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 are now open at www.futureofhospitalmedicine.org/grant and will close on January 11, 2017.
This is the third in the series from medical student Aram Namavar, MS.
I can’t pinpoint the exact time that I was introduced to quality improvement. Was it when I set foot in Ronald Reagan UCLA Medical Center for the first time as a student volunteer? Or was it during my adolescence when I would witness family members being readmitted too many times to count due to language and cultural disparities, or medication non-compliance?
All I know is that my past experiences have propelled me towards a path of being a quality improvement change agent, and I hope to inspire others along the way. Since I began working with Dr. Nasim Afsar-manesh, my long-term mentor, in January 2014, I have had the honor of participating in and leading a number of quality initiatives—some of which were presented at Hospital Medicine 2016.
My main project in the domain of patient-centered readmissions has three components: the role that decisional conflict plays in hospital readmissions; social determinants of health; and patient-centered views of the cause and preventability of readmission for Hispanic vs. non-Hispanic patients.
I have also partnered with palliative care to explore prognostication conflicts among providers. We have created two cases, which I will be administering to our internal medicine housestaff and faculty to investigate their ability to make an accurate prognosis, recommend next steps, and assess their confidence and conflicts surrounding these decisions.
Stakeholder support and strong mentorship has made it easier for me to navigate the system when creating these projects. To ensure stakeholder buy-in, it has been important for me to have conversations early on, to be transparent, and maintain an open line of communication. I participated on monthly readmissions conference calls with our quality team and informed our administrative nurses well in advance of implementing my study. Through these discussions, I was able to redefine my study aims.
I have supplemented my learning through shadowing our clinical faculty within the Division of Hospital Medicine at UCLA and joining Dr. Afsar-manesh on rounds. This has allowed me to gain insight into the daily activities of a hospitalist and the breadth and depth of clinical knowledge needed to perform at your best.
The most impactful part of the work I have done is hearing patient stories and understanding their specific plight. One encounter that stood out for me was with an elderly Hispanic woman set to be discharged from the ED. Due to the language barrier, the physicians were finding it difficult to teach her how to use an incentive spirometer. With my fluency in Spanish, I was able to ameliorate that barrier and teach the patient what was required of her. Instances like these have raised my awareness of how my unique attributes can be leveraged to decrease health disparities.
It also has been interesting to see a wide range of patient activation — the knowledge, skills, confidence and inclination to assume responsibility for managing one’s health. The following are a sampling of what some patients believe they can personally do to prevent themselves from returning to the hospital: stick to medications; avoid activities involving risks; maintain a healthy diet; go to follow-up appointments.
To date, we have enrolled 175 participants across my four studies. One of my studies is near full completion as I am awaiting final analysis from our Biostatistics team to elucidate any statistically significant results. With this particular project, I was assessing the prognostication ability of our Resident and Attending Physician providers at UCLA. I was also investigating the provider’s confidence, any conflict surrounding that decision, and what their next step would be if encountering a patient similar to the two cases that were presented.
Decisional conflict measures the uncertainty and readiness in making a decision. The literature surrounding decision making in the context of provider’s is relatively premature; therefore, I wanted to investigate it further as part of my summer research. In our prior study, we administered the SURE tool, which is a validated 4-item tool that has been shown to have adequate psychometric properties in assessing for the presence of decisional conflict as it pertains to patients deciding how to obtain medical care post-discharge from the general medicine service.
This tool was validated in an outpatient general medicine population but not necessary in the context of providers; therefore, I altered the validated tool slightly while maintaining the integrity of the questions as there was no closest proxy. Following administration, the SURE tool was scored and any 1 of the 4 questions marked as a “no” (a total score of 3 or less) was considered a positive result for decisional conflict.
By partnering with the Director of Palliative Care at UCLA who is also a hospitalist, we created two cases with a ‘Master Answer’. One was a patient with Alzheimer Dementia and another was a patient with CKD stage 5 who had short-term and long-term prognoses, respectively. While I am still waiting on the full analysis from our biostatistics team, I will detail some general trends and descriptive data. Provider’s generally over-prognostication on their patients (i.e., if there is a patient that has a “weeks to months” prognosis, a provider would state their prognosis as “months to years”). Additionally, providers are generally more conflicted when it comes to making a short-term prognosis (75% for short-term prognosis vs. 63.44% for long-term prognosis).
At the current stage, I have enough data to start writing up abstracts for two of my four projects; however, I want to see these projects through to completion. For that reason, I have enlisted the help of medical students at the David Geffen School of Medicine who are interested in Quality to continue working on these projects. This way, we will have enough data collected to submit abstracts for HM17.
For those who have the interest, the SHM Student Hospitalist Scholarship Grant is one of the best ways to get involved early in quality work and exposed to the field of Hospital Medicine. Here are some take-home messages from when I applied to the scholarship:
- Have an open line of communication with your mentor when determining the project details.
- Apply early to the scholarship, as you may experience some hiccups when submitting your proposal.
- Be thoughtful with your timeline as there may be some pre-work that needs to be completed.
- Reach out to a past winner to inquire about their project and what it takes to be successful.
As my project winds down and I return to Chicago to start my second year of medical school, I want to take a moment to thank the Society of Hospital Medicine for this amazing opportunity to gain insight into the daily lives of hospitalists.
I was able to participate on rounds with the team, lead meetings with our stakeholders, and engage diverse patient populations at two different hospitals. I also gained greater knowledge of the issues of readmissions, mortality, palliative care, and population health.
Most importantly, I solidified my intent to pursue a career in hospital medicine.
Leave A Comment