Archives for March 2016

The best way to predict the future? Create it.

1.            In 2004, Donald Berwick, physician and CEO of the Institute for Healthcare Improvement (IHI), challenged hospital administrators to save 100,000 lives in 18 months. In what became known as the 100,000 Lives Campaign, the IHI convinced thousands of hospitals to alter their behavior and institutionalize new standards of care. His team created an individualized step-by-step agenda to reduce medical error through process improvement. They provided research, instruction guides, and training. They opened up communication lines between hospitals to provide the opportunity for council. Altogether they saved 122,300 lives.

This was a massive change in health care. Not only because it challenged hospitals to change their traditional practices, but because it required hospitals to admit error and acknowledge that something in their system needed fixing. Dr. Berwick accomplished something that I am learning is rather hard to do within, let alone across healthcare organizations. Create culture change.

“Never doubt that a small group of thoughtful, committed individuals can change the world. Indeed, it’s the only thing that ever has.” – Margaret Mead

I haven’t personally saved 100,000 lives yet, but however small my role, I have helped the value-based services and quality department to make significant steps towards culture change at OrthoCarolina. I have helped OC to establish and maintain quality improvement processes in things like coordinated care and bundled payment care models. I have learned how to manage projects to test and create change in the clinic, I have helped implement a risk assessment for Medicare patients to better predict their care needs post-surgery, and most importantly, I have developed a keen eye for identifying areas of process change and quality improvement in healthcare. Every day I am inspired by my mentors and I am challenged to think of innovative and sustainable ways to improve the quality of care and the overall experience for our patients.  So on many occasions I think back to Dr. Berwick and the IHI… That’s what we’re trying to do here.

2.            Community involvement has become increasingly important to me during my post-grad life. Last year, Megan, the previous Davidson Impact Fellow, wrote of OrthoCarolina’s dedication to philanthropy and volunteerism. And to be honest, I underestimated how much I would truly value the experiences I have gained as a result of this commitment. Though now that my inbox is flooded with weekly educational and volunteer opportunities, I wouldn’t have it any other way. To the college students reading my blog—I encourage you to stay involved in the community when you graduate! The experiences you gain outside of the office, outside of the classroom, outside of your circle of friends, are so important. Trust me on this one. 

Some of the highlights of the last six months include: an all-day TedX event sponsored by OrthoCarolina where I heard from various local non-profits about their work towards social change in Charlotte, a day spent packing Christmas boxes with Operation Christmas Child, an afternoon baking cookies with residents at the Ronald McDonald house, and time spent helping to develop a specialized classroom program for our pediatric patients (more on that later!).

3.            In the beginning of February, I helped Davidson to complete the first-round interviews for six of the 65 applicants for the 2016-17 Davidson Impact Fellowship program. It is amazing to see so many students interested in the social sector! It was a long, but extremely rewarding day as I got to hear from various Davidson students about their passions and motivations for wanting to have a positive impact our society.

At the end of each interview, nearly every student wanted to know about the support system provided through Davidson and the mentor-ship component of the fellowship. As you may know, the program has monthly conference calls where we have the opportunity to update one another on our individual placements and seek any outside peer-support. We usually review an article related to philanthropy or non-profit work before the call then analyze the relevant topics on the call… It feels a lot like one of my old seminars, but I do really appreciate the opportunity for discussion. Another crucial part of the program and for me specifically, is that of the trifecta of mentors—the clinical quality manager at OrthoCarolina, a cardiologist at Novant Health, and a first-year medical student at Wake Forest. In my next blog I promise I will go into more detail about my mentors! The bottom line is that they are awesome and have provided me with opportunities that otherwise would not have been available to me. I often forget that this unique mentor-ship component is not as accessible to all Davidson graduates and it is something in which I am truly grateful.

4.            I just recently attended an ‘Evening with Dr. Atul Gawande’ talk in downtown Charlotte. Dr. Gawande is a general and endocrine surgeon who also happens to be one of today’s greatest innovators in healthcare and my personal hero. Needless to say, my friends and I were beyond excited! Like children waiting for autographs at the end of a major league game, we waited patiently following the talk to get our pictures taken with Dr. Gawande and our books signed. His talk paralleled some of the questions we grapple with on a daily basis here at OrthoCarolina. How do we fix the healthcare system? Are we doing what is best for the patient at this moment in time? How can we be better communicators and empathizers with our patients?

In reflecting on the talk, I keep returning to one comment in particular that Dr. Gawande made during the Q&A. A physician in the audience asked him about what hope Dr. Gawande has left for positive changes being made in healthcare. This physician was specifically reflecting on his experience with patients searching for the ‘quick-fix’ solution and being non-adherent to treatment plans. Dr. Gawande paused then he said, “This rests on the younger generation. As young people enter into medicine their question is, ‘What is the environment I’m going to be practicing in?’ My hope, and I’ve seen this with my residents, is that the younger physicians will not want to practice in an environment like this and they will do whatever it is they can to change it”.

5.            I know the list I have given you is quite a collection of unfinished thoughts, but my hope is that you are able to see the connections throughout and how these ramblings come full circle. I have not updated my blog in awhile so to the best of my ability I wanted to give you an update on everything that has been going on the past several months… which is a lot! All in all though, I truly feel that I am learning how to create step-by-step change in a healthcare system and how to best make a difference when I become a physician. That’s what I’m trying to do here.

 

In the shoes of a therapist for kids who have caused sexual harm

(For your information: the following stories contain potentially heavy or upsetting material. They are modifications and conglomerations of stories from nearly 200 kids and families throughout North Carolina. The identifying information and situations are fictional and could not be linked to our clients, past or present.)

Caleb, Stage II, Affect regulation and Attachment, Family

Caleb and his dad both report that they have never gotten along. Caleb’s older brother, Shawn, is currently incarcerated for selling drugs. Shawn coerced Caleb into watching pornography from the ages of 5 to 8 with him and would laugh when Caleb said he didn’t like the show or wanted to watch something else. Caleb was really close with his mother who died of cancer three years ago. A year after his mother’s death, he approached a classmate in the bathroom and touched him inappropriately. He has been in treatment for the last 5 months. Since Caleb’s offense, dad confided in you that he wants to be more involved in his son’s life. Caleb is currently living in foster care and he spends his time playing video games during home visits. Caleb’s dad does not want to stop Caleb from playing video games so there is little interaction during home visits. Family reunification is critical for treatment success and it is promising that Caleb’s dad is engaged in the treatment process.

Welcome to our bi-weekly TASK (Treatment Alternatives for Sexualized Kids) Program staff meeting where we discuss case files of our clients. TASK is a treatment model designed to meet the complex, heterogeneous needs of youth who have caused sexual harm. As the newest member of the team, you will be presenting background information for your 4 kids and current barriers you are experiencing in treatment. We will offer guiding questions to develop an action plan that could overcome the barrier. Your current clients are Matthew, Samantha,  Albert, and Rashawn. Go ahead and tell us about how treatment is going:

 

Matthew, Stage V, Risk mitigation, Affect regulation

Matthew, age 17, is in Stage V and has led conversation and offered honest responses to others during group therapy. His primary caregiver, grandma, is supportive and cooperative. She has mastered strategies on how to enforce boundaries for Matthew while still encouraging him. He wants to get a job but his grades are well below average and he is skipping class every few days, a violation of his safety plan. He told you a neighbor offered him a job mowing lawns. You would like him to be able to get a job but know that he has a pattern of starting projects and stopping halfway. You are excited about the overall progress throughout the past year of treatment and want to set him up for success as we approach his program graduation date.

Questions and action steps offered by the clinicians:

Review his safety plan and utilize motivational interviewing. Does he recognize any connection between skipping class and the rigor involved in maintaining a job? What are some of his big goals? What obstacles, like poor grades, might prevent him from reaching his goals?

Does grandma have influence in his life? Is she able to challenge him to attend school?

Has he established supportive friendships since starting treatment?

 

Samantha, Stage III, Conflict resolution and healthy sexuality, Family

Samantha is 13. She called last week during school and told you she felt like she was going to have a panic attack. You deescalated the situation by phone and she was able to function the rest of the day. During this week’s family meeting, you realize that adopted mom and dad are unaware that Samantha has struggled with anxiety. Instead, they are upset that she has not cleaned her room every day and washed the dishes like they had discussed.  They spend the first 20 minutes of the meeting describing everything Samantha has not done since your last meeting. Based on your conversations with adopted mom and dad from early on, they have tightened up their discipline and increased Samantha’s chores considerably. After 40 minutes have passed, mom announces that they caught Samantha with inappropriate pictures on her phone 2 weeks ago. Since then, they have checked Samantha’s phone every night before bed. Lastly, Samantha told them she might be interested in a boy in her class but mom and dad inform you that she is not allowed to talk to him anymore.

Questions to consider:

Have you had a conversation with mom and dad about their perspectives around healthy relationships and attitudes towards sex?

Can you provide mom and dad with specific suggestions about how to handle crises?

At the end of the meeting, inform mom, dad, and Samantha that you are going to work together to review Samantha’s safety plan in the next family meeting. Provide time for all 4 of you to contribute and ask questions. Ideally, a reviewed safety plan will address the insecurity and doubt felt by her adopted parents, provide age-appropriate autonomy to Samantha, and ensure she is progressing towards her stage goals without causing harm.

 

Albert, Stage II, Family, Affect Regulation

Albert lives with his aunt and uncle. He is in Stage II and this is your 3rd family meeting. From the beginning, aunt has requested he be moved to therapeutic foster care, unaware that some of Albert’s mood fluctuations are a result of the family system. Albert has been diagnosed with ADHD and has broken a few dishes and a chair since you started meeting with the family. The uncle drinks frequently and Albert’s outbursts coincide with alcohol related outbursts. Additionally, Albert has a history of abandonment and his parents are no longer involved in his life. During individual therapy, Albert admits he is often unable to control his anger and has had trouble sleeping recently. He has a few friends but no one he is close with. When you try to gauge whether the aunt and uncle have motivation to change, they impatiently bring up the idea of foster care.

Questions to consider:

Are there pro-social opportunities in which Alex can get involved? Would he consider joining a sports team or other intramural activity? How can he gain a sense of belonging outside of home?

Have you tried talking to the aunt and uncle about their lives apart from Alex? Showing interest in them could foster an engaged relationship that would allow them to feel more comfortable participating in the treatment process.

Could there another diagnosis besides ADHD? Could you screen for other signs of depression or bipolar?

 

Rashawn, Stage II, Crisis at school, Trauma

At school this week, Rashawn got angry during class and walked out. He was not cooperating with his teacher and the teacher grabbed him and tried to make him sit down. Rashawn responded by screaming and cursing and nearly punched the teacher. The school called you after Rashawn had calmed down a little bit and was sitting in the principal’s office. Rashawn was verbally and physically abused by an aunt from the age of 7 to 9. He has no other trauma history as far as you know.

Questions to consider:

Is the school and the teacher aware of Rashawn’s safety plan?

Have the teachers had trauma-informed training on how to handle crises?

Does Rashawn recognize when his emotions are escalating?

Does he feel comfortable or able to call you or another support person when his emotions start escalating?

 

After this meeting, you have time with Samantha and her family,  Matthew and his grandma, and with Rashawn, individually. Additionally, you have group tonight so after staffing, you get ready to hit the road to meet up with Samantha. You take a few minutes to make sure you and the other therapist are on the same page about the group agenda tonight. You are excited to hear updates from the kids. Looking forward to a full day!

Thank you for reading more about what the day to day is like for our TASK clinicians. The research projects are still underway. We are currently revising the project plan in order to incorporate more preliminary steps before a more rigorous investigation. The therapists, business team, data team, and countless others have become a cohesive, engaged working group as we bring together our questions, experiences, and expectations for this project!

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