SQUIRE Blogs
More about the Balancing Act
Susan Mooney
Time
The hardest part is finding the time to sit and look at the data and think. As I try to balance my clinical, administrative and academic responsibilities (not to mention my personal life), I sometimes feel as though I am shoveling waves at the beach. Take today for example. I got out of the OR at 10:30 with the best of intentions to come back to my office and work on this paper. Now it is past noon, the phone has not rung in 5 minutes and no one is standing in my doorway wanting to talk. So, here I sit, an hour and a half behind schedule, trying to write something worth reading.
Balance
It is a challenge to balance my time. It is an even greater challenge to balance the worlds that I inhabit. Having graduated from the VA National Quality Scholars Fellowship and having obtained a Master's Degree from Dartmouth, and working for the SQUIRE project, I appreciate the necesity of bringing some academic rigor to my improvement work. But I work at a very small, rural, community hospital. Many folks here are bright and talented and dedicated to their jobs. And they are far removed from the academic world. Few have any formal training in Quality Improvement. Many have never taken a statistics class. Everyday I struggle with this. When I do an improvement project, do I need to use statistical process control? Or can I be less rigorous? How do I talk about sample size and ANOM analysis without alienating everyone in the room? How do I celebrate someone's success even when I know that the "improvement" they are talking about is really only common cause variation? Balancing between an academic and a non-academic world keeps me intellectually engaged and grounded in the real world. I don't want to be anywhere else. But sometimes I do feel as though I am perched on a very narrow balancing beam.
The Project
It seems simple - all pregnant women should have a urine culture performed during the first trimester as part of routine prenatal care. The thing that interests me the most about improvement work is that the things that seem so simple are so hard to pull off. The local problem (as the guidelines like to call it) that I have been working on is this: Two years ago, while working on my Master's degree, I discovered that not all women who get their prenatal care at APD, get first trimester urine cultures. Interestingly, they do reliably get other recommended care (like a blood type and Rh test). I actually had several goals for this project and, not surprisingly, they have evolved over time. Initially, I set out to pilot test a data gathering methodology that was part of a larger QI project. Once I discovered the aforementioned gap, I set out to try to close it which necesitated that I understand why it existed in the first place. Now I am trying to understand why half the practice got better while the other half did not...And I am trying to figure out what to do about the half that has shown no improvment. Lots to think about, and write about, if I can find the time.
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Who, what, why? Introduction to me, my project, and this blog
Kathy Kirkland
I'm Kathy Kirkland. I'm an infectous disease physician and the hospital epidemiologist at Dartmouth-Hitchcock Medical Center in Lebanon, NH. I also coach residents and fellows in our Leadership Preventive Medicine Residency. Quality improvement, systems thinking, reflecting on what works when and why--these ways of thinking thread through my entire professional life, and I even find it informing my home life, much to my children's eye-rolling.
Until recently much of the type of work I do hasn't really had a place in the medical literature. The typical journal article would tell readers "how much" a QI intervention improved outcomes, and whether it was statistically significant, but rarely could you find out "how" the intervention was done, even by reading the methods section. As anyone doing QI work or wanting to duplicate the successes of other knows, the meat is really in the how.
So, now the SQUIRE guidelines have come on the scene, legitimizing and providing a standard approach to the publication of the "hows" of quality improvement work. And,now, there's no reason not to put pen to paper, or fingers to keyboard to try them out.
I am going to write a manuscript that captures the hows of some work we have done on improving hand hygiene at our hospital. I also intend to write up the "how much" aspect of the work (ie how much did increasing hand hygiene to 88% reduce the rate of healthcare-associated infections). But, using the SQUIRE guidelines, I'm going to try to recreate the steps we took to improving hand hygiene, and provide enough detail about them and the context within which we work, to allow others to build on the work in their own institutions. And I'm going to try to get the manuscript published.
As I embark on this journey, I will use this Blog to reflect on how easy or hard it is to do this kind of writing, how helpful the SQUIRE guidelines actually are...and I hope interact with others who are undertaking similar projects. I'm hoping it will force me to keep writing regularly, but today is Saturday and the first words are going to have to wait until another day.
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The Great Balancing Act - An improvement blog by Sue Mooney
Susan Mooney
Beginning to Work on This
My name is Sue Mooney and I work at a very small, 25 bed hospital in Lebanon, NH named Alice Peck Day Memorial Hospital. Eighteen months ago I finished my National Quality Scholars Fellowship, burnt out on Obstetrics and ready to try something new. APD was happy to have me come back to work in a new capacity - as the Medical Director for Quality Improvement. I stopped practicing OB and carved out time for a Gynecology only practice. I thought I was lucky - now I am not so sure. Two months after I arrived, The Hospital Medical Director quit. No one else was willing to take on the job, so his responsibilities landed on my lap. Today, 18 months later, I have been offered the job of Chief Medical Officer of the hospital. I am flattered and humbled by the vote of confidence and not quite sure that I want the job. The last 18 months have been exceedingly challenging and often frustrating. I spend too much time thinking about the economic survival of the hospital and why Doctors can't sign their medical records. I am overbooked with meetings and I spend too little time thinking about improving the quality of healthcare and even less time with front line quality improvement projects. And yet, I know that I am doing the right job for me and I also know that the QI work I am doing is valuable and should be shared with others.
Where to from here?
Since Fellowship, I have worked for the SQUIRE project. I am quite familiar with the guidelines - I helped to write and edit the E&E. Now I get to see if I can use the guidelines to produce a paper that is worth publishing. During my fellowship, I did an elective that evaluated guidelines for prenatal care. Most prenatal care guidelines are organized by gestational age and very few of the guideline elements are "evidence based". My advisor and I created a methodology for selecting guideline elements for improvement based on the context of the practice. We then used my practice to test the theory. What we found was a low rate of 1st trimester screening for asymptomatic bacteruria (this actually matters because aysmptomatic bacteruria is a cause of pyelonephritis in pregnancy which is a cause of preterm labor and birth. Treatment has been shown to decrease morbidity and mortality). For the past three years, I have been working to improve the screening rate. Over the last six months, I have become convinced that we have improved. I am pleased by this finding and also really concerned. It's just a urinalysis and a culture - what's with the three years? I want to understand why progress has been so slow and I want to know how to make the next project go more quickly. I also want to understand why only half the practice has gotten better. I am hopeful that the SQUIRE guidelines will help me as I reflect on this project and begin the work of writing about it.
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