Editor’s Note: Throughout the upcoming weeks, The Hospital Leader will feature posts from SHM’s 2016 Student Hospitalist Scholar Grant recipients describing the QI projects they conducted as a part of their grants. Applications for the 2017 grant open on September 14, 2016 at www.futureofhospitalmedicine.org/grant.
This is the first in the series from medical student Haverly Snyder.
As a student, it can be difficult to feel as if you are making a difference. With the long hours spent studying, I find myself seeking out opportunities to engage with the medical community and affect change in hospital medicine. For me, quality improvement (QI) work achieves those goals by allowing me to see real change at the patient level.
I first became interested in QI during my undergraduate experience at Saint Louis University where I majored in Health Sciences. I was required to take a QI class my senior year and was unsure of how I would feel about it, as it was an entirely new experience. During the semester, we were tasked with writing a white paper on any patient safety topic of our choosing. My group chose to study resident and nurse work hours and their correlation with patient safety. By the end of the semester, I knew that I wanted engage in more QI work when I began medical school.
Upon starting at the Medical College of Wisconsin, I was required to choose a Scholarly Pathway, which allows you to tailor your medical education to your passions and interests. Ultimately, you are required to submit a Scholarly Project, which is based on the work that you have done while in your Pathway. There were eight Scholarly Pathways to choose from, as seen below. Given my interest in QI, I chose the Quality Improvement and Patient Safety (QuIPS) Pathway.
After doing some research online and obtaining some suggestions from the QuIPS Pathway directors, I met with Dr. Kathlyn Fletcher to see if she would be interested in being my Pathway advisor. After discovering that we held the same interests within QI, we decided to develop a project together to dig deeper into how patients experience their hospitalization, focusing on aspects that made the stay challenging and those that were particularly helpful. Patients often leave the hospital less able to take care of themselves than when they entered. This is what we wanted to understand more about – what makes hospitalization particularly stressful? We can speculate as to what patients may perceive as stressful, but we believed that talking to real patients would provide more meaningful feedback and could illuminate areas we had never considered. This was the basis of our project – a qualitative study aimed at identifying aspects of hospitalization that are particularly stressful for patients towards which QI efforts can be targeted.
My qualitative study sought to understand hospitalization from the patient perspective and discover what patients would like improved through their hospitalizations, as there is currently only a small body of literature surrounding this topic. We can certainly make educated guesses about areas we think they may say need improvement, such as sleep quality, food quality or a feeling of loss of autonomy. However, until we ask them directly, we will never fully understand.
In the study, we interviewed 15-20 patients, with 2-3 interviews per week. In order to be eligible for participation, patients must have been at least 18 years of age, an inpatient of a general medicine team, and within two days of discharge. They were also required to speak English and be able to give informed consent. We wanted patients to be near discharge in order to obtain a full view of their hospitalization from start to finish. Interviews were recorded and then transcribed verbatim. After transcription, we uploaded the transcripts into a qualitative analysis software, where we used a self-developed coding scheme to search for emergent themes.
As my project progressed, I noticed a thought-provoking trend. I often asked my subjects an open-ended question, such as, “talk to me about your nights here.” Sometimes I received an answer with some specifics. However, I frequently received a response along the lines of, “It’s fine.” Upon receiving this response, I would then try to elicit a deeper discussion by asking them to explain further. After a few minutes of discussion, I would often get some form of a second response typically along the lines of: “What’d you expect? I’m in a hospital.”
The first few times I encountered this response, I was unsure how to move forward or how to dig deeper and discover how to learn more about that sentiment. It seemed as if patients were not happy about certain things, but felt as if these were things that just had to be tolerated – that they were just part of the hospital experience.
After discussing this phenomenon with my mentor, she agreed that it should be explored further in subsequent interviews. Since then, when I encountered this response from a patient, I instead asked them, “What if it didn’t have to be that way? What would ideal look like?” This turned out to be a very interesting topic about which I received numerous responses and suggestions.
I found that patients often became a bit more excited when I asked this question. They took a minute to consider their response before actually giving it. I hope that this question made them feel that they have the power to make real change and that I am truly listening to them and wanted to hear their honest opinions.
After exploring this further, I spoke with several colleagues and found that two schools of thought existed regarding patient tolerance. There is one group of people that believes that this is an area for improvement. There is another group that is hesitant; they wonder that if patients are not complaining, is it harmful to make them think about it? Would it raise false hopes?
This surprised me. All physicians want what is best for their patients and strive to provide the best care possible. So shouldn’t we work to provide them with a hospital experience that they are truly happy with instead of one that they merely tolerate? In order to provide truly excellent care, we must commit to thinking about patient care from a new angle – one in which we are open to creating an experience for patients that is as enjoyable and comfortable as possible and not one of which they are merely tolerant.
In analyzing preliminary interview data, three main themes have emerged: environment, hospital personnel and patient factors. Each theme has several subthemes within it. There are also subthemes that span across two or three of these themes, such as patient-provider communication. These themes and subthemes contribute to how patients experience hospitalization and the feelings they have towards their stay. These feelings range from anxious and overwhelmed to appreciative and trusting.
As my summer research comes to a close, I find myself reflecting on the work I have completed thus far. Having the opportunity to engage with patients to understand how we can improve their hospital stays has been extremely eye-opening. It taught me how to better engage with residents and attending physicians.
With the busy life of a medical student, it can be easy to become removed from the patient experience. It can be easy to settle for what is just “okay” for the patient instead of what is most comfortable for them. Settling into a routine may make the life of a medical student easier, but not every patient prefers things done the same way. For example, one of the most prominent topics of discussion I have heard this summer has been surrounding care team size. Some patients enjoy when the entire care team does bedside rounds, as it provides them with an opportunity to learn and engage with their team. Others, however, find it very overwhelming. Discussing this aspect of the hospital experience with patients has made me aware of how important it is to understand what is most comfortable for them, and I have learned that there are different ways to accomplish these tasks for different patients.
The conceptual model we are developing will explain the patient experience from the patient perspective. Once complete, it can serve as a framework for future quality initiatives at our institution and other institutions. It will provide an excellent place from which individuals can start if they want to study one or more themes in greater depth, leading to targeted QI initiatives. I am looking forward to finishing data analysis, developing the final conceptual model and sharing my results at Hospital Medicine 2017 in Las Vegas in hopes of providing a groundwork from which we can work to produce meaningful change.