Okay, so I realise it’s been a while but I’m hoping we can still make it work.

That’s me and the blog (not me and you, although it could be you and the blog). Turns out that spouting forth my opinions is really not my natural state, but hey – I’m at an improvement organisation so with the right will, ideas and execution even this blog will start rolling. We’ve all noticed the need for Pete to sort this out …I’m going to use the Model for Improvement to help me out.

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1) What am I trying to improve? > The AIM: There will be a quality blog post every week from 25th November until July

2) How will I know that a change an improvement  > The MEASURES:
1. Number of blogs per month
2. Blog ratings from blog users

3) What changes will result in an improvement? > The CHANGE ideas
1. “Interview myself”
2. Keep it brief (if possible!)
3. Think up topics in advance
4. Have a time and structure I can depend on
5. Stick a link and an image on each post

My first PDSA cycle:

    Plan: Complete my blog post on the train. Prediction: It will only take 20 minutes.
Do: It was kinda cramped on Monday night
Study: Its possible and feasible but editing and upload requires dragging it up at home – all in 40 minutes
Act: Do I adopt, adapt, abandon, test under new conditions or extend the test?
I’ll adapt. Select one fixed time in the week with internet access.

If the MODEL FOR IMPROVEMENT can be used to get my blog going then it can likely be used to fix the Obamacare website, and while we are at it the whole of the American Health Care system. Funnily enough that’s not far off the truth. There is of course a lot more to this than my drivel above. However for each blog I will aim to touch on one basic ‘improvement aspect’ for further consideration plus  reflection on what’s current on the fellowship journey.

 

What’s current?:  ‘Real Time Capacity and Demand Management’.

Last week I attended ‘Cracking the code to hospital wide patient flow’. The focus was essentially ‘Real Time Capacity and Demand Management’.

Patient flow is a major challenge that just about affects everyone in a local health care system in some way.  It’s easy to say “if only (so and so ) did this – everything would be okay”. RTCDM takes an institution out of this mindset to one that brings all hospital departments together with a common goal. No more ‘on red’, emails requesting ‘no more patients’.

The premise:

– Sort out the 8am-2pm window and one will prevent the ‘compression wave’ that causes havoc until the late evening
– You only need to release 1-2 beds per unit/day to go from the cliff edge to smooth riding
– Length of Stay: Move from managing from days to hours
– Accurate daily patient specific predictions in capacity and demand at the ward level combined with an integrative discharge planning meeting are required as the basis.

The challenge:

Flow needs to be strategic objective and high on the agenda executive.  Without that you can forget it.
Each ward 8am discharge huddle predicts:
1. Bed demand  from a) historical data b) known demand
2. Pre 2pm discharges (i.e. the specific patients) and puts together a specific (who, what, when) plan to maximize
Hospital wide bed meeting at 8.45.
1. Capacity is reported IN PERSON by every ward, ED, ITU at the hospital wide bed meeting which occurs daily at 8.45. Also in attendance is representation from theatres, pharmacy, cardio, radiology, cleaning/ environmental, social services etc. Attendance, punctuality and data is compulsory.
2. Those in the red are discussed in a standard manner and patient specific plans take shape across the hospital. Action on promised plans is vital.
– All data is collected in real time and prediction accuracy fed back to wards by email the next day

Case study – University of Colorado results

Post IHI seminar University Hospital Colorado applied RTCDM in 2010.
Since then:
– A&E left without being seen reduced 5.3% > 3.3%
– Average time on ‘divert’ 21 hours/ week > 7h/ week
– A&E ‘front door to floor’: 7 hours to 4.3 hours
– Clean to occupy in less than 45 minutes: 22% > 55%
– Median discharge time: 15:01 > 14:32
– Median Length of stay: 5.7 > 4.11 days

Balancing measures
Admissions/ year actually rose from 14000 to 16800
CMI index (measure of patient frailty) also rose

Bed occupancy currently runs at 87-97% med surg 65% crit care

 

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Phew, and onto the next phase

Apologies for the lack of blogging, those last few months were a bit intense.

I can now confidently explain the four different types of t-tests, but hey, lets not go there. We’ve got the certificate, just waiting for the results.

Few weeks holiday so what have we been up to?

  • Watched 20,000 fireworks on the 4th July. 100,000s of people and you could count the litter on one hand – what a contrast.
  • A hike in Vermont- managed to get a tick bite and as a specialist in Lyme disease convinced myself the rash warranted antibiotics.
  • Been whale watching
  • Tried to survive the humidity
  • Moved house (twice).
  • Got rinsed at an all American traditional fair (hey that’s what fairs are for)
  • Went to a Red Sox game. 18 minutes of action in 3 hours. I left at 10pm when it was  2-7 down. They then made the comeback of 40 years to 8-7! Still trying to figure out the attraction.
  • Muscled in with the locals. You have to to get $5 lobsters.
  • Been to Newfrontiers Celebration Northeast with Fenway church and Abundant Grace
  • Had Libby’s parents deliver car and a gazillion suitcases.

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Coming up:

  1. Patient Safety Officer Program
  2. Visit to the  Commonwealth Fund in New York
  3. Improvement Advisor Program – the 10 month daddy: Collaboration with renal Drs Chris Wong and Asheesh Sharma at University Hospital Aintree

Recommended reading:  Quality improvement Made Simple – An Introductory Guide from The Health Foundation

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Libby says  –  “I’ve finally arrived in my dream home…. Looking out to the sea! suddenly the last few months of packing & moving a couple times seem worth it!”

Not easy getting furnished accommodation round here. Rock Island road was the same price or less than furnished flats in central Boston which should make the commute worth it (he says in anticipation). Still, the cost of living is pretty much double here than back home excluding travel and ‘gas’.

Charlotte says “I swallowed a coin!”

Not witnessed unfortunately resulting in a taste of American healthcare a bit quicker than anticipated. Yep, it’s was stuck in the oesophagus but nothing that a big juice couldn’t sort out. The quarter was never to be seen again. Not quite sure how the $417 was calculated for a couple of breaths and two xrays. The same sticker would have been less than $200 back home.

Joshua says “Wee-whay-wee!”

… the standard whale sighting call of New England. The humpbacks were down this year likely do to the low numbers of sand eels but we saw ’em plus a minke.

 

Thought for the month:

Love suffers long and is kind; love does not envy; love does not parade itself, is not puffed up; does not behave rudely, does not seek its own, is not provoked, thinks no evil; does not rejoice in iniquity, but rejoices in the truth; bears all things, believes all things, hopes all things, endures all things.

Fancy a bit of Harvard?

Welcome to (probably) the best medical school in the world. Now, let’s get on with what really matters.

“There is absolutely no difference between statistics and gambling” says Prof. John Orav. Just maybe a little bit or money…. and gambling is more addictive I believe.

Statistics class has moved from the dryness of a fine white wine to that of a biscuit barrel (assuming there’s a log regression for that).

However, one cannot criticise the teaching dedication, availability or detail. EVERYTHING is worked through step by step, no assumptions, no brushing over. I think that’s where much statistic teaching leaves people only half way. Not here though with two hours of statistics everyday. For such a clever guy he is really happy to spell it out.

“…and so why is it important to understand this derivation of the F-distribution in testing if (sigma)x = (sigma)y ? ….. it’s not….. just make the right decision regarding the degrees of freedom and let SAS do the rest.”  Hey, still nice to know.

For those who couldn’t give a monkeys but would like to sound they do – here’s today’s statistic tips for continuous data:

a. Validity before Power. That applies to politicians too.

b. Normality is a relative term. Don’t assume anyone or anything is normal. When you run Shapiro-Wilk you will find nothing is normal.

c. Central Limit Theorem deals with everything if n is large anyway. Wahey. (If n>200 the T distribution will be essentially  Z. Yeah, 200 is a great number. I love 200 man).

d. N is small? Wilcoxon gets you home  and dry for a two way analysis (okay, you may have dropped a bit of power on the way but you are home and dry)

They take research seriously here and the publications prove it. No less on the teaching.

Many of the lectures are observed by the other course directors and the major modules have ‘office hours’ every day – open access to discuss with the lecturers any thing you want plus individual 1:1 slots bookable online with practically everyone on faculty so you can get someone to pull your project apart before actually standing up. Granted, some of the associate professors look like they are 18 but a review of their publications soon dispels this. I kind of like it how they often use their own publications to prove the concepts – New England Journal of Medicine…..of course.

The Program for Clinical Effectiveness is essentially the fundamentals of f 1/3 of the Masters in Public Health. You want to do research out here? You need an MPH or PhD or you won’t get a look in. MPH is not what I thought back home. That probably explains why this building is 10 floors at the heart of the medical school and not some poxy department no one has ever seen before.

This is where you learn the tools for clinical research. Lots of the faculty are profs at Brigham and Womens, Mass General and Beth Israel.  No surprise then that 75% of the guys on this course are from the surrounding Harvard hospitals about to start or complete their specialty fellowship. A lot have funding from their department to complete the MPH. Anyone got a bit of spare wonga and I’ll be more than happy to finish the remaining modules.

A common theme. “So what do you do then?”  “Well I’m a Paediatric Neurological Oncological Pharmacologist. What do you do?” “Oh, I’m a GP.” The only GP in this entire building as far as I can see.

Specialists rule here but people are beginning to realise the shortage of GPs means the ship is starting to keel. Hey, one more GP and the risk ratio will be (just about) halved.

What is helpful is the assignments are really applied and you get to find out what everyone else is doing. In fact the idea is after you have got your grant proposal assignment sorted, you get the grant, do the research and publish it. A lot of it’s pretty niche specialised stuff but the methodology and analysis applies across the board.

Next class, measuring patient centred health outcomes. If you don’t know the difference between an SF36 and EQ5D then go and grab a cup of tea.

What it’s really like in Boston

Apparently Boston ranks the 3rd snobbiest in the USA, has the best baseball team, regularly produces presidential candidates and is usually under 4 feet of snow for most of the winter.

For the newbee to town though it’s the tube or “The T” (for transport not tube) that best reflects Bostons true nature. Every other advert is literally a university or a health related trial. “Do you have a persistent issue about your appearance? Are you always thinking about how you look? Then please consider signing up to our study on body image at Massachusetts General”. Funnily enough I don’t have that problem but would be happy to help spend your excess research money on a less vain cause. Commuters are clearly more polite than in London and stand in line reading books I never go near including plato, latin for beginners, reaching your inner self and the odd novel. The tube driver may amicably coach passengers at peak time and can be heard in the train AND on the platform. “Patient folks, let the guys off first, we gotta packed train so move on down. Have a 5 star Friday and don’t let anyone get ya down”.

 

The average Bostonian looks about 29, is well groomed, wears smart casuals

 

Harvard College

Harvard College (Photo credit: Wikipedia)

 

and looks pretty healthy. It’s Brighton meets Oxbridge – an eclectic mix of postmodern individuals and academia. No fake eyelashes here and if you are wearing North Face you are certainly no scally. Indeed there are 35 universities or colleges in the Boston area. Harvard itself was founded in 1636 – pretty old for America. An undergraduate education here is often cheaper than expected due to the large amounts of scholarships provided. Income meets expense of over $3 billion a year.  About  6,000 undergrads and 14,000 post grads so do the sums. Assuming you can speak latin, have been doing algebra from aged 5 and one’s parents have an income less than $150,000 (America – you don’t know how rich you are!) you can apply for a scholarship. More than 60 percent of Harvard College students receive scholarship aid, and the average grant this year is $40,000 meaning such parents are paying less than the  UK counterpart – averaging $11,000 a year. Those on low incomes can get through this place for nowt.

Indeed you don’t have to go far to find a ‘genius’. I attended a charity classical concert ‘thrown together by a guy who had cancer’.The people playing were pros of the highest degree (how does one get a doctorate in violin performance anyway?) and if you hadn’t completed a 30 hour triathlon that morning, played with REM or written a number of electrical engineering bestsellers too – then who the heck are you! Not a bad night out for $25.

 

Boston is ‘the walking city’ and yep, I’ve done my fair bit in between the T. As a result obesity appears less prevalent while everyone is frantically eating organic food off farmers markets and recycling. I’ve already been skinned at ‘whole foods’ – where’s Aldi when you need one?

Right now where is that Health Outcomes Research book?

Touchdown!

With one working day in it we managed to get to the embassy with no cuts to our fingers and all the documents in tow. ‘Cute kids’ said the consulate officer ‘and where are you going to live’. Not quite sure where the interview ended and chat began.

Seven suitcases, 4 carry ons, 2 car seats and a double buggy later and we were finally at the airport. ‘You need to check in before security luv’ said the airport steward. ‘We have, that’s just the hand luggage’

Thanks to everyone who got us here, especially the 10 angels from church who packed us up and Sarah and Jamie for putting us up.

Arrived to  32oC in Orlando and the odd tropical storm. The roof has just been hit by lightening, generator has sparked up. Happy to get a few days recharge before I hit (or get hit) by the stats. Nearly there….still, I think I’m overdue that ice cold beer.

Five weeks to go

Yet to rent house, sell car and get the visa but we have selected modules in faith for the School of Clinical Effectiveness.

Kick off starts with:

– Biostatistics and epidemiology

– Healthcare Statistics

– Healthcare measurement

– Healthcare Informatics

It’s route one to numbers, and a head in a spin. Bring on the confidence intervals!