My QI Story
Tuesday, January 15, 2019
I Cannot Stop Thinking of 'CUS'
Sun Young Kim, MD, PhD
Quality Improvement (QI) was a new term for me when I started my residency. During resident orientation, there was a very impressive lecture regarding QI and why all physicians should take part in it. To be honest, I didn’t know what QI was, but fortunately, I had an opportunity to meet the attending physician who gave the lecture. I was so fascinated that after our discussion, I decided to join the QI department in our hospital.
At that time, our hospital was working on the publication of a QI journal and I became the editor for this publication. We reviewed papers regarding QI and edited some papers and eventually, we were able to publish a journal. We also ran several hospital projects and I had opportunities to present our data at the National Patient Safety Foundation, Association of American Medical Colleges and ACMQ meetings.
Subsequently, I obtained $10,000 from the Committee of Interns and Residents, to educate residents in our hospital on how to start QI. I wrote a simple book on how to start QI, what meetings we can take part in, IRB (Institutional review board) exemption and what types of projects require IRB approval.
I then joined the American Journal of Medical Quality editor committee and reviewed the Q-tip which is the paper written by residents. And I am currently working as a member of the education committee and the student/resident/fellow committee of ACMQ.
I also had the opportunity to join the Telluride patient safety leadership training and was awarded an ACMQ scholarship and Samuel Katims Scholar in Medical Humanism award. These awards were important steps for me because they not only encouraged me to get more involved with QI but they gave me confidence that my work was important and could help contribute to improving patient safety.
As time went by, I learned more about QI and conducted more than 10 projects in my department with resident colleagues and our attendings. Everybody asked me how to start QI. I always answered that it would be very simple and easy if you know the ‘CUS’ which means – I am concerned, I am uncomfortable, and this is a safety issue.
To be honest, in the beginning, I didn't understand why physicians should get involved with QI. I later learned that we are the ones who can identify problems and take the steps needed to fix these problems. If we ignore problematic issues, then dangerous events will happen again and again, affecting patient safety and creating communication issues.
A QI project does not have to be a massive undertaking, it can be based on small things that concern you. I started with small issues; changing the discharge summary and subsequently bridging inpatient to outpatient cares, decreasing the unapproved medical terms showing the data we were using, which could cause communication issues, making set order templates in the NICU for sick babies to decrease the medication error on admission, and so on.
I finished my residency and started my hematology-oncology fellowship last year, and still, I cannot stop thinking of ‘CUS’.
From time to time, when I review the patient’s records in the morning, I find that transfusion reaction panels were sent overnight. Most of the results are negative. I asked senior residents how often they send the transfusion reaction panels. Some of them said ‘never’, some of them answered ‘more than 10 times’. I asked again whether they know the specific indications for sending the transfusion reaction panel or not. They answered only one indication. I went to the nursing charges and discussed sending the transfusion reaction panel. She has more than 30 years’ experience in our unit and has seen many patients who have experienced the transfusion reactions. Sometimes she had a hard time with residents deciding whether we should send this transfusion reaction panel or not. The problem is we don’t have a specified guideline. If we send the transfusion reaction panel more than the patients needed, then what would happen? That could be caused because residents were not educated enough to make the decision, and nursing staff were not sure because they don’t have specified guideline, and they should do extra work especially at night time, and the blood bank should discard the blood which is not necessary, and what about the cost to send this panel and also the discarded blood? Most of all, the patients who are already immunocompromised, they should be approached to send another blood test which might be unnecessary. Also, most of them have a central line, so it could increase the risk of central line infection.
Being a first-year fellow, I was concerned if I had to watch out for this. Would somebody else try to figure this out? Probably not. I decided to raise my hand to bring this issue to the surface. I met with the attendings in the blood bank, nursing staffs, hematology attendings and also residents. They all agreed that this could be a problem. I made a simple QI proposal to make all of them understood why this QI is needed. I asked one of my attendings to help me to make our hospital guideline. I found a very detailed guideline published in Lancet 2016, and we have modified it to tailor it to our hospital’s requirements. Finally, we made our guideline and we were able to start our project. Currently, about 50% of cases meet this guideline, but we are targeting more than 90% in 6 months.
There are several more projects that I have considered, and I would start one by one after communicating with all the departments involved. Personally, I think the most important thing in QI is communicating with staff members involved in the problem. All of them should be on the same page in order to make changes happen.
Doing the QI is simple…changing the uncomfortable problem around you. Because you are working in your hospital, you are the one who can make changes. If you change the improper workload, you can increase the patient safety. That is for sure.
This is my QI story. I want to learn about what your QI story. Let’s talk about our QI experiences and learn with each other. We are the ones who can make changes!
Sun Young Kim, MD, PHD, is an ACMQ resident member, practicing at Indiana University, specializing in public management, organizational behavior, and human resource management.
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