Value of QI experience at Virginia Mason

[Midaz&Fentanyl]

So, I interviewed at Virginia Mason for anesthesia and had a great interview experience there. It stands out among the other programs I've interviewed at so far in unique ways, but because it is unique I'm having trouble comparing it to other places I have encountered.

In particular, they are very into quality improvement, and have adapted the Toyota production system into the "Virginia Mason Production System" (VMPS). They have used interdisciplinary teams to completely redesign their ambulatory surgery area, as well as other units of the hospital. The culture of constant change and improvement was obvious and refreshing. Residents are actively involved in QI projects and receive formal training in the VMPS. The PD very much promoted this emphasis on QI and Lean principals as a strength of the program, and as something that makes their graduates unique and marketable. I guess my question is how valuable is this experience really when it comes time to get a job? Will anyone actually care that you have developed this skill set?

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[chfo]

You don't need QI experience to figure out how to QI.

 

[narcusprince]

I think this experiance is valuable. Where I trained they had similar QI, PI, intellectual property projects going on. 4-5 years into practice I still see models from residency that could streamline flow in my current hospital.

 

[criticalelement]

what the f is QI.. Learn anesthesia, don/t worry about QI. and Dont believe a gosh darn thing any program director or chairman tells you. It is all Malarkey.

 

[Mman]

what the f is QI.. Learn anesthesia, don/t worry about QI. and Dont believe a gosh darn thing any program director or chairman tells you. It is all Malarkey.

You have to know anesthesia cold, but learning process improvement methods is helpful in the real world. Or at least in private practice it is. Academia is full of BS anyway so probably doesn't matter.

 

[Pooh & Annie]

It's valuable and marketable. EVERYONE who's aware of it will ask you about it.

 

[Random Anesthesiologist]

People will care if you've been able to present results of a study or project that showed improvement in cost analysis. Other systems are doing QI improvements and implementing systems. Some are doing six-sigma like programs. Several children's hospitals are partaking in the "wake up safe" campaign.

Perpetual QI starts to sound like you're working at Initech, and no one wants that.

 

[Pooh & Annie]

what the f is QI.. Learn anesthesia, don/t worry about QI. and Dont believe a gosh darn thing any program director or chairman tells you. It is all Malarkey.

When someone admits to not knowing what something is and then advises you not to consider it, you should probably take the things they say with a grain of salt.

 

[criticalelement]

When someone admits to not knowing what something is and then advises you not to consider it, you should probably take the things they say with a grain of salt.

ok so dont learn anesthesia and learn all about QI. that will help you! NOT!!!!!!!!!!!!

 

[Mman]

ok so dont learn anesthesia and learn all about QI. that will help you! NOT!!!!!!!!!!!!

maybe you could point out where somebody suggested to not learn anesthesia and instead learn all about QI.

oh wait, you can't.

 

[saywhaaaaa]

QI is such a buzzword "hot" topic this year on the interview trail. I'm surprised Virginia Mason is the only program you've come across that touts their QI experience. Basically, from what I've heard/understand, QI experience/projects have been somewhat of a loose ACGME "requirement" but are transitioning into a more concrete part of mandatory residency training. You're gonna get QI exposure anywhere (I think), but if it's your cup of tea and you wanna go somewhere that it's already been integrated firmly into the curriculum, Virginia Mason seems like a good bet based on what you say. Personally, it seems like yet another b.s. component of anesthesia training that I'm not looking forward to...

 

[Arch Guillotti]

learning process improvement methods is helpful in the real world. Or at least in private practice it is.

How so? Anyone who works for a while can figure out how to make process improvements.

 

[pgg]

ok so dont learn anesthesia and learn all about QI. that will help you! NOT!!!!!!!!!!!!

My god, your schtick is geting old. You're like Consigliere but without the occasional insightful comment or any hint of street cred. Why are you here?

 

[Mman]

How so? Anyone who works for a while can figure out how to make process improvements.

Because hospitals appreciate and use things like six sigma and lean. If you are already familiar with the language and the work flows and thought processes it can make your input more valuable to them. It isn't as simple as figuring out how to improve things.

Now does that mean you can't learn it? Obviously you can. It was a foreign language to me the first time I got involved. But there is no argument it is not a useful skill/background to bring to the table.

 

[Monty Python]

Because hospitals appreciate and use things like six sigma and lean. If you are already familiar with the language and the work flows and thought processes it can make your input more valuable to them. It isn't as simple as figuring out how to improve things.

Now does that mean you can't learn it? Obviously you can. It was a foreign language to me the first time I got involved. But there is no argument it is not a useful skill/background to bring to the table.

"Robust process improvement" is one of the three legs of Joint Commission's "High Reliability Organization" philosophy for this year. When I took Operations Management in my MBA program, the professor was a Navy Captain with a PhD in the field from Naval Postgraduate School. At first I thought it would be just a lot of common sense hokey all dressed up in ivory tower academic verbiage. I was wrong. Applied properly, and in the right context, it can yield significant benefit (less waste, better throughput, lower cost, improved safety etc etc). Its a scientific, statistics-intensive process.

 

[Midaz&Fentanyl]

Thank you all for taking the time to provide your input.

 

[loveumms]

I'll bet most major academic programs have these type of processes. We have a QI rotation and I've been involved in many black belt projects. Many times it can be implementation of those projects. I would look more for a program that is going to train you well and you will be happy (location, resident happiness, didactics, cases, etc) - QI and PSH are bonuses.

 

[criticalelement]

My god, your schtick is geting old. You're like Consigliere but without the occasional insightful comment or any hint of street cred. Why are you here?

I got shot in the fleshy part of the thigh once.. How is that for street cred?

 

[criticalelement]

maybe you could point out where somebody suggested to not learn anesthesia and instead learn all about QI.

oh wait, you can't.

Learning that garbage that the original poster posted about takes away from anesthesia training. You spend 6 months a year doing process improvement, 6 months a year doing pain, 4 months a year doing ICU work. 4 months doing OB, and don't forget the surgical home for 3-5 months. after all that.. guess what? you graduate and you dont know what the fu ck you are doing. You are a paper pusher, t hat needs to go to the corner office because you sure as sh it are going to have major problems in any reasonably busy clinical environment. I can almost freakin guarantee it.

 

[deleted171991]

QI is the latest corporate NewSpeak. Checklists, protocols and other BS, destined to transform medicine from the art of the solo practitioner into the industrial factory of a big healthcare organization. If you are into it, good luck, because it speaks volumes about the type of drone you are.

I think good doctors have their own QI process; that's the way they get better at their jobs. However, organized QI is about as valuable as organized religion: good money for the leaders, nice brainwash for the masses. Doing anything your way, just because it works better for you with the same or better outcomes, is the equivalent of (corporate) heresy.

 

[deleted171991]

At first I thought it would be just a lot of common sense hokey all dressed up in ivory tower academic verbiage. I was wrong. Applied properly, and in the right context, it can yield significant benefit (less waste, better throughput, lower cost, improved safety etc etc). Its a scientific, statistics-intensive process.

The problem is with the emphasized part (emphasis mine).

Most humans (including many three-letter career bureaucrats) are way too stupid (mathematically speaking) to understand (the limits of) statistical methods. Just look at all the BS medical "research" papers that are accepted as proof of somebody's intellectual and academic value. They are choke-full of poor statistics and bad conclusions. Why would you expect it to be different in the clinical world?

The problem with institution-wide QI is that it brainwashes stupid people into thinking that they should design processes for the smart ones, that it imposes a one size fits all mentality. Stuff like Six Sigma works for creating some order from chaos, but it should stop exactly there; the enemy of good is better, "continuous" QI, obsessing with hair-splitting improvements for the sake of saving another 0.01% in a big corporation, regardless of the impact on employee happiness. (Reader, if you'd have written "satisfaction" here, you belong to the bean counters).

 

[chfo]

Anyone who has spent time in a QI-heavy institution knows what QI means: bureaucratic heavy-handedness by non-clinical or hardly-clinical know-it-alls who make a job for themselves by selling snake-oil, the miracle cure-all for all that is evil in the medical world, i.e. individual clinician decision-making.

Avoid these places like the plague, because they reward drones, and punish the free-thinking innovators.

Like I said in my initial reply, you don't need QI experience at one of these snake-oil places to figure out how to improve your own practice, or figure out deficiencies/inefficiencies in the system, and recommend alternatives.

Frankly, the more you work in a place like that, the less likely you will be able to figure out QI in the real world, because your worldview will be tainted. You will think QI means whatever the dogma of your old institution held. You will try to translate your past experience into your future job. Your colleagues will see through it and will detest you for the corporate bullcrap you bring to the table.

 

[Temeraire]

It would be nice to actually hear a Virginia Mason grad talk about whether or not their training gave them a leg up on anything in the real world.

We can pontificate all day about the utility of QI training...

 

[Mman]

Learning that garbage that the original poster posted about takes away from anesthesia training. You spend 6 months a year doing process improvement, 6 months a year doing pain, 4 months a year doing ICU work. 4 months doing OB, and don't forget the surgical home for 3-5 months. after all that.. guess what? you graduate and you dont know what the fu ck you are doing. You are a paper pusher, t hat needs to go to the corner office because you sure as sh it are going to have major problems in any reasonably busy clinical environment. I can almost freakin guarantee it.

I'm sorry, maybe you could show me anywhere in this thread where it said you took 6 months off from clinical work. I haven't seen that.

 

[Planktonmd]

This is the future of medical practice and like it or not it's here to stay!
The administrators and accountants have figured out that the best way to completely erase the identity of Medicine, and turn it into a marketable commodity where everything and everyone is replaceable and interchangeable, is by adopting the Toyota factory model, and to turn humans into little robots or minions who only know how to obey orders.

 

[IlDestriero]

I'm not sure that QI is very unique. Though they may try to emphasize it and sell it that way at VM. Much of what passes as QI is just data mining and manipulation looking at trends. If the department has a bioinformatics group, they're doing QI projects. There's nothing wrong with that, but your PP group won't have a bioinformatics group, they won't have expensive statistical software, nor will they have access to Ph.D. statisticians to help you.
I wouldn't be surprised if there were many obvious problems in their systems that don't get changed 2/2 momentum and lack of surgical buy in, so I'm not sure I would bank on it being a golden ticket to a >90th percentile dream job.

 

[pgg]

I got shot in the fleshy part of the thigh once.. How is that for street cred?

That would depend on caliber and whether or not it was self inflicted.

 

[Arch Guillotti]

Because hospitals appreciate and use things like six sigma and lean. If you are already familiar with the language and the work flows and thought processes it can make your input more valuable to them. It isn't as simple as figuring out how to improve things.

Now does that mean you can't learn it? Obviously you can. It was a foreign language to me the first time I got involved. But there is no argument it is not a useful skill/background to bring to the table.

I would weigh this very little if at all when deciding whether or not to hire someone.

 

[Nivens]

I am at a program where being a great clinician is not enough- everyone is expected to bring something extra to the table. It's extremely frustrating and difficult to resist getting wrapped up in the game, keeping in mind that it isn't this way everywhere, or even anywhere, else. I came very close to applying for an in-residency MBA, but ultimately decided that marginalizing my clinical training in any way now is only going to devalue me later. I'll be far more valuable as a triple boarded Anes/CCM/Cardiac physician with advanced TEE certification to a group/academic center or even consulting/startup company than I would be if I spent an additional year learning statistics, or basic business principles. I can achieve a rudimentary understanding of either far more cheaply and in much less time, and the credentials won't mean jack in the long run. Me + a Stats PhD with years of experience, a true specialist in his/her field, is going to be far more effective and valuable than a less subspecialized version of me with a couple of courses in stats or "leadership training".

This stuff is really hot right now. If you truly have a passion for it, by all means give it a go, but beware time and energy are finite resources, and whether your program admits it will detract from clinical time or not, while you are doing your QI projects others will be spending their free nights sharpening the skills the marketplace expect from physicians.

Or, you know, slamming pints at the bar down the street from the hospital.

 

[criticalelement]

I'm sorry,

I know you are..

 

[criticalelement]

I am at a program where being a great clinician is not enough- everyone is expected to bring something extra to the table. It's extremely frustrating and difficult to resist getting wrapped up in the game, keeping in mind that it isn't this way everywhere, or even anywhere, else. I came very close to applying for an in-residency MBA, but ultimately decided that marginalizing my clinical training in any way now is only going to devalue me later. I'll be far more valuable as a triple boarded Anes/CCM/Cardiac physician with advanced TEE certification to a group/academic center or even consulting/startup company than I would be if I spent an additional year learning statistics, or basic business principles. I can achieve a rudimentary understanding of either far more cheaply and in much less time, and the credentials won't mean jack in the long run. Me + a Stats PhD with years of experience, a true specialist in his/her field, is going to be far more effective and valuable than a less subspecialized version of me with a couple of courses in stats or "leadership training".

This stuff is really hot right now. If you truly have a passion for it, by all means give it a go, but beware time and energy are finite resources, and whether your program admits it will detract from clinical time or not, while you are doing your QI projects others will be spending their free nights sharpening the skills the marketplace expect from physicians.

Or, you know, slamming pints at the bar down the street from the hospital.

I stopped reading after you said triple boarded because the only people who say triple boarded are sell out MOCA arses.

 

[Nivens]

I stopped reading after you said triple boarded because the only people who say triple boarded are sell out MOCA arses.

.

 

[criticalelement]

I'm not sure how wanting to do cardiac OR and CVICU makes a "sell-out", but kudos to you, anonymous attending, for managing to reduce everything I said to the two words that make you feel inadequate.

When Daniel-san in The Karate Kid (1984) was impressed with Mr. Miagi's karate prowess, he says to Mr. Miagi, "That was awesome, Mr Miagi, What belt are you?. You must be a black belt or something." Mr Miagi responds grabbing his belt and looking down at it, " J.C. Penney 6.99. " I hope you get the meaning behind that anecdote.

 

[Nivens]

.

 

[Mman]

I know you are..

better than being wrong and pissy

 

[Psai]

When Daniel-san in The Karate Kid (1984) was impressed with Mr. Miagi's karate prowess, he says to Mr. Miagi, "That was awesome, Mr Miagi, What belt are you?. You must be a black belt or something." Mr Miagi responds grabbing his belt and looking down at it, " J.C. Penney 6.99. " I hope you get the meaning behind that anecdote.

Yeah mr miyagi needs to stand up to his corporate overlords and stop advertising for free

 

[WingedOx]

QI is the latest corporate NewSpeak. Checklists, protocols and other BS, destined to transform medicine from the art of the solo practitioner into the industrial factory of a big healthcare organization. If you are into it, good luck, because it speaks volumes about the type of drone you are.

I think good doctors have their own QI process; that's the way they get better at their jobs. However, organized QI is about as valuable as organized religion: good money for the leaders, nice brainwash for the masses. Doing anything your way, just because it works better for you with the same or better outcomes, is the equivalent of (corporate) heresy.

Anyone who has spent time in a QI-heavy institution knows what QI means: bureaucratic heavy-handedness by non-clinical or hardly-clinical know-it-alls who make a job for themselves by selling snake-oil, the miracle cure-all for all that is evil in the medical world, i.e. individual clinician decision-making.

Avoid these places like the plague, because they reward drones, and punish the free-thinking innovators.

Like I said in my initial reply, you don't need QI experience at one of these snake-oil places to figure out how to improve your own practice, or figure out deficiencies/inefficiencies in the system, and recommend alternatives.

Frankly, the more you work in a place like that, the less likely you will be able to figure out QI in the real world, because your worldview will be tainted. You will think QI means whatever the dogma of your old institution held. You will try to translate your past experience into your future job. Your colleagues will see through it and will detest you for the corporate bullcrap you bring to the table.

...noticed this thread from doing a search and needed to chime in despite it not being my specialty.

This is actually why for the cynical among us, getting good exposure to QI even at the institutional bull**** QI-focused centers is important during training. So much of the useless time consuming non-medically related crap we're forced to do is a result of well-intentioned QI gone off the rails. If you develop an eye for "yeah, this is bull****" and learn to translate that into "look, we could achieve the same results by doing x instead of y and avoid 98% of the bull****", it goes a long way toward making your life easier down the road.

Sadly I learned during my own residency QI projects the number of admin-gunning physicians who can't recognize the former. That alone was far more educational than I'd like to admit.

 

[loveumms]

QI is the latest corporate NewSpeak. Checklists, protocols and other BS, destined to transform medicine from the art of the solo practitioner into the industrial factory of a big healthcare organization. If you are into it, good luck, because it speaks volumes about the type of drone you are.

I think good doctors have their own QI process; that's the way they get better at their jobs. However, organized QI is about as valuable as organized religion: good money for the leaders, nice brainwash for the masses. Doing anything your way, just because it works better for you with the same or better outcomes, is the equivalent of (corporate) heresy.

But have we not proven that checklists help decrease the risk of errors? I don't think anyone on this thread said to take six months from clinical training and devote it to QI only. I think having well rounded training is essential and I personally believe some QI is vital to becoming a well rounded physician. Learning how to do a root cause analysis and improve your practice (whether personally, at department or institutional level) is important for all physicians. I also think that the more you know, the more marketable you become. You best bet anesthesiologists that position themselves within the hospital "BS" are going to fare better then those who only sit in the OR doing cases all day. The good old days of anesthesia are over - but that is another discussion all together.

These sorts of things (black belt projects, QI projects, whatever you want to call them) are going to be happening at most hospitals. You can either learn it and participate or you can decide to sit back and let others do it. But when the "bureaucrats' make changes while you were absent, then don't complain.

 

[calvnandhobbs68]

Why should you give a crap about learning QI? Because everyone is going to care about it in the future. As much as the old timers on here will bitch and moan about it being corporate crap, it's the way things are going. The gov and insurance companies are going to pay based on QI metrics, every hospital in the country will have QI departments. You're not going to be able to beat 'em so join 'em. Would you rather have a bunch of non-clinical "analysts" and MBAs dictating these projects or would you rather actually have some input into it? Because it's happening whether you decide to join up or not.

 

[WingedOx]

Why should you give a crap about learning QI? Because everyone is going to care about it in the future. As much as the old timers on here will bitch and moan about it being corporate crap, it's the way things are going. The gov and insurance companies are going to pay based on QI metrics, every hospital in the country will have QI departments. You're not going to be able to beat 'em so join 'em. Would you rather have a bunch of non-clinical "analysts" and MBAs dictating these projects or would you rather actually have some input into it? Because it's happening whether you decide to join up or not.

Bingo.

 

[criticalelement]

All of it is gobledygook. It's like writing He who expresses merriment subsequent to everyone else expresses merriment of most superior quality when you wanna say he who laughs last laughs the best.

 

[nimbus]

All of it is gobledygook. It's like writing He who expresses merriment subsequent to everyone else expresses merriment of most superior quality when you wanna say he who laughs last laughs the best.

I agree. Real quality is hard to measure so nobody does it. Instead we check off a box after we give metoprolol 1mg to a cabg patient. Complete BS.

 

[IlDestriero]

That's not really true.
If you have the volume and easy access to the data through a good EMR, you can track your own quality metrics.
Ie post op pain scores with different drug combinations, emergence delirium rates, antibiotic administration, post op temperature, turn over time, etc.
That can potentially change your practice for the better and identify outliers in your group.

 

[fakin' the funk]

When Daniel-san in The Karate Kid (1984) ...Mr Miagi responds grabbing his belt and looking down at it, " J.C. Penney 6.99. " I hope you get the meaning behind that anecdote.

I think you have a point.

But also keep in mind, Mr. Miyagi was training a dangerous sociopath:
The Karate Kid: Daniel is the REAL Bully

 

[criticalelement]

I think you have a point.

But also keep in mind, Mr. Miyagi was training a dangerous sociopath:
The Karate Kid: Daniel is the REAL Bully

daniel san was and is no bully. He was sticking up for himself. The cool kids felt because he was courting the girl that they wanted they could bully him.

Karate here, karate here, karate never here (pointing at the belt). In okinawa belt means no need rope to hold up pants. Evading his questions because he knows none of those belts mean anything even though myagi has achieved 5th dan black belt status. He has trascended worrying about belts and arrived where wisdom is more important. Lots of strong lessons to be learned from The Karate Kid 1 (1984).
take a look..

 

[nimbus]

That's not really true.
If you have the volume and easy access to the data through a good EMR, you can track your own quality metrics.
Ie post op pain scores with different drug combinations, emergence delirium rates, antibiotic administration, post op temperature, turn over time, etc.
That can potentially change your practice for the better and identify outliers in your group.

Again you're talking about a lot of surrogate measures of quality, not actual quality. We should be measuring postop infection rates, not antibiotic administration. Periop ischemia and MI, not beta blocker administration. And anybody can get a good postop temp by throwing a bair hugger on the patient's head. Is that really quality? You can be a ****** giving lousy sloppy anesthetics, routinely sticking patients 5x for an IV or Aline because you don't know how to use ultrasound and have nearly perfect "metrics". I have seen it.

 

[Mman]

Again you're talking about a lot of surrogate measures of quality, not actual quality. We should be measuring postop infection rates, not antibiotic administration. Periop ischemia and MI, not beta blocker administration. And anybody can get a good postop temp by throwing a bair hugger on the patient's head. Is that really quality? You can be a ****** giving lousy sloppy anesthetics, routinely sticking patients 5x for an IV or Aline because you don't know how to use ultrasound and have nearly perfect "metrics". I have seen it.

Not really. We should be measuring those things, but the way you get better is by improving the process that contributes towards the final outcome. Just measuring the final outcome and nothing else doesn't help you actually improve. Process improvement is the way you get the outcome as close to perfect as possible.

 

[Psai]

Not really. We should be measuring those things, but the way you get better is by improving the process that contributes towards the final outcome. Just measuring the final outcome and nothing else doesn't help you actually improve. Process improvement is the way you get the outcome as close to perfect as possible.

But if you set out sticks and carrots for the process then the process becomes disproportionately important and something to game. Instead of doing what's right for the patient, this encourages people to do what's right for their paycheck. Pretty bad way to practice medicine.

 

[IlDestriero]

Again you're talking about a lot of surrogate measures of quality, not actual quality. We should be measuring postop infection rates, not antibiotic administration. Periop ischemia and MI, not beta blocker administration. And anybody can get a good postop temp by throwing a bair hugger on the patient's head. Is that really quality? You can be a ****** giving lousy sloppy anesthetics, routinely sticking patients 5x for an IV or Aline because you don't know how to use ultrasound and have nearly perfect "metrics". I have seen it.

If your hospital/surgeons aren't already tracking infection rates, periop MI, blood use, etc. you're behind the times. That's a given. They were tracking that 20 years ago.
Those other things I mentioned are quality metrics, just not metrics that you seem to value. If you keep the patient warm, you avoided unintentional hypothermia, that's quality. If your patients post op pain score is 3 out of 10 higher than your partners, that's not quality. If you don't give abx within an hour of cut or give them late, that's poor quality whether the patient gets an infection or not. If your room turn over time is excessive and unpredictable for the same level of case, that's something to identify and correct. Though that would be more quality of life, you could go home earlier or make more money with another case.
If someone is giving "******ed" anesthetics you should have internal QI and chart reviews to track that and identity problems. Isn't that a requirement for MOCA? I thought someone in the department had to sign off that I was participating in QI via M&M conference and internal chart reviews?

 

[calvnandhobbs68]

But if you set out sticks and carrots for the process then the process becomes disproportionately important and something to game. Instead of doing what's right for the patient, this encourages people to do what's right for their paycheck. Pretty bad way to practice medicine.

And that's why it's important to have physicians involved in deciding what process measures to measure and which ones dont't matter. But hey if nobody wants to be interested and step up the hospital is going to start measuring something anyway and you guys can all complain about it later.