I came into that role recognizing that although the executive and administrative leaders of the educational programs had a lot of expertise to contribute, that truly our house staff had not only experienced an interest but in many cases individuals who done masters who were real QI/OS gurus who could really contribute both leadership and really their perspectives to advancing your quality and safety work. So that has been also a great collaboration each year. We started a few years ago a clinical learning environment review orientation because previously when folks would orient to our training programs it was more administrative in function, but we recognized that to help prepare our trainees to be on the wards, in the clinics, and the hospitals that it would be important to give them a framework. Not only around how to do QI projects, but also how do you actually ask questions - and we've all heard of the smart aim - that have the potential for generating solutions that can actually really make a difference. And so, I was able to work with a great team of faculty as well as resident and fellow physicians to deliver that orientation over several iterations in the past few years. And then also just thinking about Texas Children's Hospital where I’m based clinically as a pediatric intensivist, thinking about their very strong QI fellows college that has been a great way to contribute as a core group coach to again help our physicians that are already choosing careers in academic medicine to be able to make quality improvement part of their academic portfolio with the right skills and foundations. And so, those are just some of the areas where I've had a chance to witness firsthand the strength, the quality, and the real interest around quality and safety at the organization. And that's really just for starters. There are a number of people doing great work across the continuum UME, GME, and CME to really bring learners and faculty together around common areas of interest in this discipline and field.
Brandon: That's amazing! So with this conference, with your role in bringing educators and students and clinicians together, what do you think would be probably the most exciting change that you've been able to see as a result of this kind of work? Has there been anything recently like that?
Dr. Coleman: That's a great question. I think the successes often are small but measurable. So, I remember when I first started in this role a few years ago. CLEAR and that concept was unfamiliar to everyone. No one knew what CLEAR was, why it mattered, but I think back to the results of some of our recent ACGME CLEAR site visits at some of our local affiliates. And to hear the unsolicited purely anonymous responses from our resident and fellow physicians and faculty surrounding their experiences in quality and safety - be it do they feel that they are acquiring training that helps them to be able to make better choices for their patients? Do they get performance metrics that guide their professional development? Do they now receive greater feedback and feel better prepared and trained to participate in root cause analyses and other critical event reviews? Do our learners and trainees feel that they are better equipped to give quality and effective handoffs? Do they better understand their roles for supervision do they understand professionalism expectations and how to execute areas where our patients are really asking for them to be present and to be their advocate? Are they able to recognize the impact of wellness on health outcomes and how they can deliver care safely? All of those are small but collectively, what I think of, really wonderful wins that have been collaborative in nature but that have helped really to achieve our first foundational goal really making this a dialogue that was normative for us in our community. And so, I have great appreciation and gratitude for the privilege of having been able to be a part of that journey over the past few years here at Baylor.
Brandon: That's awesome! And you know it doesn't have to be landmark sweeping changes. It's just like you said the small things that collectively come together can make a huge difference. And it's cool to hear these kind of stories and hear about what's going on to actually make a real difference.
Dr. Coleman: I just can't say enough about the great collaborations, which I think that's probably the real success story. Because at every affiliate every site within programs specifically, we can name and show it - that would be its podcast on its own as you said! So much great work that's being done that we can really showcase. And so, just thinking about where we have evolved from our culture thinking about some of those concepts that ability to have driven change collaboratively and together, I think is probably the most meaningful and sustainable impact of the work we've done to date.
Anoosha: I wanted to kind of maybe ask a little bit more about your involvement with the medical students. You talked about the conference that we have been able to work together for in the past couple of years. In your opinion, is the appropriate time to start learning about quality improvement and patient safety is that in medical school? And how does starting there help make you a more successful and efficient resident, fellow, faculty etc.
Dr. Coleman: That's a terrific question Anoosha. Thank you for sharing that, thanks for your kind words. It really is a team effort, and it really does take a village. Because one person's ideas and vision can't move forward and make a change if we don't all come together. And so, that for me is really one of the greatest joys of this work being able to help connect people and bring them together. I think with regard to your question - but when should this start - the earlier the better. Why do I say that? One, I and one of the things that again just thinking about how medical education has evolved even just from when I was in medical school to even now as faculty, I think that one overall medical education is realizing that at the point where we begin to integrate some of these principles in residency and fellowship, it's a little too late. It's hard to indoctrinate people into a way of thinking when they're already even under more stress than they may have been under in medical school, they're beginning training, they're on the wards. And it almost represents a missed opportunity if we wait until then. The ideal would be for every patient and for every intern reporting on their patient to come in the door and go through the systems or problems based analysis of what's going on with their patient and then at the end to also note not only well this is our plan, these are the x-rays, these are the labs, these are the studies, but also to think about what can we or what have we not done to help optimize this patient's chance of leaving the hospital or returning to clinic with a good or safe outcome. I think medical school is the right place to begin a lot of this work for many reasons. One because I think as many of us were coming into medical school we come in with an energy and altruism a vision that is pretty unbridled at least at the beginning. And I think the openness and the reciprocity to new concepts and ideas is there. Number two, we now have evidence that actually suggests through be it the AAMC core competencies in QI/PS and other such health systems science work that actually demonstrates that when core principles like this are introduced earlier in the continuum of medical education and training that it's more likely to be sustained throughout. And so, when it becomes a journey that one takes in terms of sequential and progressive competency acquisition as opposed to an add-on here you go quality and safety year one year and three, we come back to it but it's just something that's woven into the fabric. Much like we know that for every presentation there's an assessment and a plan, if we begin to help teach students even at that early phase and cultivate their interest at that early phase as this is just what we do for our patients, I think it has the opportunity to be a lot more meaningful such that by the time students are coming into residency and fellowship they already have a framework. They're better able to integrate into the medical team. They're better able to integrate into the health system because they're not learning a new language, but they already knew the language before coming in.
Anoosha: That is incredible perspective Dr. Coleman thank you so much for that. And just to expand a little bit more, so understanding that there are many possible ways for medical students to get this kind of education, you know ranging from IHI’s Basic Certificate and Quality improvement, Baylor itself has pre-clinical courses that have worked in some QI/PS principles, we have electives, and you're a part of building up many of those projects for you and me as well. This is maybe more of a vision board question, but what in your opinion is an ideal way for medical students to kind of attain this knowledge and have it become sort of a part of them?
Dr. Coleman: First of all, I have to say I love the term vision board. I like that vision board question. I probably need to get one as well. So in terms of vision, that's one of the things I'm actually very excited to have the chance to spend more time thinking about and working with others on in the in the next phase of my career. But a few things that kind of come to mind so first of all, I think many of the programs that you've already outlined are absolutely the right first second and third fourth steps. Why do i say? That you have courses you have interest groups and you have incredible student leaders such as yourselves who even just thinking of something like this mini-series, thinking of the quality of the work that you're doing already brings a level of interest, excitement, prestige, and respect for this as a discipline. I think an important second step or next step as part of that vision is mentorship. I think mentorship is very critical because it not only helps to spark interest but it also helps to really support individuals in their own professional journeys. And so, I think mentorship and having formal mentorships between students and trainees who are interested in QI and safety as a future career and have interest in Health System Science is very key. I think the third piece is really thinking about engaging patients and families. That has long been an area of real interest of mine, one because of the work that I do in the ICU. We're so connected with our patients and our families, one because it's pediatric medicine and two because the heaviness and the weight of what we're doing in a critical care environment really requires I think that not only are we working with families but recognizing that families and patients are the center of the team. At least that's the model that I like to use, and that we all support them. I think recognizing that and giving students and early trainees the opportunity to really prioritize those connections and recognizing the value that patients can bring to the care process is really critical. And so, as I continue to develop my vision board, I am really excited to hear from all of you. Because in many ways, there are things that I can see, but there are many things I cannot see. And so, that's where I think creating forums for openness and thought and dialogue as well as action is really critical to helping to move the work forward. Recognizing from not only what educational leaders and administrators have seen and believe but recognizing from all of you what are the gaps that you perceive when you're on the awards, when you are working pre-clinically, what do you feel is the gap? What do you feel that you as training physicians no matter where you're training no matter what field you're choosing what do you believe would help you to be the kind of position you want to be in the future?
Anoosha: Thank you for that Dr. Coleman. I think so far, we've really covered a wide breadth of what we were hoping to talk about in this episode, from your previous roles and how you got here to your roles in medical education and your passions for furthering the development at Baylor College of Medicine of this kind of work with trainees. And thank you so much again for everything you're doing for the college. Is there anything else that you'd like to share maybe some words of inspiration, or any other projects that you're very passionate about that you think medical students and you know even incoming pre-medical students to Baylor to residents and you know all of Resonance podcast audience that you think could be good for them to hear?
Dr. Coleman: Sure, so first of all I just want to say thank you thanks for the opportunity to be here today but thank you to the colleagues, partners, supporters, and champions who are doing this very very fine work in so many different ways. This is one organization where I've been where I really feel that there is a collective interest commitment and passion to quality safety Health System Science as a whole. There are so many areas of light, so many areas of excitement innovation that are ongoing. And so, I just want to compliment and thank those individuals that have been true partners with me in helping to advance the work. I could not be more excited to be in a community like this where there's so much fervor and excitement around this area. I think in terms of preparing individuals who not only want to pursue quality and safety as a career but recognize its basic importance, I think if I had to say one thing I would say take a moment in every interaction to realize the propensity for improving the outcome of the person for whom you're carrying through processes systems and individuals. And what do I mean by that? No matter the outcome good, bad, or ugly, or somewhere in between, I always believe there's something that we could do if not better at least differently. I think as physicians and trainees and students and members of the clinical and medical community and our bioscience and biomedical community and beyond, we are comfortable with inquiry. But I think we have to be even more comfortable with inquiry and self-reflection to think about even if this went swimmingly well and just perfectly, what could I have done differently or better or could our team have done differently or better for this patient. Because it doesn't always go perfectly or swimmingly because it's human life and thus unpredictable. I think being in a habit of so doing and realizing that is normative, then when the bad things happen not only do you have a potential action plan, not only can you be more proactive in terms of risk mitigation and management, but it also becomes okay and feel psychologically safe to have the dialogue and the conversation around what could we have done differently. Because that dialogue is something that happens all the time. I think as systems grow and teams evolve and individuals develop, I think that concept of open honest authentic discussion really with integrity and mutual respect, that is what helps teams to work well. The best teams and the best organizations with regard to quality and safety are consistent, and they have a culture where it's okay to recognize that we're not perfect because none of us ever will be. It's okay to recognize that sometimes the outcome is not what we want, but rather if the outcome is not what we want, how can we get closer to what we're all hoping to achieve with the next patient or the next experience. And so, I think instilling that through role modeling, leadership, mentorship, culture advancement, all of those areas together I think can really help to elevate our community of individuals who really are passionate about and committed to these really important ideals in medicine.
Anoosha: It truly is so inspiring to hear you speak of these sorts of visions. And I'm just so excited to continue in my own journey hearing here after hearing you talk about your own and all of that. So wonderful, well I don't think i have any more questions for now for this episode at least. There's plenty of things I would love to ask Dr. Coleman's advice about.
Dr. Coleman: Well this has been a real pleasure. I have really been grateful for the opportunities that all of you have given to me to really connect with all of you. Be it through being part of your courses, the conference, the councils, it's really been honestly a joy. I appreciate the opportunity to serve in so many different capacities, but I have to say that being able to work with all of you it is energizing, it's insightful, it's humbling, it just brings me a lot of joy. And so, I wish you could see the smile on my face as to how excited I am that this interview came together, but more importantly just to see the success of all of your work. I just, I'm available, I'm here to support your endeavors and just really thank you for letting me connect with all of you it's been a real pleasure.
Anoosha: Thank you, we're so lucky to have you Dr. Coleman.
Dr. Coleman: Thank you so much take good care bye-bye.