Heather McLean

1. 1. As the Vice Chair for Quality in Duke University Medical Center’s Department of Pediatrics and Medical Director of Quality and Safety for Duke Children’s Hospital, what advice do you have for pediatric hospitalists that want to improve quality and safety in their day-to-day work?Hospitalists are in a great position to improve quality and safety for patients. As leaders of the healthcare team working in a high risk environment, we have a great opportunity to understand problems and use quality improvement (QI) methodology to enact change. I recommend seeking out QI/safety training whether it is in your local hospital/department, at national (like PHM!) and regional conferences, or on-line such as the Institute for Healthcare Improvement (IHI Open School). Next, I would look for opportunities to participate in QI projects or collaboratives (such as Value in Pediatrics, Solutions for Patient Safety, or Children’s Hospital Association). Honestly, the opportunities are endless--use your passion and interest to find a problem you want to improve. Seek advice from your local QI team or reach out to your PHM colleagues across the country for guidance--there are many QI experts and mentors around who are happy to help you out!  
   
   2. You developed an “Introduction to Quality” module for faculty as a pre-requisite for submitting QI projects at Duke. Some physicians think QI projects and MOC 4 projects are “busy work”—what’s your approach to teaching others about this meaningful work? My approach to changing the “hearts and minds” of physicians is to first understand that broad acceptance of QI by physicians requires culture change which takes time. I personally start with the “early adopters” to develop a strategy. Although I am very enthusiastic about QI, I know I can’t do this by myself, and I have worked hard to build a QI posse of experts & collaborators in my department. Together, we developed a MOC portfolio program, sponsored and mentored QI projects, and created an online QI educational model using PDSA to meet the needs of my department. We listened to faculty feedback and made changes to improve acceptability our QI curriculum. For example, we first developed a low-tech voice over PowerPoint “Introduction to Quality” module because faculty told us that the IHI Open School modules took too much time and they didn’t want to come to workshops. Over time, we have created a better version of “Introduction to Quality” with colleagues in the Duke PA School and Department of Family Medicine (open to anyone to use).  We have also launched our own longitudinal QI course (Improvement Science Leadership Course) adapted from Cincinnati Children’s Intermediate Improvement Science Series (I2S2) this past year so we can continue to build our own internal QI capacity.
   
   3. A project of yours titled “Eliminating Surgical Site Infections at Duke Children’s Hospital” won the Rebecca Kirkland Award for best abstract at the annual Duke Health Quality and Safety Conference. Can you tell us more about this project? My role in this project was as a QI mentor to a team of anesthesiologists, surgeons, pediatricians, and administrators working to reduce harm from surgical site infections (SSI). These individuals represent our SSI Hospital Acquired Condition (HAC) team which is a part of our Solutions for Safety work at Duke. I helped them apply quality and safety methodology to measure, understand, and use PDSA to implement change. The key to this teams’ success was to adhere to an all-or-none evidence based bundle which led to reduction in SSI.
   
   4. As a member of the group who composed the widely known “Choosing wisely in pediatric hospital medicine” list from the Journal of Hospital Medicine in 2013, how do you think we’re doing with those five opportunities? And what would you put on a new Choosing Wisely list for pediatric hospital medicine? What a great privilege to participate in the PHM Choosing Wisely list in 2013 with some very distinguished hospitalists! Across the country, still have work to do to reduce unnecessary testing in our patients and the answer depends on your local practice performance. I am guessing there is a great deal of variation across hospitals if we measured performance for each of these five opportunities. I would add use of routine labs to the list for consideration.
   
   5. You have spoken and published about your quality improvement initiative to improve pediatric health care worker hand hygiene. What were some of the keys that not only increased hand hygiene compliance but also sustained it? Our project team implemented several different types of interventions to reach our goal. One key part of this project was to select higher reliability interventions such as the use of hand hygiene champions. Performance was sustained primarily due to the culture change we were able to affect as a result of this project. Compliance with hand hygiene protocols is “just what we do”.
   
   6. An asthma pathway you implemented improved length of stay at your hospital both on the pediatric floor and in the PICU. There is newer research to suggest its okay to discharge patients once getting albuterol every 3 hours instead of waiting until every 4 hours. What is your current practice? Do you think there are other ways to improve asthma care and LOS in the hospital? Sounds like we need to make some changes to our asthma pathway to consider this new evidence! There are always ways to improve asthma care. One of my colleagues at Duke has been working to improve the transition of care to home and implement the use of a road map for parents to enhance learning and communication. Pulling all of the pieces of ambulatory primary/specialty care and population health management into the hospital care would be great. The focus would then shift from reducing LOS to improving asthma control at a population health level and reduce therefore admissions in the first place.
   
   7. You are a physician champion for your hospital’s electronic medical record. Many physicians complain that their EMR requires “lots of extra clicks” and slows them down in their practice. How have you been able to use your EMR to make you more efficient with your work? Well, I used to be an Epic champion but I don’t do that anymore. I agree there are “too many clicks” and I think QI projects should involve streamlining workflows to improve hospitalist usability. Maybe we should add EMR waste to the “Choosing Wisely” list?!? I hope we will continue to see improvements in the acceptability and usability of EHRs over time.
   
   8. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents? Find joy and humor in your daily work. We work in dynamic villages and cultivating community mitigates against burnout. As I’ve gotten older, I am more and more comfortable being silly and it helps me thrive. Stay safe and well out there my friends! Those are my “2 cents”.