Quality Improvement in Healthcare Episode 4: QI Chiefs and the impact of COVID-19

Erik Anderson: All right, and we are here. My name is Erik Anderson and this is the Residence podcast. We're doing a bit of a special mini series here on quality improvement specifically in the health care field. And we're working with the student org at Baylor College of Medicine, the Institute for Health Care Improvement. And I'm going to let our student representative Jinna take it away. So, Jinna, you want to introduce yourself and the faculty?

Jinna Chu: Yeah, hi. My name is Jinna and I'm a current MS3 at Baylor. So today we have two invited guests with us. First we have Dr. Cai. She's the current chief resident for quality improvement at Baylor. And we also have Dr. Nowalk, and he was a former chief resident for QI and currently a hospitalist at the VA at Baylor.

Dr. Nathan Nowalk: Good to be here. 

Dr. Cecilia Cai: Hi, everyone. I'm happy to be here as well.

Jinna Chu: So I guess we can just go ahead and start asking some questions. Our first question that we had for you all was how did you become interested in QI?

Dr. Cecilia Cai: I can start. So I actually became interested while I was a medical student at Baylor. Some of my friends were in the IHI chapter, and they introduced me to the concept of QI. And I thought that was really cool that we can improve the care that patients receive and their safety as well. Actually, as a medical student, I did a research elective with Dr. Naik at the VA. He's one of the QI experts at Baylor and I was really interested in it afterwards, and then continued that interest in residency and learned more about QI through our residency curriculum.

Jinna Chu: Ok, that's very cool. What about you, Dr. Nowalk?

Dr. Nathan Nowalk: Ok, so I actually came about a little differently. I didn't discover QI really until the second year of residency. My medical school didn't have as much of an emphasis on QI and patient safety. I think that's changed since I graduated as it has changed across many universities and medical schools.

Dr. Nathan Nowalk: So for me, I didn't find it really until that second year when we do our internal medicine QI curriculum. And in doing that, and having already done some research in some other areas, I felt like this was an area that I was very interested in. It spoke to me quite well. 

Erik Anderson: So I just have a quick question – just in your perspectives. What is, and for those of us who might not be completely in tune with this, what is quality improvement pertaining to health care?

Dr. Cecilia Cai: I can talk about that. So quality improvement is improving the existing operations and processes in the hospital to improve the quality of the care that patients receive and what we call the value of the care they receive. So not only that outcomes are good, but that it is the most cost efficient for the patient as well. And there's also a big emphasis on patient safety as well. So providing the best, safe care for the patients. So it's a little bit different than research because research usually has randomized control groups or something. In research you're trying to innovate something new and quality improvement is not always innovating new things – although sometimes you can create new processes. But it is a lot about improving existing processes.

Erik Anderson: Gotcha. But do you generally do it… I mean, you brought up the research sort of example… Do you try to do it kind of one variable at a time, or is it more just you isolate a few things that need to be changed at once and make the change and then sort of see how, I imagine, you have outcomes that you're measuring?

Dr. Cecilia Cai: Right. Yeah, I think you bring up a good point. And often people get confused between QI and research. So yes, you're right. Doing research, you kind of isolate different variables. You prioritize one thing at a time. For QI, you can actually do multiple things at once depending on what you think is the most impactful. And it's an ongoing improvement. We do what we call different cycles of improvement. So it is just kind of ongoing, and you test the change and you continuously see the results at the same time. So research has a more defined start and ending point, but QI is kind of a continuous process of change. I think Dr. Nowalk can also speak about this, too.

Dr. Nathan Nowalk: Yeah. So I think your description was really, really well said. I'll also add that it can occur outside of the hospital. So really in any health care or any health care setting, really. It's about recognizing the quality gap that we see between what we intend to do or maybe what the evidence tells us based on this research you're referring to in the clinical research, basic science research – all these other areas. But yet we're not seeing done in our patients care, whether that's the patient in front of us in that small area, that micro level or on a macro scale. And it does have lots of overlap into other areas of research. I think of health services research as a big one, HSR, that you see quite a bit of people who have their foot in QI and also in health services research. I think that when it comes to QI, you're right, it is very much a continual process. It doesn't have really an end point. However, you can define some endpoints and still publish and still contribute to the literature. There's obviously gigantic areas of literature within quality improvement and it is considered an academic arena by all means. Every major conference has got some form of QI submission opportunity. And every journal, usually even very high impact journals, has some form for QI. Some are completely devoted to QI. So still a very academic area.

Erik Anderson: I see. Thank you.

Jinna Chu: So, Dr. Cai, you're currently the QI chief. And Dr. Nowalk, you are a former QI chief. Why did you all apply for it and what was the process?

Dr. Cecilia Cai: I can start first. So to become QI chief. This is a position offered through the national VA system, and there's some clinical sites across the country that have this position. So not all residences have this position. It has to be affiliated with the VA. It's paid by the national VA office. So for us at Baylor, we can apply to become QI chief within internal medicine as a second year resident. It's usually during the spring of second year – the application process. I applied because I thought it was a great opportunity to learn more about advanced QI techniques. And as Dr. Nowalk mentioned earlier, there are more advanced QI methods that are more research related. And so I wanted to learn more about that and how to apply it to my clinical practice in the future. And also wanted to have an experience to be a leader in the hospital and within the residency. And basically, there's a process of application. They ask for your CV, references, the personal statement of why you want to be a QI chief, and then you go on several interviews.

Erik Anderson: So this is QI pertaining to the VA specifically, or is it more generally like where you are working?

Dr. Cecilia Cai: Yeah, that's correct. So our position specifically, the chief resident quality and patient safety is a position offered through the National VA Center for Patient Safety. It's actually a national program, and we have a set national curriculum that actually goes with it. So there's an educational component as well as like a practical component where we do our QI project.

Erik Anderson: Oh, wow. 

Dr. Nathan Nowalk: Yeah. So I think just from discussing it at different interviews for fellowship, which is really where I found different versions of the chief medical resident. There is more and more push within chief medical residents to have a QI designation or some recognition of quality improvement within their curriculum. And often they will have a chief medical resident take on that title of, you know, there's an ambulatory chief and there's also a QI chief and there's this hospital's chief. So although it's not VA funded, as Cecilia and I were part of a program that's definitely the most long-lasting. Actually, I think this is the eighth year technically at Baylor. This is the eighth year that we've had a QI chief that's funded by the VA. The program itself is a little bit older than that, although our Houston VA is one of the largest and one of the earliest ones to have this position. There's other versions of this at other residencies that aren't VA funded by the VA's Office of Academic Affiliations. This was originally started by the V.A. National Center for Patient Safety and Dartmouth Institute – the whole national curriculum Cecilia was mentioning. And it has expanded into other specialties. So you could do QI chief within your general surgery residency now and your psychiatry, your radiology, anaesthesia – they all could do QI chief years, or as part of their training, and be funded through the VA. And I think now there's 66 internal medicine QI chiefs as of last year across about 60 centers. So it's definitely a national program, and it's recognized by many residencies because of it.

Dr. Cecilia Cai: Yeah, I think they're actually expanding it to more than one hundred residents next year. 

Erik Anderson: Oh, wow.

Jinna Chu: Oh, wow, that's awesome. So what role does the QI chief have for graduate medical education or residency?

Dr. Cecilia Cai: I think they play a major role within the GME community. So every residency is required to have a QI curriculum for the residents. So no matter what residency it is, whether it's internal medicine, surgery, radiology, the Accreditation Council for GME, the ACGME, basically requires all residents to complete QI training and patient safety training doing their residency. And so the QI chief at Baylor, in our internal medicine program, we teach the residents about QI and patient safety. We are in charge of their curriculum. We're also mentoring them for their own QI projects. And we kind of help them along the way for their projects. And we also, at the same time, advocate for the residents at the different hospital levels or different things that come up.

Jinna Chu: Oh, that's really cool. Do y’all support residents that are doing QI projects at the VA or it’s at any of the hospitals here at Baylor?

Dr. Cecilia Cai: At any of the hospitals.

Erik Anderson: Ok, I was wondering because you say a QI year but this year you just mean that is the amount of time that you're the QI chief and doing the curriculum, but it's integrated with whatever year of residency you are in. It's not an extra year, correct?

Dr. Cecilia Cai: Oh, that's correct. Yes. So our QI chief year is an extra year after residency, but the QI curriculum itself is for the residents throughout their residency, specifically during their second year. They have their QI curriculum.

Erik Anderson: Oh, the QI chief is an extra year after your residency finishes. Gotcha.

Jinna Chu: And is this QI curriculum standardized across the nation?

Dr. Cecilia Cai: No, it's not. No, Dr. Nowalk, you may know more about that.

Dr. Nathan Nowalk: Sure. Yeah. So I think if you're talking about the VA affiliated QI position, by OAA, the VA Office of Academic Affiliation, then that absolutely does have some standardization to it. As Cecilia was mentioning earlier, there is a curriculum that's nationalized that we are following. We do monthly meetings, actually twice monthly, where we're actually learning QI ourselves and we're sharing these online lectures with other QI chiefs at other VAs. However, the idea of a QI chief is really not standardized. And in fact, even the VA version, they like to keep it as open as possible, really to not box you in and allow you that freedom to take what you want with the position. And as I said earlier, you'll have QI chiefs in anesthesia, mental health, surgery, and other areas. So they really don't want you to be too closed in as far as, like you said, standardization. But we'll all receive like a certain amount of training that's expected with it. 

Jinna Chu: Ok, very cool.

Dr. Cecilia Cai: And Jinna, I don't know if that answer your question, but the residents’ QI curriculum is also not standardized across the nation. There are some basic requirements that the residency has to meet. So a lot of the QI curriculum and residency addresses those objectives. But it is depending on the residency programs themselves. And they also actually use a lot of IHI materials that are online to plan for those curricula.

Jinna Chu: Hmm. Ok.

Dr. Nathan Nowalk: Yeah, I agree. IHI is probably the most widely used, I think, because it's such a smaller form of QI modality that I think can be easily disseminated and practiced to within your residency. Some of the other modalities are long term courses and things like that. That would require a lot of commitment. But I think the QI curriculum could be easily developed off the Institute for Healthcare Improvement Model for Improvement. So, yeah, to second what Cecilia said, I think that this QI curricula across the different residences are open and the ACGME wants to keep it that way also. So that that's the fun part. Like if we made it so that every resident had to see a certain number of patients of a certain type. “You must see so many pneumoniae to graduate”, then you may not get that flexibility that comes with working in different health care systems. And the same is true of QI. They want to allow us to take advantage of what makes our resident unique, so the curricula are all open as well.

Jinna Chu: Ok, that's awesome. So have y’all seen any changes in your role with the covid-19 pandemic that's going on currently?

Dr. Cecilia Cai: There's definitely been a lot of changes for me as a current QI chief. I still have some clinical duty as an attending at the VA, so I round with the residents. But the rest of my time I'm working more remotely at home now just because they try to not have nonclinical people at the hospital. So when I'm at home, I’m working from home. I'm attending different hospital meetings that are all online now on. On zoom. Lots of zoom meetings. I do a lot of emails with leaders about anything that comes up.  Any issues, they want me to help with. I coordinate with the residency about the different resident projects that were delayed or they need to be presented. So I coordinate with the residency for the different resident project as well.

Erik Anderson: Actually, so that kind of answers the question that I had of what the year as QI chief kind of looks like in terms of how much clinical work are you doing, alongside I guess, your responsibilities as the chief. What's your time breakdown between nonclinical and clinical responsibilities?

Dr. Cecilia Cai: I think that's a great question. So we actually wear a lot of hats. So clinical is only a small part of what we do. As for the national VA CRQS requirement for us, we just do eight weeks of inpatient clinical work. So during that period I round as a normal attending at the hospital with the resident team. I also can moonlight, meaning take on extra clinical shifts at other hospitals. So I do some moonlighting at Ben Taub as well. So that's extra clinical work. But other than that, I'm also an educator. So we do the educational curriculum, as we talked about, for the residents. We do different educational conferences for the residents as well. I'm also helping with administrative stuff in the hospital, so I attend different hospital administrative leadership meetings for the different hospital committees, for patient safety, or for what we call inpatient discharge committee. There's many hospital committee meetings that I go to. At the same time, I'm also doing my own QI projects, and I'm also a learner as well. As Nathan talked about, we have the national VA QI curriculum that we attend. We have monthly meetings for those educational sessions. And at the same time, trying to apply what I learned to my own QI projects, because that's more like research/QI projects.

Dr. Nathan Nowalk: Yeah, so I agree with Cecilia. Just to summarize, you could be an educator of both medical students, allied health students and residents. You are a researcher, conducting QI projects and contributing to literature, if you will. And then you're a learner yourself, going through a curricula and then encouraged to continue learning even outside of the curricula that the VA gives you. And then you're a clinician, even still in whatever. You know if you’re internal medicine, in our case, it would be quite a few weeks of wards. I think my year we did eight. I believe Cecilia did eight as well. So that's a fun experience, obviously. And then you're also an administrator contributing to committees and the day to day that goes on at the VA.

Jinna Chu: And can you tell us about some of the QI projects or any innovations that you've had to implement because of COVID-19?

Dr. Cecilia Cai: I can talk first. Though, I help with several different QI initiatives during the COVID-19 pandemic that’s happened. One of the major things I worked on was kind of improving the discharge processes for COVID patients, or patients who are still having their COVID test pending at discharge. So I work with different hospitals, the primary care doctors, nurses, case managers, social workers, I.T. people. And we all kind of created a comprehensive follow up plan for these patients at the VA when they're ready to get discharged. It's been working well so far, so I was happy to help contribute with that. I know Nathan has been on the COVID task force, so he is definitely more in tune with all of the COVID projects at the VA, so I’ll let him talk.

Dr. Nathan Nowalk: Yes, I wouldn't say I was more in tune. I thought your work on the discharge side was really, really impeccable. It was a huge part of a very gigantic question mark for our hospitals group in an outpatient setting. So she was huge in working with our IT specialists, and working on getting appropriate discharge criteria fulfilled, and making sure that these COVID patients were leaving safely, and that their tests and so on were followed up. From my perspective, I was working, as you mentioned, on the COVID task force, which was a multidisciplinary task force. I was the hospital's representative for it at the Houston VA. The other representatives were of the nursing, the pharmacy, et cetera, and then some other ICU leadership, some other physicians –  many other physicians also on there as well. But I was representing hospitalists and as mentioned earlier, that experience as an administrator - leading other committees or participating in other committees - really does benefit you when you enter as a faculty in terms of continuing such administrative work. And that's kind of what I was doing with the COVID task force. I personally am interested in pulmonary critical care. I’ll be going into fellowship for pulmonary critical care at the University of Chicago this summer. And so for me it was a really nice overlap between my clinical interest and also my QI interests. So the task force was fantastic. The two biggest projects I was directly involved in, although I kind of have my hands in a few things, the two biggest were by far redefining how we safely do rapid responses and how we safely do a code blues with all the new PPE and everything, and making sure that our staff of every type - whether it be trainee on the ACGME side or our nursing, et cetera, anesthesia, everybody - is prepared for protecting ourselves and that we can still continue to deliver very good care in these rapid responses and code blues despite the concern for covid. So that was really my probably biggest project of the COVID experience. So it's really part of the covid preparedness, if you will. 

Erik Anderson: That's all very interesting, and it was making me think. I know we talked about endpoints, maybe, it might be a semantic thing, but I'm just wondering about, like, what are the criteria that you're choosing to determine? Like, if your plans are successful? For example, Dr. Cai with your discharge summaries for figuring out, like, we're going to implement this so that we're discharging everybody safely. Do you have to, I imagine, you have to come up with something to measure that by – or maybe I'm getting caught up on the research again.

Dr. Cecilia Cai: No, no, that's great. Actually, in QI we use something called measurers

Erik Anderson: Okay, so it was a semantic thing.

Dr. Cecilia Cai: Yeah, yeah we do. We do use measures, and there's different types of measures that you use in your QI projects. So, for example, what we use process measures for is to measure whether the process is actually working. Like are people actually doing the things we asked them to do? What is a percentage of the time that patients are people are actually doing this process correctly? So for example, for our discharge improvement, we measure that by whether -  people are one part of a process - is that when providers are discharging a patient, they have to call the hospital physician assistant to make sure that the physician assistant knows his patient is getting discharge, so she can record it on a follow up master document. So one way we track that is to see when these patients are discharged, are they really calling this person? Is that person really tracking everyone who has COVID who was discharged? And is that person actually documenting these patients’ information and calling on the patient afterwards for a follow up? So that's one process measure that we have. The other type of measures are called outcome measures. So whether… so, that's kind of the final result of what you say of QI projects, whether your QI project has actually changed the outcome that you wanted to change. And for us, sometimes our QI project, it is a little bit hard to define a good outcome measure. And for us, we were thinking we could try to see if the discharge improvement process can decrease readmission or decrease ER visits for these patients. And so that's something we're looking at - a long term outcome improvement.

Dr. Nathan Nowalk: Yeah, So just to piggyback that, when you talk about like measures and points and outcomes, I think we start to mix up the idea of what is research and what is QI.  just to kind of clarify one last time. It still very much follows the beginning, middle, and end within a  QI project. I think the difference between what we're doing in the quality improvement world versus what is being done at the bench or what is being done in clinical research is that whatever we're implementing, or hoping to achieve, is not going to stop right there. It's a continuum. It's going to stay alive in this dynamic system, and you're going to continue to be able to hone it. And our stop, middle, and end points, and all these kinds of things are really just to define a single cycle of change. And so you can still comment on the effect of that cycle of change. And these measures, as Cecilia mentioned, are actually very, very important to define very clearly. Specifically up front, we use something called SMART Aim statement to define these within the model for improvement for IHI. So it does have to be quite specific. And if you've ever heard of things like catheter-associated UTI rates or our rates of this type of infection - things like that - those rates are usually different measures that Medicare or Medicaid are following that are very much QI measures that we try to impact. So there's definitely still an end point to this.

Erik Anderson: Right, right. And can you speak to some of the end points in the projects you discuss or sorry, some of the measures, the outcome measures, I should say?

Dr. Nathan Nowalk: Yeah, some of the measures we would be looking at because our project was really focused on taking something we're already doing that is already very well founded within the literature, in terms of its effect and what it does for the patient - rapid responses, in terms of slowing the clinical deterioration for patients; and then obviously ACLS Code Blue Rescue. So for us, there really wasn't as much of a clinical outcome or even a measure up front other than the adoption of this. We wanted to make sure that this was being adopted. And so for my project, it was much more focusing on an area of quality improvement, which there's multiple areas. But the one I'm very engaged in is implementation sciences. So that's very much focused on how do we get something adopted? How does a group of people accept that? Because there's a large adoption curve in terms of how people take on a new initiative. And so for me, it was the implementation sciences aspect. And so our measures were really more focused on the adoption rate, the performance rate in terms of people having showing compliance or adherence to these new protocols, and then eliminating barriers that were keeping them from achieving 100 percent of following that standard operating procedure. So it wasn't as strong of measures as I would say. And Cecilia’s project, which was a more traditional QI project, this was much more on implementation side where we were taking something that we know we should be doing, but just editing it so that it would stay safe in the time of covid.

Erik Anderson: I see.  Very important, because if the data isn't being implemented, if it's not good data in the first place, and - or you know what I mean, like the if the endpoints aren't good because people aren’t implementing them - how can you interpret anything?

Dr. Nathan Nowalk: Yeah, And this is how I love QI. And this goes back to implementation science, because I think you'll you'll read something in the New England Journal and you'll say, wow, you know, that is a great drug. Why don't we use that drug here? How do we do that? And then you find out that the reason that that study was so successful is because it was so controlled, and it was a very specific population, and it may not actually apply to the patient in front of you, though your patient might actually benefit from it. But we haven't really implemented it, even though it may still be part of the guidelines. And so that's where we start getting into evidence-based therapies, inequality gap. And that's really where a lot of QI can occur, is trying to bring these evidence-based, what we call research-founded approaches, and data to the patient. And so a lot of that is implementation science. And I think that that's a big part of what we're doing in QI is closing the quality gap.

Dr. Cecilia Cai: Yeah, I just want to echo what Nathan said, because I think that's a great point, that we have so much great research already, evidence-based guidelines, but there's still a gap between what we know is ideal evidence-based care and what's actually implemented in real life. As you guys know there are so many challenges in the real hospital setting with operational difficulties and many different things. And that's where the QI implementation science, when it comes in to try to address that gap with what we know that patients should receive and what they actually receive. So to bring that up to standards.

Erik Anderson: It's sort of, I don't know, it’s more, I guess, an existential question. I guess, as a doctor, because guidelines are so important like you were saying. And I think probably we do live in a time where these are being implemented more, and certainly being studied, whether the implementation is happening more than ever before. Is there any talk in QI about sort of I guess you could call it like the… I don't want to call it downside, but there is, I think, something that people lose when they work too much from algorithms and they don't think as much about like… ok,  every patient is their own patient. So you have to sort of juggle the algorithm or the guidelines, if you will, is what I mean, versus this is a unique person and might not fit as precisely into these discrete guidelines.

Dr. Nathan Nowalk: So I'll I'll jump on that real quick. So really, the Institute of Medicine, which is who first started making QI really something we need to pay attention to in America, the IOM, they came out with six aims for improvement as part of a quality improvement in trying to define what would be quality care. And so they defined it as STEEP which stands for safe, timely, effective or efficient and equitable. And then the last is P, which is patient centered. So you definitely don't want to just come out with standardized approaches that work for large groups of people but don't impact the patient in front of you. So we do want to leave as much room for clinicians to continue practicing a patient centered care, but we just want the system to help them achieve those goals.

Erik Anderson: Gotcha.

Dr. Cecilia Cai: And I agree that the patient centered approach will always be there. But the goal of some kind of standardization of procedures is to… For example, a checklist that has been shown to really improve a lot of adverse outcomes for surgery and for many other procedures. And that's the way that we all know that as humans, we all are bound to make mistakes. And so really the standardization of procedures is to kind of help prevent those preventable human errors. And so it's not to make us like robots, but to help us do the work. 

Erik Anderson: Right, right.

Dr. Nathan Nowalk: Many of these evidence-based modalities, you know, they apply for a large percentage of the population. That's why they're guidelines. But we really want the clinician to recognize the guidelines and then say, yeah, but this patient's different. I'm acknowledging this landmark trial study, guideline, whatever; but this patient's different. There are going to be patients who just don't fit into the study.

Erik Anderson: Yeah, that was my big question. So I don't know if you want to do some of the extra ones or if whatever.

Jinna Chu: Well, those are definitely some very cool projects. And it's something that I was actually wondering is how did you identify those issues, or did you think of them before they even occurred?

Dr. Cecilia Cai: That's a great question, Jinna. So I think one thing that's really cool about being in QI is that if you see a problem, you can address it or you can initiate the efforts to start addressing those problems. So for me, when I work as an attending on the wards in March, that was when we first started seeing COVID cases in Houston. And I kind of noticed that for my patient who had COVID, who was getting discharge, that I wasn't sure when he was getting proper follow ups. And I just wanted to make sure that he's staying safe at home after he leaves the hospital. And that's when I brought up the issue with some of the other hospitals. And they had similar concerns. And that was kind of when we altogether decided, “oh, we should start a team to address this problem”, to make sure that these patients are all get proper follow ups. 

Dr. Nathan Nowalk: Absolutely. 

Dr. Cecilia Cai: So definitely kind of on the job learning and identify issues. And it feels really good to be able to do something about it, versus sometimes a lot of times with research, it just takes a lot of time to plan to implement. But QI is really about implementing fast, rapid changes and to see those taking effect.

Dr. Nathan Nowalk: Yeah, I really love Cecilia’s answer because many of our projects do originate with the original operator or leader of the project, and I think that - not to get too existential here - but not to go into other areas. But I do think there is overlap. And I might add, my QI chief from last year, June Pickett, she had a nice way of putting it where you really do start to feel that QI is giving you the toolkit of skills and modalities to impact the world around you and feel like less of a product of that world. And so you kind of have a heightened sense of agency. And with that, you do feel that you can make the change you wish or expect of your patient. If you feel like, why aren't we doing this? This looks as we should be doing this or that. That's because someone probably hasn't come and close that quality gap. And you can do that now because you have been trained and you know how to do it in your environment, the people you need to know, and to lead that project. So I think it even goes into burnout. When we talk about some of the biggest reasons physicians burn out, they often say that they just feel like they're a product of their system and they're not really able to mend it or fix things or eliminate redundancy and adjust their system around them. And I think quality improvement really does give you that toolkit you need to do so. So for me, it's like my own personal antidote to burnout, because I do feel like I can make change happen on a regular basis.

Erik Anderson: Well, that's interesting because that was actually one of the reasons I asked my question, because, I mean, you know, I haven't had nearly as much clinical experience as I think any of you guys on the call. But in my limited amount, it does make you feel like, “OK, so I just need to memorize these guidelines and then, you know, do this process.” But you're saying that maybe that's the thing, like you were saying, to keep in mind is that you can change something if you feel like it's needs to be changed.

Dr. Nathan Nowalk: Yeah. The pendulum could shift so far that we become very bound to, you know, these things that maybe were originally designed with a good intent, like she's mentioned checklists to these types of things. But if they stop working, meaning those measures that we originally used to describe them, and show their effect have become ineffectual. We do actually de-implement in those cases. We start pulling back and readdress the change because it is a very dynamic system. So you're not bound to anything. And the idea of a QI researcher or leader is really not to put everybody in a box and make them follow certain measures and complete certain checkboxes. These kinds of things as an administrator sometimes gets blamed for it. It's not that bureaucratic, I guess, is what I'm trying to say. We actually do encourage the creativity and we want to make the system as good as possible for the patients and the providers. And so you may see a study come across that says how to improve wellness in your residency. Well, that's great. This worked at Ohio State University. Now, how do we implement it here? Well, that's quality improvement, right? That's taking somebody else's research and wellness. And they're now learning how to implement it in your system effectively because their environment was probably different. So that's QI affecting medical education, QI affecting wellness. It can really go outside of the clinical arena as well.

Erik Anderson: Are there many projects - I guess, going back on the COVID project topic - that are targeting sort of quality improvement with telemedicine? Seeing how, I mean, this has become probably a bigger aspect of clinical medicine and maybe had been before.

Dr. Cecilia Cai: Yeah, you hit the nail on the head. There are many different actually telemedicine QI projects going on right now. And actually our VA received a grant recently to improve the telemedicine services at our VA. I think it's through Dr Naik and one of the endocrinologist who applied for the grant and received it already. But there's also talks about improving the telemedicine visits for cancer patients in the heme-onc department. And nationally at the VA. They're trying to improve their telemedicine services, increase their capacity, just because we're relying on that a lot more heavily now. Definitely, yes.

Dr. Nathan Nowalk: I think it's a gigantic area of future health services research. There was already a gigantic trend towards that. Like if you had said that COVID had happened two decades ago. Think of how different our world would be. We would be able to connect on Facebook and do telemedicine at the same level we are able to. So we were in some ways very empowered already by our current tools. But there is going to be a huge paradigm shift going forward towards more telemedicine. And the important thing is that we have health care or health services researchers are already looking at making sure this is effectual, that it is a good change, and that outcomes are still appropriate. We're not like having any quality gaps. And then with that, you start building and more and more quality improvement in terms of how do we continue honing the system and making it more equitable and effective.

Erik Anderson: Wow. And very interesting.

Jinna Chu: Yeah. I love how y’all make QI just sound so empowering and that's honestly why I also really am interested in QI. Do y’all have any tips for medical students that are transitioning into residency where they can maybe try to focus on QI?

Dr. Cecilia Cai: For sure. I think it is very exciting field. There is more focus on QI positions and QI research, I would say over the last decade. Definitely hospitals are paying more attention to QI now as well as residency. As we said, it is a residency requirement. So for any medical students who are transitioning to residency, I would say may first be a good intern, where your clinical skills are at the same time, just keep your eyes open for any type of system issues, patient safety issues that you that you see that keeps reoccuring. And just take note of that. And speak to your chief resident, speak to your program directors and your mentors, and see if there's any way for you to get involved at the hospital level to make a change or to make a QI project so that you can improve some of the deficiencies or problems that you see. And people are very well and open to doing these QI projects. Especially the hospital leaders love it if you try to implement a process that will improve the hospital care. So definitely just keep your eyes open and talk to mentors, try to find QI mentors, clinicians who do QI or have a QI background, and they can definitely direct you to what you can do to help out and to learn more about.

Dr. Nathan Nowalk: Yeah, I would completely agree with what Cecilia said, especially about finding the mentors, which can be a hard part. But I think reaching out actually to the QI Chiefs is a good first step, knowing that this position now exists after hearing this podcast. So I think that whoever the Chiefs are at your residency, I think, can connect you with people who are inclined or engaged in QI. I will also say that we often have students who come to me and say, “you know, I already have an MBA, already have an MPH”; and there's a huge overlap. And these other masters and in fields of public health and business and management, and they already have a lot of these modalities. They were actually exposed to some of this quality improvement training earlier. And it's really just about then connecting you to the project, if you will, the opportunity. And maybe you haven't had enough clinical experience or really exposed to lecture halls. You don't have the clinical experience to say, why aren't we using this drug and heart failure? That's a pretty advanced question to probably ask that, you know, we'd expect more of our residents. So I think what you could then start looking at it, again, talking to people like QI chiefs in different departments that are interested in QI. Like there are a number of different departments at every university medical school. But in addition to that, you could first decide if you want to be inpatient or outpatient, if you want your surgery or medicine. Like some of these big, gigantic questions every medical student faces, and then start just kind of narrowing it down into an area you want to do your work in. And maybe you originally wanted do clinical research in that area where now you can start to look at it as “are there any quality issues that you guys are trying to solve within your department that you think the assistance of a medical student could help or early intern resident could help in terms of fixing?” That's really how QI can be looked at as like fixers. And so I think that that's another area to find these projects. Many times they're assigned to us, like we mentioned earlier, how a lot of it initiates within us and our own personal frustrations. But often you get assigned a project and you at first maybe don't feel as passionate about it. But over time, you start to realize there was incredible need here and you're really glad that you had opportunities to fix it.

Jinna Chu: Well, thank y’all. Thanks for taking the time to do this interview. I really appreciate it. 

Erik Anderson: Yeah, thank you. 

Jinna Chu: There are some really great thought out answers, so thank yous.

Dr. Cecilia Cai: Awesome. This was fun. Alright, thanks.

Dr. Nathan Nowalk: Yeah. Thanks again, guys.