Sunday, October 21, 2012

Survey Says!

Picture an episode of the game show "Family Feud." The question: One hundred health care workers were asked, "Name the first feeling you have when you hear the words 'The Joint Commission.' " 

Chances are, when the show's host shouts his famous "Survey says!" line, TERROR will be the top answer on the six-item list. (Followed by fear, anxiety, dread, panic, and shock.)

The Joint Commission ( is the organization that accredits most hospitals and many other health care facilities in the United States via so-called "surveys" (a nice phrase for "inspections"). Accreditation is the key to Medicare reimbursement, as well as a generally recognized standard of patient care. So organizations desperately want to comply with The Joint Commission's standards, for both financial and public relations reasons. Complying with these standards, though, can be a challenge, due to the sheer volume of requirements. The updated 2012 version of the CAMH (Comprehensive Accreditation Manual for Hospitals) is more than 750 pages long. No joke; I've got a PDF of it on my laptop. So this terror response to an impending Joint Commission survey is somewhat understandable.

But I believe in The Joint Commission, and its mission statement:

To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. 

Maybe that sounds corny, and naive (given that I am not yet in the trenches of health care work). But I am currently doing freelance editing and writing for Joint Commission Resources, the publishing arm of The Joint Commission. And the materials I have been exposed to have convinced me that overall, The Joint Commission isn't out to punish people, it's out to protect patients, and ensure the best possible care for them. And isn't that what physicians, nurses, and other health care professions should strive for as well?

I am both a journalist and a scientist, and out of service to both of these roles, I will provide evidence to support my claim. Others may or may not agree with me, but I hope that this post will at least provoke some thought, and perhaps some discussion.

First of all, most of The Joint Commission standards I have seen - while complex and extensive - make sense and have a purpose. For example, organizations are required to have a formal, written "Emergency Operations Plan" (EOP) that takes what is called an "all-hazards" approach to emergencies. Basically, what this means is that a hospital (or other facility) has to be prepared for whatever may happen, along with having specific steps and procedures in place for dealing with certain types of more likely situations such as fires. The EM (Emergency Management) standards and related EPs (Elements of Performance, which are basically broken out objectives) literally comprise 20 pages of the CAMH. There are standards related to evacuation, utilities management, licensing of independent practitioners in event of a disaster, and many other scenarios and issues. That's a lot to keep track of, obviously. But think of it this way - if you were a patient, or had an ill family member in the hospital, wouldn't you want a hospital to have such a plan in place and ready to initiate at a moment's notice? Without such a plan, an emergency or disaster would cause absolute mayhem. Of this I am completely convinced. 

One of the things I have enjoyed most (and also benefited from) with regard to my freelance work for Joint Commission Resources is reading case studies related to implementation of certain standards. For example, one of the case studies I read involved a small community hospital that faced a major hurricane. The hospital lost power, and risked losing generator capability as well, so was forced to evacuate all of its patients to surrounding facilities. Without electricity, though, such an endeavor is a feat. Consider that the hospital was several stories tall, and the elevators were out of service. So non-ambulatory patients had to be carried down the stairs on gurneys. Remember also that without electricity, photocopy machines were not working. Which meant it was impossible to copy patients' charts prior to their transfer elsewhere. The solution to this problem was that hospital staff accompanied patients to the transfer locations, copied the charts there, and brought the original charts back to the community hospital (because both locations needed the patients' records). While the case study (and the hospital administrators) acknowledged room for improvement, and a few hiccups in the process, for the most part this complicated evacuation went pretty smoothly. And that was because the hospital had a detailed EOP. 

Second, The Joint Commission genuinely (in my opinion) tries to provide resources to help hospitals better comply with all of these standards (via Joint Commission Resources publications). Many of these resources are articles and books that specifically address complex standards. Some of them are best-practice examples from organizations that have gone above and beyond in developing a particular policy, procedural checklist, etc. I have been working with Joint Commission Resources to secure permissions for some of these best-practice examples, and have seen how Joint Commission standards can inspire organizations to improve their own workflow, procedures, and policies with the ultimate goal of providing improved patient care. 

Third, I have been inspired. I know I'm not even in medical school yet, much less a practicing physician facing a Joint Commission survey. But some of the case studies, and responses to Joint Commission standards, have given me ideas on how to better provide patient care in my capacity as a Spanish medical translator, as well as ideas for patient care practices in my future as a doctor. For example, one case study I read referenced the development and use of something called a "Patient Care Notebook." This was in response to miscommunications and accidental gaps in care, especially after a patient was discharged from the hospital and went into the outpatient setting (or vice versa). The Patient Care Notebook is just that - a notebook (rather, a three-ring binder) with dividers for different types of information, medication logs, doctor's visit logs, space for patients to write down their own questions (and the practitioners' answers), important contact information, discharge papers, care plans, etc. This helped organize a patient's medical information in one place, and provided a tool for both the patient and his or her practitioners. It was something the patient could bring to every visit, hospital stay, etc., and add (or remove) information (medications, etc.) as time went on. 

As I came across this, I thought to myself, "How brilliant!" I immediately e-mailed the community outreach coordinator at the clinic where I volunteer, to see whether she might be interested in incorporating this tool into the patient health literacy initiative she is working on (and I am helping with). I also realized that this type of tool is something I could develop and customize for my own patients in the future, as it is not readily commercially available. (Which does not make sense to me at all, given how beneficial it has the potential to be.)

So if I were one of the health care survey respondents, and was asked that question I posed at the beginning of this post, my answer would be different: "Gratitude."

Sunday, October 7, 2012

Long-Overdue Update

Well, it seems it's been 2 months since I last posted. How time flies, doesn't it? But I've been keeping myself out of trouble, I promise. Here is a bit about what I've been up to ...

I wrote in a previous post that I had a tentative part-time job at the University of Illinois-Chicago Anesthesiology lab where I worked as an unpaid assistant for two summers (2010 and 2011). I started that job (paid this time!) back in mid-August. Working there, being paid to do what I do, and having so many more responsibilities than I ever did before, I feel just a little bit more like a "scientist." If that makes sense. I'll see if I can explain.

When I was a summer lab assistant at UIC, I worked with a wonderful post-doc named Olga who has become something of a mentor to me. She still works in the same department, and her lab room is actually next to mine now. When I have a question about something, I usually go ask Olga. Not only will she help me (or help me figure out where to find the answer to my question, if she doesn't know), but she does so happily and willingly. Not everyone is like that. Olga taught me to pipette, to set up PCR, to run gels, to culture cells. It was while I worked with her that I discovered my love of bench science and research.

With the wonderful background Olga provided me, as well as what I learned in my post-bac coursework and research at Dominican, I felt I was ready for a position with more responsibility and autonomy. Well, I got it! While there was a bit of a rough start, things are going quite well now. And in that rough start, I learned a great deal about the scientific process, and my aptitude for it.

I was hired at UIC to genotype mice. My department is trying to breed double knockouts (DKOs, for short) of several genes in order to study these genes' combinatorial roles in lung diseases. Genotyping mice, at least the way we are doing it, involves (in part) two techniques that are quite familiar to me: PCR and gel electrophoresis. I did both of these with Olga, as well as in my Research Methods course at Dominican. But genotyping involves many more steps as well, steps which were new to me. In addition, while I had done both PCR and gels, I had never done them completely from start to finish. By that, I mean from ordering primers to taking the gel photo in the dark room. I had done the middle part - the actual PCR and the gel - but not the initial and final steps. So I definitely had a lot to learn when I started this new position.

So here is the basic outline of the genotyping process:

1. Cut small pieces (about 0.5 cm) of mice tails
2. Digest mice tails to extract DNA
3. Run two rounds of competitive PCR (one for each gene) to amplify the DNA
4. Run a gel to determine whether each mouse is a wild type, knockout, or heterozygote for each gene
5. Analyze results, and hopefully set up new breeding pairs if you get any DKOs

Steps 1 and 2 were brand new to me. But I am proud to say that I am now a mouse anesthesiologist and surgeon! On one of my first days at the lab, my supervisor took me down to the animal facility and taught me how to anesthetize the mice, tag their ears, and snip of a bit of tail into an eppendorf tube (being careful to wipe with ETOH in between each mouse to avoid DNA contamination).

One of my gels, from last week. Pardon
the over-exposure and the line of dNTPs
at the bottom. I'm still working out the
kinks with my primer concentrations
and still getting the hang of working
the darkroom camera ... it's a work in
progress, but I'm getting there!
The tail digestion step was a bit of a debacle to begin with. I started out with a complex and time-intensive protocol that was handed down to me by another post-doc at the lab. It involved using proteinase K and several other reagents, heating the tail tubes in a 55°C water bath for four hours, and then inactivating the proteinase at 95°C for 10 minutes. When you counted prep time (thawing reagents, pipetting, labeling tubes, etc.), the whole process lasted somewhere between five and six hours. And I was getting very inconsistent results. But honestly, I wasn't sure whether it was the tail digestion or the PCR that was the problem. For example, my primers could have been bad, or I could have been over- (or under-) digesting the tails. I literally worked with this protocol for a month, to no avail. Then my supervisor suggested I go talk to the woman, Debbie, who runs the Molecular Core, where the PCR machines are. I asked her how long she incubated her tails for.

"Oh, I use a kit," she said, nonchalantly. "Why, what are you doing?" After I gave a brief outline of my method, her co-worker literally busted out laughing and said, "Wow, you're really doing it old school!"

This "kit" is a miracle: while my protocol was taking five to six hours, the kit takes 30 to 45 minutes. And, as if that weren't enough, the kit comes with a pre-made PCR master mix that contains a Taq JumpStart antibody which prevents the Taq from activating at room temperature ... meaning you can set up PCR on the lab bench rather than on ice! It's absolutely amazing.

Debbie let me borrow her kit to try it out, and it worked beautifully. My results are now consistent, and I even determined last week that we indeed did have several DKO mice - three males and one female.

While it's obviously exciting to get results, what's also exciting to me is the process of science. I faced frustration, and I didn't give up - I worked on figuring out what was going wrong. Also, one of the things that always amazed me about Olga (when I worked with her those first two summers) was that she always had several experiments running simultaneously, and somehow the timing all worked out. I am learning how to do that as well - how to time my agarose melting, reagent thawing, and PCR and gel running (along with meticulous notebook note-taking) so that I get the most out of my time there.

I work at the UIC lab three days a week. This past Thursday I was working from home on freelance writing. When I woke up that morning, I felt a little sad, and thought to myself, "I wish I were going to the lab today."

I think that's a good sign.