When Every Minute Counts, Even Minor Details Matter to Patient Care

Kim Miyauchi, Chief Nursing Officer
Kingman Regional Medical Center, AZ 

Saving the lives of heart attack patients is one of the biggest challenges for hospitals. When every minute counts, we all need to be looking at the same clock…that is one of the key messages our hospital learned when we examined mortality rates of patients with acute myocardial infarction (AMI). 

Kingman Regional Medical Center (KRMC) discovered that sometimes the simplest solutions can be the keys to saving lives. As part of the Leadership Saves Lives program, KRMC partnered with the Yale Global Health Leadership Institute and we were challenged to examine our hospital culture and treatment methods for patients with AMIs. We were part of 10 U.S. hospitals involved in the two-year program to determine causes of high AMI mortality rates.  

To reduce the AMI mortality rate at KRMC, we examined several possible determinants and honed in on three: 1) timeliness of EKGS; 2) protocols, pathways and guidelines; and 3) discharge process. We first addressed the causes by encouraging more teamwork. We created committees to examine each of the three causes contributing to our high AMI mortality rate. As teams engaged with each other and with other hospital staff they were better able to understand how and why goals weren’t being met and how to improve the results.

For example, a large number KRMC patients arrive at the hospital by private vehicle – delaying the electrocardiogram (EKG) process that normally would take place in an emergency vehicle. Kingman Regional Medical Center strives to complete EKGs within 10 minutes of an AMI patient’s arrival. However, when we reviewed patient charts, we discovered our EKG completion times were inconsistent and recorded times depended on which clock a staff member was using. We had eight clocks in the ER and they were not synchronized. This had to be addressed to improve patient care.

Our hospital replaced all of the ER clocks and synchronized them with our computer system.  This simple, inexpensive solution, along with its other efforts ended up significantly improving timeliness of care. Although all of KRMC’s process changes were not as simple as replacing clocks, we have already seen the efforts paying off with a decrease in AMI mortality rates.

Hospital Change -- How to Make it Stick

Amanda Brewster, Ph.D., GHLI research and education associate 

Health care professionals constantly invest time, effort and expense trying new methods to improve care only to see promising innovations evaporate rather than become part of everyday work habits. When this happens, hospitals miss potential performance improvements, waste money and time, and feed quality improvement fatigue among staff.

New evidence published in Implementation Science from the Yale Global Leadership Health Institute shows that there are predictable patterns in what it takes to make change “stick.” Reviewing data from hospitals that participated in the State Action on Avoidable Rehospitalizations (STAAR) initiative, GHLI researchers examined different strategies hospitals tried to reduce readmissions.

The research showed that getting new practices integrated depended on how the integration process was executed. When hospitals appointed staff to oversee that a new practice was performed regularly for several months up to a year, more permanent integrating mechanisms had time to start working. Staff had a chance to feel direct benefits from the new practice – like greater job satisfaction or less stress – which motivated them to keep doing it even without close oversight. Or failing that, job expectations had a chance to catch up with the new practice, making it a non-negotiable part of work.

What should hospital leaders make of these results? Truly integrating a new practice takes patience and extended effort over time. And, staff members’ own desires to improve patient outcomes can give a powerful boost to quality improvement. Ensuring that staff responsible for implementing a new practice have the opportunity to see the positive impacts – through data feedback as well as personal interactions – can enlist them as partners in integrating the innovation into the permanent fabric of the organization.  Finally, the work does not ever go on auto-pilot, but incorporating the effort into ongoing management oversight efforts allow champions to move onto the next burning platform.  

Reducing Hospital Readmission Rates -- What Really Works?

Erika Linnander, GHLI Senior Technical Officer

Unplanned hospital readmissions are estimated to cost more than $17 billion each year for Medicare alone. Across the country, hospital executives, clinicians, policymakers, and researchers search for the best ways to reduce unplanned hospital readmissions. Hospitals are intently focused on this issue, and are joining quality improvement networks and programs to guide their efforts. A dizzying array of tools and best practices are available, but which approaches are in fact tied to reduced readmission rates?

Researchers at Yale’s Global Health Leadership Institute continue to study which strategies work best for providing quality patient care and reducing hospital readmissions. Between 2010 and 2012, they found significant increases in the use of nine frequently recommended strategies among hospitals participating in the State Action on Avoidable Rehospitalization initiative or the Hospital-to-Home Campaign.

The latest evidence appearing in the May 2015 issue of the Journal of Internal Medicine shows that hospitals that incorporated any combination of three or more of these strategies which focused on changes to hospital culture and administration, saw significantly larger reductions in risk-standardized readmission than those hospitals that took up fewer strategies. After adjusting for hospital size and location, hospitals that implemented several strategies reduced their readmissions rates by 0.4 percentage points more than hospitals that implemented fewer strategies. Scaled nationally, this improvement could save the Medicare $400 million annually.

The study findings showed rather than a single recipe, many different combinations of strategies led to similar reductions in readmission rates.

What can health care professionals make of these results? First, there is no silver bullet. None of the nine strategies alone accounted for sizable reductions in readmission rates. Second, the successful hospitals were implementing at least three new strategies to reduce readmissions. Because readmissions have multiple root causes, a bundle of strategies is likely needed. Different hospitals used different means for achieving results. Last, change is hard. Despite their enrollment in major quality improvement initiatives, 70% of the hospitals surveyed had taken up fewer than three strategies during the course of the study.  

Leadership Towards the Advancement of Human Rights

Photo Credit: Thi Nhat Le

Zahirah McNatt, GHLI Director, Leadership Education and Practice

As part of the Senior Leadership Program (SLP), I recently worked with delegates from Cambodia, Laos, Myanmar, Philippines, and Viet Nam in Phnom Penh, Cambodia to address strengthening the enabling environments for persons with disabilities. Each team brought with them a national problem - high staff turnover, too few rehabilitation professionals, poor access to physical rehabilitation centers and limited knowledge among people with disabilities about their legal rights.

For this program, all written materials were translated into four languages and we had simultaneous interpretation during lectures and group activities. For five days, we explored problem solving, leadership and management, good governance and the United Nations Convention on the Rights of People with Disabilities (UNCRPD).

The trip was an awe-inspiring opportunity to encourage collaboration among several stakeholders. We had representatives from national disabled people’s organizations, government ministries, parents, teachers and physical rehabilitation facilities. The diversity created dynamic teams and allowed for cross-country dialogue about better integrating disability rights efforts in Southeast Asia.

The SLP created a safe space for discussion on how to operationalize the aspirations of the UNCRPD. Many countries stall once ratifying such agreements and are unable to make the dreams reality. These five nations have the potential to implement practical solutions that increase accessibility and diminish discrimination against people with disabilities.

While there are many difficult stories about children who use wheelchairs being unable to get to school or people with visual impairment being denied the right to vote - I remain hopeful. I am personally motivated by the role models present in the Program itself - women and men with and without disabilities who have chosen to champion the rights of others. I left Phnom Penh struck by the power of our unified voices and further committed to encouraging and demanding justice and equality for all.

Call me Shelemat

Shirin Ahmed, Program Manager, GHLI 

As I sat at a restaurant not far from the White House discussing Ethiopian (and Pakistani) politics and bonding over honey wine with my friends from the Ethiopian Ministry of Foreign Affairs (MFA), it struck me how issues of regional security and organizational capacity are quite similar across borders.  

I was at the end of spending two weeks with delegates from Ethiopia who were visiting the United States as part of Yale GHLI Strategic Thinking in Foreign Affairs Symposium followed by a tour in DC to meet with leaders on Capitol Hill, at think tanks and the State Department. I felt so welcomed by the group— they even gave me an Ethiopian name, Shelemat, a prize or reward in Amharic. 

During our time in DC, I was pleased to see the enthusiasm on both ends, reinforced by mutual commitments to resolving regional conflicts, fostering business development and strengthening US-Ethiopia relations. But I also sensed a concern from the Ethiopian side about its “image” in the US, often misrepresented by western interest groups and now exacerbated by Ebola. However, it was encouraging to hear that despite these perceptions, as noted by someone from the US Chamber of Commerce, Ethiopia stands at the “cusp” of economic growth and it is only a matter of time that the country would become a major player for US investments.  

One individual at the Foreign Services Institute asked me what Yale was doing with the group -- a question I asked myself at the beginning of the program. But I get it—building and strengthening.  I had seen those words in writing in our Symposium brochure, but I truly understand it now. The learning at Yale coupled with relationship building in DC may be the jumpstart for the MFA to advance its foreign policy agenda. 

With each passing day, I have new Ethiopian followers on twitter and Shelemat continues to receive thank you messages from the MFA.

A Closer Look at Cardiac Care

Heather Fosburgh and Dayna Keene, YSPH Professor

Heather Fosburgh, GHLI Program Manager

It’s still hard to believe that in the course of seven weeks, the GHLI Leadership Saves Lives team has travelled to ten hospitals in ten different states to conduct more than 150 interviews to learn more about the cardiac care process in each of the hospitals.

I had the opportunity to participate in interviews and observations at three hospitals in Arizona, Illinois and Florida. Each hospital, like its geographic location, was unique … as were the people. However, interwoven in these differences, were common threads of excitement and eagerness to find new ways to improve patient care. Whether it was a nurse, a physician or an information technology specialist, hospital staff and faculty were truly interested in how they could help make a difference. It was inspiring to see their passion and motivation. 

Conducting these interviews for the LSL program provided me a brief but up-close glimpse into how things are behind the scenes of hospital patient care and management. We spoke with more than a dozen staff members at each hospital who shared, stories, experiences, and honest feelings with us.   

We have six months before the next round of hospital site visits start and during that time, we will be busy reading and analyzing the information collected to date. I find it fascinating to know that taking these individual experiences and combining them all together will contribute to a body of research that strives to understand what aspects of organizational culture can help improve mortality rates for patients with heart attacks.

Although it was less than two months work for me, I remain impressed by how much coordination it takes to effectively care for a patient who suffers from a heart attack coupled with the dedication of the people who provide this care.

Making Babies Breathing Affordable

Charles Stone, ‘ 14, GHLI Intern

Each year, an estimated three million babies die during the first four weeks of life around the world. More than 50% of these deaths are attributed to birth asphyxia, respiratory insufficiency and complications stemming from preterm birth.  Devices to help prevent some of these deaths – such as the Humidified High Flow Nasal Cannula (HHFNC), which costs $5,000, are prohibitively expensive for low resource settings.

As interns at the Yale Global Health Leadership Institute, undergraduate engineers Katy Chan '15, Jordan Sabin '16 and myself (Team PremieBreathe), made encouraging strides to address this issue. Building on a design I developed for my senior project, our goal was to fabricate a functional, low-cost prototype of the HHNFNC. 

Every day presented new challenges as we grappled with tricky physics concepts. We spent hours theorizing and testing (and re-testing) how best to control the vapor pressure of traveling air at varying temperatures.   Perhaps the most insightful part of the project involved understanding how our prototype would behave when in contact with a baby.  For this we had to be quite creative.  We rolled up heating pads to resemble the size of a premature infant and “dressed” the bundle in Jordan's finest set of baby clothes.  From this we learned that this thermal contact with the nasal cannula significantly reduced condensation in the system. We celebrated that small milestone over tasty hamburgers at Louis' Lunch (home of the original hamburger!). 

By the end of this summer, we demonstrated that our prototype closely mimicked the commercial device -- for the modest price of $340. It delivers a customizable flow of humidified and warmed air, through a standardized nasal cannula that feeds into a baby’s nostrils.

We are excited to continue project with the ultimate of goal of visiting Ethiopia to better adapt the device for use in the developing country context. To learn more about our project, visit https://premiebreathe.wordpress.com/

Changing Hospital Culture to Save Lives

Zahirah McNatt, project director, Yale GHLI

Last week, GHLI and a group of representatives from hospitals across the country convened in the city of Atlanta because we believe that leadership saves lives and that organizational culture can impact clinical outcomes in the hospital setting.  

A stretch? Perhaps. 

A decade of research led by Yale highlights five strategies for reducing mortality rates for patients with heart attacks. We argue that these strategies are proxies for aspects of organizational culture and that culture may be just as significant as new drugs and devices.

During the Leadership Saves Lives (LSL) launch, we met with hospital executives, nurses, interventional cardiologists, emergency room physicians, physician assistants and quality improvement directors - all with the goal of understanding the evidence base for organizational culture and clinical outcomes and creating a learning community.

We spent two days cultivating relationships across ten U.S. hospitals, reviewing the science behind the intervention, laying out a plan for our two years of work together and exploring each hospital’s organizational culture through artistic activities. We partnered with amazing institutions--The Medicines Company and the Mayo Clinic Care Network--both at the vanguard of their industries.  

The commitment and enthusiasm expressed by each of the 10 hospital teams was inspiring. They came from across the nation, including Montana, Florida, North Dakota and Kentucky. They spoke of issues like “turf wars” between professions and a need for a greater sense of respect in the workplace. They highlighted their successes with integrating pharmacists into the AMI care continuum and challenges with better engaging emergency medical services in quality improvement efforts.

Together, we focused on creative problem solving, a technique for finding solutions to clinical and operational issues, through engaging key staff, developing strategy and being open to new ideas. And we explored how best to encourage interdisciplinary communication and coordination. 

The launch and the project are the result of both personal and professional efforts to improve care for patients with AMI. We are proud to be a part of this endeavor.

Innovation and Strong Partnerships: The Equation for Global Health Success

Mike Skonieczny, executive director, Yale Global Health Leadership Institute

Recently I attended a gathering of major influencers in the world of global health  – ministers of health, U.S. government officials, and representatives from NGOs, philanthropic organizations and the private sector. “Acting on the Call,” brought together these leaders to celebrate recent successes in improving maternal, child, and newborn health and to examine new methods to improve health care access in even the most remote parts of the world.   

It was impressive to me to see this broad array of people exchanging ideas, particularly on how to improve the health of women and children around the globe. Dr. Kesete Admasu, the Ethiopian Minster of Health, shared examples of significant strides made in his country including the Health Extension Program, a national strategy for primary health care in Ethiopia. 

A program featured during the gathering was Project Last Mile (PLM), which leverages the Coca-Cola Company’s supply chain expertise to bring medicine to rural African communities. Spearheaded by Coca-Cola the partnership also includes USAID, the Global Fund, Accenture Development Partners and Yale GHLI. Project Last Mile has already seen tremendous results in Tanzania, where the availability of medicines has increased by 20-30% in some cases. Over the next five years the project aims to reach a total of 10 countries with work already starting in Ghana and Mozambique. 

“Acting on the Call’ highlighted the fact that success in maternal and child health requires not only creative solutions, but also strong partnerships between the public and private sectors. By leveraging the unique assets of the private sector, like Coca-Cola, we can see amazing results that truly change lives. 

What Does a Culture of Health Mean?

Elizabeth H. Bradley, Ph.D., faculty director, Yale Global Health Leadership Institute 

Last week, the Vitality Institute released a report offering five recommendations to build a culture of health that motivates Americans to make healthful choices – including strengthening leadership through networks, focusing on the health of the workforce and reframing the word prevention. The report aims to establish health as state of complete mental, physical, and emotional well-being.

I was delighted to participate on the panel at this event that raised thought provoking ideas about leadership for health. How should Americans be thinking about health leadership? Does it start at home, in schools, in the community, or in the workplace? By the time we enter the medical care system, health habits are fairly well established and difficult to shift. Hospitals and doctors influence only a portion of our health; the real drivers of health – how we eat, play, work, and live – have developed long before we ever walk into a medical facility.    

To make headway on improving health care in the United States, we must endorse the broad view of health as a core value of society. We must engage diverse groups of people, companies, organizations, and communities. Expanding the circle of partnerships, beyond the typical players in health care, such as pharmaceutical companies and insurers, may bring a more holistic approach to the culture of health.  For example, partnerships with technology companies that focus on innovations for our future, as well as urban design companies, may be more important to ensure that health issues are addressed at all levels.  Such partners provide leadership focused on innovations that lead people to healthy and sustainable lives through perspectives on health. 

We also need to think differently about what prevention means and when it starts.  We can do this by looking upstream with our prevention efforts –urban planning, early childhood education, safe housing – methods that happen even before some medical preventions.    

This report was inspiring and I think the Vitality Institute has a real opportunity to grow a network that can change the culture of health.  I’m in.  

Yale Women: Health Innovation and Entrepreneurship

Seth Nigrosh

As an international relations major at Connecticut college, classes that relate to public health and global health were not on my radar for a long time. I have recently become interested in the subject, and realized that as senior year was coming to a close, I had few ideas about what a job in the global health industry would look like. When I had the opportunity to attend Yale's “Women in Innovation: Leading Yale Women in Social and Healthcare Startups” panel discussion I was eager to go. All three panelists, Barbara Bush, YC ’04, founder of Global Health Corps; Jennifer Staple-Clark, YC ‘03, founder of Unite for Sight; and Laura Niklason PhD, MD Yale faculty and co-founder of Humacyte explained origin of their respective organizations and how they ended up at the forefront of the global health community.

I was curious to hear how people who do not have any sort of health or medical background can still be involved in a global health project. When Ms. Bush spoke about her time at Yale as an architect student and Ms. Staples-Clark talked about the importance of removing barriers to care, I realized that global health is an inherently interdisciplinary undertaking. Scientific work by people like Professor Niklason, whose research into regenerative tissue and arterial implants is breaking new ground, will always be needed. But, we also need people who are experts in logistics who can get new medicines and technologies around the globe, and advocates to keep up pressure on public figures to respond to global health crises. I used to ask myself, “Should I have majored in IR? I love it, but I don't want any of those traditional government or finance jobs!” Now, I see that instead I should be asking myself, “How can I take what I've learned and apply it to a complex and intriguing field like global health?” In today's interconnected world, it's not just what you know, but how you apply it creatively, that matters.

Lessons on Counterinsurgency from the Human Body

Kristina Talbert-Slagle, Ph.D., GHLI Associate Research Scientist

The worlds of public health and war don’t often collide, but over the past two years I have had the opportunity to work with retired General Stanley McChrystal relating my research on HIV/AIDS to counterinsurgency warfare strategy. When we compared notes, we found many parallels between a human body that is under attack from infectious disease and a nation that is under attack from an insurgency. 

This month, Gen. McChrystal and I spoke at the Brookings Institution in Washington, DC. where I outlined the basic theories behind infection and the human body’s immune system response to disease – specifically, how infections in the human body can be “outmaneuvered” by the body’s defenses. Similarly, Gen. McChrystal noted that, “Human bodies aren’t the only things that get infected … if you think in terms of a nation … you can have infections, and we’ll call it insurgency … that are threats to a nation.”

We compared the way HIV destabilizes the human immune system and enables opportunistic infections to the way that long-term instability in Afghanistan enabled the Taliban insurgency. Success in treating the HIV virus is not simply about anti-viral drugs – it’s more than just rebuilding the immune system. It is a multiparty, multi-aspect approach to rebuilding health. In a similar way, counterinsurgency requires a multi-faceted and holistic approach rather than a single, magic bullet solution. Ultimately, in both cases, sustained stability is the essential factor for both healthy bodies and nations.

After our presentation, Gen. McChrystal and I took questions from audience members and reporters, which included, "Can this model be applied to help us understand challenges to the health of the world, such as climate change?" and "How can we apply the role of stigma to our understanding of improving health?" The genuine interest in our work was a rewarding part of this experience.

This work is truly helping me to understand that counterinsurgency and public health strategies have more in common than I once thought...we ultimately share the same goal, which is to help people live happy, healthy, peaceful, productive lives.

Click here to get the full audio from our presentation at the Brookings Institution.

Dr. Nicholas Alipui Speaks on Future Vision of UNICEF

Dr. Nicholas Alipui and Pia Rebello Britto, Ph. D.,
assistant professor at the Yale Chid Study Center

As the closing keynote for the 2013 GHLI Conference Nicholas Alipui, M.D., director of programs at UNICEF, noted the organization’s recent successes and their decision to focus now on early childhood development. With a 40% reduction in the transmission of HIV between mothers and infants, nearly one billion people lifted out of poverty, and immunization rates on the rise, great accomplishments have been made. These achievements are challenged by the need for new strategies in other areas. Early childhood development issues are a growing concern and UNICEF is dedicated to determining who, where and what needs to change to improve the lives of children around the world.

The first 24 months of a child’s development are crucial. Child development paradigms are very different based on culture and social norms. UNICEF’s work aims at understanding the environment where children are raised as key to their growth. As Dr. Alipui noted, “Early childhood development is essential to fostering productive citizens and sustainable communities. By acknowledging and taking ownership of issues, it is possible to sustain impact.”

Delegates from Brazil, Ghana, the Eastern Caribbean and Uganda spent one week at the GHLI Conference learning from each other and Yale faculty about strategies to address specific health issues.  At the close of the week, Elizabeth Bradley, Ph.D., offered a toast to the group acknowledging the importance of their work in tackling global health issues.  “This Conference allows us the opportunity to be in each other’s shoes and to learn from each other.  With this collaboration we are able to create more comprehensive, creative and compassionate approaches to health issues.” 

The country delegations focused on taking on the challenging issues related to early childhood development, non-communicable diseases and mental illness.  Each delegation will be accompanied home by a GHLI Student Fellow student who will work with them for two months to execute the strategies developed at the Conference