How are there only two and a half weeks before the end of this internship? It is extremely scary to see the end coming into view; I cannot believe that we have been in India for over eight weeks.
In my last blog post, I had written about a Japanese manufacturing approach called mistake proofing, and my hopes to see if certain mistake-proofing ideas could be implemented to improve patient safety. My supervisor for that project did not see mistake proofing for the panacea that I did, and she instead suggested that the issue was really making sure that the various checks in place do in fact occur. I still feel that certain small uses of mistake proofing can help, but I have also taken my supervisor’s suggestion to heart. I have tried to quantitatively model patient safety to see how many errors we should really expect to see if every protocol is strictly adhered to. The results of the simplistic model that I created suggest that my supervisor is correct in that much of the execution of protocols looks to be incomplete; many of the checks that are supposed to be done to prevent mistakes from occurring do not seem to be taking place. My own personal observations also confirm this; in the pre-op room, sometimes doctors or nurses will forget to do a recommended check, or they will fill out a checklist after dealing with a patient, when it is too late for the checklist to do any good. The question is how to change this: how do you increase concentration on patient safety and adhering to protocols?
Of course, the work that I am doing in helping to put together a patient safety manual with complementary presentations and posters should be helpful. But beyond that, I have wondered whether additional measures can be taken. One idea I have is to try to give doctors and nurses more feedback on patient safety. At present, doctors and nurses only get feedback about adverse events and documentation errors- they only hear that a certain number of errors occurred in a year or they hear that a certain number of documentation errors were discovered in an audit of their files. In many ways, feedback on the adverse events that have already occurred may fail to have much impact on the average doctor or nurse. Aravind has so few complications and adverse events in a year that most staff may rarely feel connected to an adverse event. In this way, there is not much to inspire change or reveal mistakes in execution of protocols. My thinking is that we may be able to turn to other industries to learn about how they avoid mistakes and instill cultures of safety. For instance, how do those in the financial services industry avoid getting burned by an economic downturn, or how does a nuclear power plant, which truly cannot afford any mistakes, maintain a perfect record? In both of these industries, we can hardly say that full proof solutions has been found- the recent financial meltdown in 2008 and the list of infamous nuclear power plant disasters from Chernobyl to Fukushima certainly are evidence of this. However, something that both of these industries take advantage of, which I think is instructive, is the use of leading indicators as well as lagging and current indicators. Leading indicators are data and information that tend to move a certain way in advance of something; an example in economics would be something like business inventories, which tend to trend up in advance of a recession. Nuclear power plants over the past two decades have been using certain leading indicators to identify problems in reactor safety before they happen as opposed to waiting for an event and then studying it for insight after the fact. What if Aravind had certain indicators and data that it collected that could predict medical errors? What if there was a way to measure whether patients feel safe in a clinic or adherence to proper protocols even when no adverse event occurs? This could be powerful data because it could allow you to catch lapses and holes in the system before they led to something dangerous. But perhaps more powerful even than that, just continually returning data and feedback on patient safety to staff should encourage them to think more about the issue of patient safety. It should promote a culture of evaluation, reflection, and improvement that already exists in other data driven areas of quality at Aravind. A key challenge is what exactly are the key leading indicators and how do you continuously and accurately measure them? I have some ideas about this that involve taking advantage of the existing infrastructure in obtaining patient feedback, but I’ll save some of those thoughts for my next post, when I will hopefully have more updates on this front.
Beside patient safety, the last few weeks have also been marked by some exciting new adventures. We owe more than a few of those adventures to the faculty at the hospital, who have repeatedly given us excellent advice on places to visit and food to try. Mr. Devendra, works in an office just two doors down from us, has taken a particularly prominent role in shaping our experiences over the last few weeks. Three weeks ago, Devendra invited us to go along with him and a band of young doctors for a Sunday trip to an eponymously named mountain spot called Ramakkalmedu, which is mythically tied to the legendary Indian figure, Ram. Part of the beauty of the spot was that when you stood at Ramakkalmedu you also effectively stood at the border of Tamil Nadu and Kerala. Amazingly, it was actually possible to make out the different trademark terrains and foliage of the two states. On one side were the lush, green, rainy hills of Kerala, and on the other side were the flat, arid plains of Tamil Nadu. It was without a doubt one of the most astonishingly beautiful sights of the trip thus far.
Devendra also contributed to an adventure the following weekend. Early on in the trip, Devendra had suggested trying a local food joint called Murugan Idli Shop. He told me that the CASI interns of last year had been big fans of the traditional south Indian food served there, and when I later asked Abhi Ramachandran to confirm, he told me that it was indeed worth a visit. On a Sunday evening, I decided to pay Murugan Idli a visit after going to check out the famous “Thousand Pillar Hall” in the Meenakshi Temple. Hillary, a Hong Kong native and graduate of Georgetown, who is interning at Aravind for the month of July, tagged along with me, and when we arrived at the Murugan Idli Shop, I have to believe she was questioning my claims that it had received top marks from two trusted sources. The banana leafs used instead of plates and the questionable hygiene of some of the containers that waiters were wafting around before doling out heaps of chutney and sambar on the banana leafs could not have inspired much confidence. But Murrugan Idlii lived up to expectations and then some- I do not think that I have ever had better South Indian food in my life. We have since returned there with Busra and Olivia in tow, and I am already hatching plots for a third trip there in the coming weeks.
This past weekend, Busra, Olivia, and I visited Kodaikanal, a nearby mountain town. We were very fortunate in that my aunt, who is a wildlife conservationist and lives at the edge of a tiger reserve in the neighboring state of Karnataka, had offered to come along and drive us to Kodai. On Sunday, we were able to enjoy a morning of trekking around the hills before returning to Madurai. It will be impossible for me to fully capture, in words or pictures, the beauty of some of the mountain views in Kodai- it has the feel of a town in the Alps, something that is astonishing when you consider the fact that the muggy, 100-degree-faherenheit climate of Madurai is just a three-hour drive away.
This week, we are all excitedly looking to the weekend, when we will be off again, this time to Pondicherry. The motivation behind the trip is of course in part to be able to check out the unique former French colony, but it is also to be able to visit the Aravind base hospital located just outside of the city. At the Pondicherry hospital, we will get a chance to discuss our projects with relevant parties. In my case, I will be sharing the fruits of my labor in studying trends from patient feedback data and discussing the new plans to install a comprehensive patient feedback program, equivalent to the current setup in Madurai. I look forward to sharing some of those experiences in my next (and what will be my final) blog post from India.