Aram A. Namavar

Leveraging lean principles in creating a comprehensive quality program: The UCLA health readmission reduction initiative

INTRODUCTION UCLA Health embarked to transform care by integrating lean methodology in a key clinical project, Readmission Reduction Initiative (RRI). METHODS The first step focused on assembling a leadership team to articulate system-wide priorities for quality improvement. The lean principle of creating a culture of change and accountability was established by: 1) engaging stakeholders, 2) managing the process with performance accountability, and, 3) delivering patient-centered care. The RRI utilized three major lean principles: 1) A3, 2) root cause analyses, 3) value stream mapping. RESULTS Baseline readmission rate at UCLA from 9/2010-12/2011 illustrated a mean of 12.1%. After the start of the RRI program, for the period of 1/2012-6/2013, the readmission rate decreased to 11.3% (p<0.05). CONCLUSION To impact readmissions, solutions must evolve from smaller service- and location-based interventions into strategies with broader approach. As elucidated, a systematic clinical approach grounded in lean methodologies is a viable solution to this complex problem.

Academic characteristics for successful national institutes of health funding in dermatology

Background: The National Institutes of Health (NIH) is a prominent organization that provides funding to academic scholars for research opportunities in the field of medicine, including dermatology. Objective: The purpose of our study was to identify academic characteristics in successful NIH funding in the department of dermatology. Methods: The following measurements of scholarly productivity were assessed to examine if there is an association with higher funding: number of publications, H-index, leadership positions in dermatological societies, gender, academic rank, and degree type. Results: After examination of all full-time faculty members in the department of dermatology receiving NIH funding in 2014, the study found that the number of publications, leadership in societies, and H-index are correlated with higher NIH funding. Limitations: There is a lack of information on whether faculty that did not receive NIH funding for the year of 2014 actually applied to be funded and were rejected, or chose not to apply for funding at all. Conclusion: Scholarly productivity is an important factor in securing NIH funding. The study also found that the degree type does not influence NIH funding, suggesting that faculty with all types of degrees are equally productive in academic dermatology. Correspondence to: Aram A Namavar, Stritch School of Medicine, Loyola University Chicago, Chicago, Illinois 60153, USA, E-mail: ANamavar@luc.edu Received: April 21, 2016; Accepted: May 30, 2016; Published: June 01, 2016 Yaghoubnejad R (2016) Academic characteristics for successful national institutes of health funding in dermatology Glob Dermatol, 2016 doi: 10.15761/GOD.1000181 Volume 3(3): 311-314 analysis revealed that 9% of funded females were department chairs as opposed to 17% for their male counterparts. 0% of the females were research directors compared with 2.4% of NIH-funded male faculty. 27% of the females were Professors compared to 36.5% for males. 27% of the females were Associate Professors compared to 17% for males. 27% of the females were Assistant Professors compared to 19.5% for males. 9% of the females were Instructors compared to 7.3% for males.

Impact of an Enhanced Transition Process on Patient Readiness for Discharge

To the Editor: Our institution has previously shown that patients who perceive a lack of readiness at the time of index hospital discharge are more likely to consider their readmission preventable. When patients were queried about why they felt unprepared for discharge, they reported concerns about the medical care they anticipated needing at home, despite the majority of patients having considerable posthospitalization support. Thus, understanding how patients experience transitioning from hospital to home is important for improving the process. To understand this transition, we conducted a quality improvement study comparing our hospital’s standard discharge process with an enhanced transition intervention. We evaluated the study in terms of impact on patientperceived readiness for discharge, patient satisfaction, and readmission rates. All general medicine patients approaching estimated discharge to home within 48 hours were included. Patients were then randomized to the intervention or standard discharge process. A nonclinical transition coach randomized patients to the intervention arm and approached these patients in their hospital room within 48 hours of expected discharge to complete the combined intervention on providing verbal consent. The intervention involved 2 components: (1) inperson administration of a discharge checklist assessing the patient’s preparedness for logistical and emotional aspects of post-hospitalization life and (2) viewing a 20-minute video detailing important aspects of the discharge process in our facility. The checklist asked patients to envision themselves at home and play out how they will overcome certain problems or situations, such as clinical deterioration, and thereby self-identify areas of educational need. Discharge readiness and patient satisfaction were measured in both the control and intervention arms using a Discharge Satisfaction Survey administered on the day of discharge. Patients were tracked prospectively after discharge for readmission; readmission rates were compared between groups. Among 321 eligible patients, 78 refused or were unavailable. Of the remaining 243 patients, 117 patients were randomized to the control intervention, and 126 patients were randomized to the combined intervention; 80 (68%) and 53 (42%) patients completed the control and intervention, respectively. Analysis of the Discharge Satisfaction Survey showed that patient readiness for discharge in the intervention group was significantly higher in 3 items assessing patient readiness (P < .1). Readiness for discharge in the intervention group trended higher but did not reach statistical significance in 5 additional questions. The 3 questions showing significant improvements were the following: (1) I know what problems to watch for after I go home, (2) I know what restrictions I will have when I go home, and (3) I am ready to handle the demands of life at home. Overall, no difference was noted in readmission rates between the control and intervention arms; however, the sample size was not large enough to power for this. This study suggests that an enhanced discharge process may increase patient emotional readiness on discharge. The act of patients contemplating aspects of their post-hospitalization care through the Discharge Checklist may have aided their ability to think about how they will transition to life at home, thus supporting the incorporation of an optimized transition process to increase patient readiness.

Implementing High-Performance Teams Strengths of a Standard Communication Tool in Neurosurgery

To the Editor: Cognizant of the challenges of processing data while supporting a high level of communication, the UCLA Health Neurosurgery Department developed an innovative tool refined around a mnemonic, HPT, to ensure optimal communication between team members daily. The HPT tool comprises 3 elements: Hospitalization Goal, Plan for Today, and Transition/Discharge. We assessed the implementation of the HPT tool during daily care coordination meetings in neurosurgery. The neurosurgery team met every morning with a multidisciplinary team of nurses and allied health care professionals to review each patient case. During these meetings, communication regarding the elements of HPT was recorded by the quality team. After collecting baseline data for 7 weeks, the results were reviewed by the neurosurgery chair and the unit’s nursing and case management leadership. A go-live date was selected and education on HPT components was conducted for residents, nursing, and case management by placing posters in the physician rounding and care coordination rooms. Upon go-live, each case was presented in the HPT format. For example, “Mrs Jones is a 68-year-old woman with glioblastoma, Hospitalized for increasing nausea and emesis post recent chemotherapy treatment. Plan for today is to consult palliative care for symptoms management. Upon Transition to home, patient will need home health.” The baseline period revealed that the team did not use a standard communication framework. Over the course of 6 months, we checked adoption 3 times: (1) post intervention (for 6 consecutive weeks), (2) 4 months after (for 4 weeks), and (3) 6 months after (for 3 weeks). During the study period, 903 patient encounters were discussed during the care coordination meetings. Baseline data revealed the H, P, and T components were discussed 71%, 81%, and 83% of the time, respectively. Post intervention, performance on H, P, and T increased to 87%, 90%, and 90% of the time, respectively. The ability of unit nurses to recount the elements of the P and T was assessed through interviews. Baseline data denoted that nurses repeated the P 74% and the T 47%. The HPT framework improved the nurses’ ability to repeat the P 80% and the T 74%. To evaluate this tool from a patient-centered perspective, patients were interviewed to assess their knowledge of P and T. During baseline data collection, patients knew their P 36% and their T 50%. The HPT framework increased the patients’ ability to repeat their P 53% and their T 68%. The intervention provided a standard model for improving communication among multidisciplinary teams. The study demonstrates that the HPT framework not only improved the high-performance team abilities with regard to knowledge of the condition, treatment, and care of neurosurgery inpatients, but it also improved the ability of nurses and patients to understand the P and T. The results provide empirical support for the implementation of formal practices, such as the HPT communication tool, to strengthen communication among providers. The simple and robust framework of the HPT intervention facilitates future implementation and enhances the sustainability of the tool.

Difference in Ability of Hospitalized Patients to Identify Their Attending Physician From Surgical and Nonsurgical Service Lines An Academic Medical Center Study

To the Editor: Delivering high-value, patient-centered care is at the core of ensuring patient engagement and active participation that will lead to positive outcomes. Physician–patient interaction has become an area of increasing focus in an effort to optimize the patient experience. Patient identification and knowledge of who is in charge of their condition and care is at the heart of this relationship. There is a paucity of data and research in this area, particularly in teaching hospitals. Little is known about hospitalized patients’ ability (or lack thereof) to identify their attending physician. This study analyzed data gathered from an audit tool assessing physician–patient interaction at University of California, Los Angeles (UCLA) Health from 2010 to 2013. Analysis focused on whether or not there was a significant difference in the number of hospitalized patients who can identify their attending physician from surgical and nonsurgical specialties in 9 clinical departments at UCLA Health. The methods of this study are based largely on the methods of a previous study published by the ARC Medical Program. The ARC Medical Program has an established infrastructure to conduct evaluations on a system-wide scale, including 9 departments within UCLA Health. ARC volunteers use a CICARE Questionnaire (ARC Survey) when interviewing patients to assess their physician’s communication patterns. During retrospective analysis using the Student t test and evaluating for variance using the analysis of variance test, 15 828 surveys were evaluated from patients in the departments of internal medicine, family medicine, pediatrics, general surgery, head and neck surgery, orthopedic surgery, neurosurgery, neurology, and obstetrics and gynecology. Exclusion criteria included patients who were not awake, were not conscious, could not confidently identify a resident, or stated that they were not able to confidently complete the survey. Student t test analysis of survey responses revealed that attending physicians in surgical lines were identified significantly more frequently (P < .001) than attending physicians in nonsurgical specialties; the breakdown was 65.7% and 35.7%, respectively (P < .001). In total, 48.02% of patients were able to identify the inpatient attending physician in charge of coordinating their care. Moreover, patients in every surgical specialty identified their attending physician at a significantly higher rate than patients in every nonsurgical specialty, excluding family medicine (P < .001). Attending physicians from orthopedic surgery were identified by 92.2% of patients, a significantly higher percentage than any other service line (P < .001). In all, 99.4% of patients who reported receiving a business card from their attending physician were able to positively identify their attending physician. Patients admitted to the neurology service line were least able to positively identify their attending physician (27.2%). Taken together, the differences in attending recognition rate identified may be rooted in the nature of the relationships that are developed in a surgical specialty compared to a nonsurgical specialty. Cumulatively, these factors could contribute to patients being able to recognize their surgeon more often than their physicians from nonsurgical service lines. Furthermore, these data suggest that more than 99% of patients who reported receiving a business card from their attending physician were able to positively identify them. These results suggest an interesting method attending physicians can use to improve the ability of their patients to positively identify who is in charge of their condition and care, ultimately enhancing the patient experience and physician–patient relationship.