- David Johnson
1. You are the Medical Director of Inpatient Quality and Patient Safety at Monroe Carell Jr. Children’s Hospital at Vanderbilt; tell us how that fits into your work as a pediatric hospitalist.
As hospitalists, we are able to interact with a variety sub-specialists and staff throughout the hospital, with the exception maybe of being in the operating rooms very often. The breadth of our everyday roles can really give a pretty nice 10,000 foot view of hospital systems and processes that we encounter every day. These relationships that I get to build across multiple units and my (at least cursory) understanding of the way things go really allow me to reach out to people who intimately know processes and help me begin to know what questions to start asking when approaching a potential systems problem. So much of quality and safety work relies on listening and learning, and being a hospitalist really provides me a starting point and common ground for many of the issues that we address.
2. You have been involved with several QI efforts surrounding mindful resource utilization like laboratory tests or radiographs. How do you convince providers to move away from these practices? Who is harder to convince--the residents, the hospitalists, the surgeons, the subspecialists?
I love the way these questions are phrased because I think this illustrates a common misperception of QI work. I would say that if anybody tries to start a QI project trying to convince anybody of anything, they better go back to the drawing board and rethink the purpose of the project! I believe, especially in healthcare, that the folks working in our systems inherently want to do to what is best for the patient. As we work through improvement projects, it is our job to create systems that are within their workflows to help them do the right thing. This means that solutions often come from the people who are actually doing the work. So if you want to improve a process that involves residents or hospitalists or surgeons or subspecialists or nurses or supply chain or whatever, start by asking them where they see issues with the system instead of trying to convince them of anything. Our work around reducing unnecessary laboratory testing and CXR reduction in asthma incorporated priceless ideas from residents, fellows, hospitalists, ED colleagues, respiratory therapists, laboratory personnel, and on and on.
3. What advice do you have for someone who has an idea for a QI project but doesn’t know where to start?
Step 1 of any good QI project is to begin with a SMART aim statement. A good SMART statement will provide you and your team with a concrete and measurable goal that will act as the starting point of everything the team does. It answers exactly what you want to accomplish, which not coincidentally, is also the first question in the Model for Improvement. As “fixers” in healthcare, we often want to start with an intervention because we all know exactly what we need to do to fix a problem (spoiler alert: no we don’t!). Take the time to flesh out your SMART aim with operational definitions for your measures if they are needed, and then use a framework such as the Model for Improvement to begin to drive change.
4. You not only lead and participate in many QI projects, but you have also published much of your work. Any tips for others that want to publish their work?
Over 90% of the importance in publishing QI work is creating and following through on a thoughtful, rigorous improvement project. This includes using some sort of QI framework (I am biased towards the Model for Improvement), plotting and analyzing your data over time using run and control charts, and annotating your interventions on those charts to provide some information as to how these interventions may have led to the changes you are reporting. Once you have a rigorous project, the publishing part is really about telling the story of what you and your team learned through the improvement process. I think of it as story-telling and part of that story-telling is sharing your failures, because that is how we learn. Don’t be shy about spending a whole paragraph on things that most clearly didn’t work. The SQUIRE guidelines really lay out a nice framework that anybody writing a QI manuscript should try to follow. For any PHM fellows out there that might be interested, Dr. Amanda Schondelmeyer from Cincinnati Children’s and I will be giving a talk about publishing QI in March/April 2021 as part of the PHM Fellows National Webinar Series. We will be giving the same talk on two different dates – exact dates TBD. Come check it out!
5. Can you tell us more about your Performance and Quality Improvement Fellowship you completed at Duke University? And the year-long Quality Improvement series at Cincinnati Children’s Hospital?
These were both career-shaping experiences for me. The fellowship was developed for me to gain some further experience in Patient Safety and Improvement work during my chief year. To the best of my knowledge, this idea was the brain-child of the late Dr. Tom Kinney and Dr. Joe St. Geme who was chairman at Duke Pediatrics at the time (sorry if there were other people involved in coming up with the idea, but I’ve never really gotten a straight answer as to how this came about!). But this was a great opportunity for me to absorb all that I could from the wonderful Dr. Karen Frush, who served as my mentor through the fellowship. Dr. Frush taught be a great deal about systems thinking and Just Culture. After starting at Vanderbilt as faculty, I was encouraged to participate in two year-long quality improvement programs at Cincinnati Children’s – the Intermediate Improvement Science Series (I2S2) and Advanced Improvement Methods (AIM) programs. These were both vital to really accelerating my understanding of quality improvement and have been instrumental in improving care for patients at Monroe Carell Jr. Children’s Hospital at Vanderbilt and in providing me a framework to create an academic niche for myself.
6. Dr. Derek Williams says you are good at “living in quadrant 2”. Can you tell us more about what this means, and how you “live” there?
Ha. This question made me chuckle. This is a concept from the wonderful book The 7 Habits of Highly Effective People by Stephen Covey. Being in “quadrant 2” represents the quadrant of Covey’s 2x2 matrix where you are spending the bulk of your time addressing important/non-urgent issues. The idea is that this gives you the opportunity to be creative, get things done, grow in your skills, and continue to do what you really love instead of continuously putting out fires. I’m the type of guy that prefers to have things done the week before a deadline. That is quadrant 2. In many ways, I think this mindset helps me with my QI work.
7. You were a co-author of “Improving the Discharge Process for Opioid-Exposed Neonates” in Hospital Pediatrics. You developed a discharge bundle—can you tell us more about it? Have you created (or thought about creating) discharge bundles for any other patient populations?
A few years ago, our hospital began to transition children with neonatal abstinence syndrome out of the NICU and onto the hospital medicine teams so that moms could room in with their babies and help with many of the non-pharmacological methods needed to help soothe these babies. This bundle came out of the work. To be honest, I didn’t have much to do with the creation of the CONTENT of the discharge bundle, so I guess I haven’t thought about creating discharge bundles for any other populations. This bundle was developed by the multidisciplinary team that we called Team HOPE that was working intently on caring for these babies. My role was really helping think through the processes, test changes, and assist the team in determining whether changes were making the intended difference. This is one of the things that I love about QI – you don’t have to be an expert in a specific topic to be able to help. But if you have some QI skills and you can team up with subject matter experts working on a project, you can be part of some really amazing projects.
8. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
For those out there trying to figure out their career path or niche or whatever you want to call it, make sure you don’t close too many doors too early. And when you have leaders who are providing you opportunities to acquire more training, don’t try to make up silly reasons not to do it. I didn’t know much about Patient Safety and/or Quality Improvement in medical school and residency. The fellowship just kind of fell in my lap. Dr. Tom Kinney called me into his office one day (I had never met him) and told me all about this fellowship he had created and had approved through our GME office because people in my program could tell I liked thinking about systems and safety. I was hesitant to do it, but so glad I did. Same goes for the I2S2 program at Cincinnati Children’s. Jenny Slayton, who currently leads quality and safety for the entire Vanderbilt University Medical Center enterprise, encouraged me to go and was willing to fund it. I tried to make excuses about how it would be too hard to schedule as I was early faculty and had a lot of service time. Next thing I knew, Kris Rehm (my division chief at the time) called me into her office and told me in no uncertain terms that I’m doing it and she would make sure my clinical time is scheduled around the program. I needed that push from all of those people and, if I hadn’t explored those avenues, there is no way I would have just bored you with 7 answers about the Model for Improvement, control charts, teamwork, and SMART aims. So don’t close doors too early. Be open to trying new things when leaders and people you respect are urging you to do something. And if you find something you love, take it and run with it.
Twitter: @DavidPJohnsonQI
As hospitalists, we are able to interact with a variety sub-specialists and staff throughout the hospital, with the exception maybe of being in the operating rooms very often. The breadth of our everyday roles can really give a pretty nice 10,000 foot view of hospital systems and processes that we encounter every day. These relationships that I get to build across multiple units and my (at least cursory) understanding of the way things go really allow me to reach out to people who intimately know processes and help me begin to know what questions to start asking when approaching a potential systems problem. So much of quality and safety work relies on listening and learning, and being a hospitalist really provides me a starting point and common ground for many of the issues that we address.
2. You have been involved with several QI efforts surrounding mindful resource utilization like laboratory tests or radiographs. How do you convince providers to move away from these practices? Who is harder to convince--the residents, the hospitalists, the surgeons, the subspecialists?
I love the way these questions are phrased because I think this illustrates a common misperception of QI work. I would say that if anybody tries to start a QI project trying to convince anybody of anything, they better go back to the drawing board and rethink the purpose of the project! I believe, especially in healthcare, that the folks working in our systems inherently want to do to what is best for the patient. As we work through improvement projects, it is our job to create systems that are within their workflows to help them do the right thing. This means that solutions often come from the people who are actually doing the work. So if you want to improve a process that involves residents or hospitalists or surgeons or subspecialists or nurses or supply chain or whatever, start by asking them where they see issues with the system instead of trying to convince them of anything. Our work around reducing unnecessary laboratory testing and CXR reduction in asthma incorporated priceless ideas from residents, fellows, hospitalists, ED colleagues, respiratory therapists, laboratory personnel, and on and on.
3. What advice do you have for someone who has an idea for a QI project but doesn’t know where to start?
Step 1 of any good QI project is to begin with a SMART aim statement. A good SMART statement will provide you and your team with a concrete and measurable goal that will act as the starting point of everything the team does. It answers exactly what you want to accomplish, which not coincidentally, is also the first question in the Model for Improvement. As “fixers” in healthcare, we often want to start with an intervention because we all know exactly what we need to do to fix a problem (spoiler alert: no we don’t!). Take the time to flesh out your SMART aim with operational definitions for your measures if they are needed, and then use a framework such as the Model for Improvement to begin to drive change.
4. You not only lead and participate in many QI projects, but you have also published much of your work. Any tips for others that want to publish their work?
Over 90% of the importance in publishing QI work is creating and following through on a thoughtful, rigorous improvement project. This includes using some sort of QI framework (I am biased towards the Model for Improvement), plotting and analyzing your data over time using run and control charts, and annotating your interventions on those charts to provide some information as to how these interventions may have led to the changes you are reporting. Once you have a rigorous project, the publishing part is really about telling the story of what you and your team learned through the improvement process. I think of it as story-telling and part of that story-telling is sharing your failures, because that is how we learn. Don’t be shy about spending a whole paragraph on things that most clearly didn’t work. The SQUIRE guidelines really lay out a nice framework that anybody writing a QI manuscript should try to follow. For any PHM fellows out there that might be interested, Dr. Amanda Schondelmeyer from Cincinnati Children’s and I will be giving a talk about publishing QI in March/April 2021 as part of the PHM Fellows National Webinar Series. We will be giving the same talk on two different dates – exact dates TBD. Come check it out!
5. Can you tell us more about your Performance and Quality Improvement Fellowship you completed at Duke University? And the year-long Quality Improvement series at Cincinnati Children’s Hospital?
These were both career-shaping experiences for me. The fellowship was developed for me to gain some further experience in Patient Safety and Improvement work during my chief year. To the best of my knowledge, this idea was the brain-child of the late Dr. Tom Kinney and Dr. Joe St. Geme who was chairman at Duke Pediatrics at the time (sorry if there were other people involved in coming up with the idea, but I’ve never really gotten a straight answer as to how this came about!). But this was a great opportunity for me to absorb all that I could from the wonderful Dr. Karen Frush, who served as my mentor through the fellowship. Dr. Frush taught be a great deal about systems thinking and Just Culture. After starting at Vanderbilt as faculty, I was encouraged to participate in two year-long quality improvement programs at Cincinnati Children’s – the Intermediate Improvement Science Series (I2S2) and Advanced Improvement Methods (AIM) programs. These were both vital to really accelerating my understanding of quality improvement and have been instrumental in improving care for patients at Monroe Carell Jr. Children’s Hospital at Vanderbilt and in providing me a framework to create an academic niche for myself.
6. Dr. Derek Williams says you are good at “living in quadrant 2”. Can you tell us more about what this means, and how you “live” there?
Ha. This question made me chuckle. This is a concept from the wonderful book The 7 Habits of Highly Effective People by Stephen Covey. Being in “quadrant 2” represents the quadrant of Covey’s 2x2 matrix where you are spending the bulk of your time addressing important/non-urgent issues. The idea is that this gives you the opportunity to be creative, get things done, grow in your skills, and continue to do what you really love instead of continuously putting out fires. I’m the type of guy that prefers to have things done the week before a deadline. That is quadrant 2. In many ways, I think this mindset helps me with my QI work.
7. You were a co-author of “Improving the Discharge Process for Opioid-Exposed Neonates” in Hospital Pediatrics. You developed a discharge bundle—can you tell us more about it? Have you created (or thought about creating) discharge bundles for any other patient populations?
A few years ago, our hospital began to transition children with neonatal abstinence syndrome out of the NICU and onto the hospital medicine teams so that moms could room in with their babies and help with many of the non-pharmacological methods needed to help soothe these babies. This bundle came out of the work. To be honest, I didn’t have much to do with the creation of the CONTENT of the discharge bundle, so I guess I haven’t thought about creating discharge bundles for any other populations. This bundle was developed by the multidisciplinary team that we called Team HOPE that was working intently on caring for these babies. My role was really helping think through the processes, test changes, and assist the team in determining whether changes were making the intended difference. This is one of the things that I love about QI – you don’t have to be an expert in a specific topic to be able to help. But if you have some QI skills and you can team up with subject matter experts working on a project, you can be part of some really amazing projects.
8. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
For those out there trying to figure out their career path or niche or whatever you want to call it, make sure you don’t close too many doors too early. And when you have leaders who are providing you opportunities to acquire more training, don’t try to make up silly reasons not to do it. I didn’t know much about Patient Safety and/or Quality Improvement in medical school and residency. The fellowship just kind of fell in my lap. Dr. Tom Kinney called me into his office one day (I had never met him) and told me all about this fellowship he had created and had approved through our GME office because people in my program could tell I liked thinking about systems and safety. I was hesitant to do it, but so glad I did. Same goes for the I2S2 program at Cincinnati Children’s. Jenny Slayton, who currently leads quality and safety for the entire Vanderbilt University Medical Center enterprise, encouraged me to go and was willing to fund it. I tried to make excuses about how it would be too hard to schedule as I was early faculty and had a lot of service time. Next thing I knew, Kris Rehm (my division chief at the time) called me into her office and told me in no uncertain terms that I’m doing it and she would make sure my clinical time is scheduled around the program. I needed that push from all of those people and, if I hadn’t explored those avenues, there is no way I would have just bored you with 7 answers about the Model for Improvement, control charts, teamwork, and SMART aims. So don’t close doors too early. Be open to trying new things when leaders and people you respect are urging you to do something. And if you find something you love, take it and run with it.
Twitter: @DavidPJohnsonQI