Now it's my pleasure to welcome our keynote speaker, Dr. Michael Grant. Just a few words on his background. Dr. Grant is an Assistant Professor of Anesthesiology and Critical Care Medicine at the Johns Hopkins University School of Medicine, where he works clinically as a dual fellow ship trained surgical critical care intensivists and cardiovascular anesthesiologist. He's the Director of Clinical Operations for the division of cardiac anesthesia, the Deputy Director of critical care medicine and the Institutional Director of anesthesiology for the enhanced recovery program at Johns Hopkins. In addition, he's a core faculty member of the Johns Hopkins Armstrong Institute for Patient Safety. If that's not enough, he's in his last semester of the EP Systems Engineering master's degree program. He also happens to be the son of Conrad Grant, the Chief Engineer at APL. Conrad was one of the authors and one of the founding fathers of the health care systems engineering program here at AP. So we've invited Dr. Grant tonight to share with you how he applies systems engineering principles to health care setting, Dr. Grant. It's a great pleasure to be here tonight. So I thought one of the best ways to articulate this space to you was to walk you a little bit through the medical problem that I think of, talk about in a little bit on a local level, and then talk a lot about how this program has shaped not only in the way that I think about these problems, but some of the solutions that I've come to. A little bit about me. Some of this was mentioned, but I'm first a clinician and I only say first because that's how it happened chronologically. What I have come to appreciate more recently in fact is that there are other hats probably just as influential as that clinical piece. I'm a core faculty of the Armstrong Institute. For those that aren't aware of what that is, it's a patient safety and quality outfit where we strive to really hone in on those key aspects of patient care that are exemplars of ways to not only enhance the quality of care that you provide patients, but also reduce some of the safety issues that occur every day. Then specific to what I'm here tonight for, I am in fact a master's candidate, and I hope to defend knock on wood this December my thesis to be able to complete that program. Importantly, each one of these pieces has very strongly facilitated and influence the way that I think about this problem space. So what does that mean? So I'll start a little bit about what the population health care problem actually looks like. It turns out that we spend about $3.5 trillion annually in the United States on health care. That's about $10,000 on each individual patient in the United States, and that's number one in the world. That's not the number one that we want to be, obviously. Well, it turns out that that is also the highest percentage of our gross domestic product, but in fact it's actually twice what comparable country averages are across the world. That might be okay if not for the fact that we're actually not doing a great job with our health care. So it turns out that our health care quality and access index rating, which is a measure of not only access to care, but the quality of the care that you actually get is amongst the lowest among industrialized nations. In fact, we not only don't live as long as other industrialized countries, we actually unfortunately experience longer periods of time disabled from otherwise preventable illnesses. So again, these are statistics that are a little bit harrowing and in fact we fall amongst the worst in a number of the major outlier ways that we care for patients. It turns out that at the end of all of this, when you bring somebody in to care for them, we actually harm them. So it turns out that about 20 percent of our patients experience some medical error during the course of their medical care. Again, this is a really damning set of statistics. More recently, what we've come to find is that in fact medical error is the number 3 leading cause of death in the United States, that's after cardiovascular, cancer, and then it's medical error. In fact, I've heard a recent specialists say that if you were to crash an airplane into a building every single day for a year, you wouldn't amount to the medical error that leads to the harm that we're seeing every single day. So this is a problem. Now, that's so insurmountable problem that in fact you might say to yourself, "This is just too big a problem. This is something that I alone cannot manage." So that's a somewhat difficult and maybe future problem for us to tackle, but let's think a little bit more locally. So the local health care delivery problem, I became aware of that over a drink with this goofy guy. So this is Conrad Grant, this my father, and I want to correct one thing. I'm not his son, he's my father. For a millennial moment, just for everybody to see. So I asked my father if he could send me a selfie for the sake of this presentation, and this is the one who sent me. So apparently you get some dark ranger in the middle of the desert when you want a selfie from your father. But suffice to say, this is how the story goes. I came home from my very first shift as a clinical fellow in the ICU, and that night was a pretty tough one. We ended up having a couple of patients unfortunately passed, but one patient in particular rang true to me. What had happened was I ran into the room in the midst of a collapse, a hemodynamic collapse. I was able to place a breathing tube into that patient, but then also use a needle to decompress his lung, and it saved his life. I remember walking away from it and having people literally cheer. The next morning on rounds, we talked about all of the things that we had done for this patient. We felt really good about ourselves, and I remember telling this entire story from beginning to end in front of my father, and I thought I'd get the same reaction. In fact, I didn't. In fact, I got a whole host of things that I've come to become appreciative of in engineers, and that is just more questions. But one thing that stuck out to me was a quote that I don't think he realized he said at the time, and it was, this, "Heroics should not be idolized. These acts are examples of near-misses, unanticipated risk, and poor system design."That part really stuck with me. I didn't understand that part. So I thought to myself, "What are you talking about? This is Johns Hopkins that we're talking about. They wanted me there. I'm the specialist in the room. I have unique set of talents and gifts that are supposed to be able to fix this problem. " But in fact, that's not the point, right? So as this room knows quite well, if you get to the point of heroics then something's gone wrong. So when we started to think about what this could look like in this problem space, I remember this slide very commonly used in some of the major engineering texts. The idea is that this is a complicated system, untenably complicated to the point that no individual alone could possibly understand the ramifications of all of these interlocking systems. In fact, what I didn't appreciate is this is that same thing. This is a patient who I was wheeling down, and taking this picture. This is my patient that I'm wheeling down the hallway. It's unfortunate male who's just undergone a open-heart surgery, connected to a heart and lung bypass machine. In the back, is a whole host of medications infusing. There are a number of other support devices, and collectively around that patient, we have almost 200 years of experience in taking care of that person. That sounds an awful lot like a complicated system, not something that I would have appreciated at the time. What I realized was I needed more training. Unfortunately I had done 15 years of traditional clinical training and realized that I didn't know anything, basically. That in order for me to actually have the kind of impact I needed, I needed to go back and understand these systems. So that's when I enrolled in this program. What I realized was the next step after both of these is a marriage of the two that allows me to integrate that learning and that knowledge into a care pattern that can help to improve patients from the ground up. So that's where systems engineering came into play. So what I had in the very first presentation of the very first class that I took, and by the way, this was Frank Wells, who was the instructor: Introduction to Systems Engineering. I saw this slide, it was presented about four different ways during the course of the entire lecture. But the point of it was, at the very beginning of any problem that you're trying to solve, you have to establish one of two things, you either need a user need, you need some deficiency in your system, some opportunity there, or you need a technological opportunity, something you didn't have before that might make you do better as a result. I can't tell you how important this was to me because what I began to see in my everyday life was technological opportunities and deficiencies. In fact, in some ways, this was a problem, right? We saw individual pieces of technology that in and of themselves have incredible opportunity. They can be harnessed to give us something that we as individuals can't possibly have in and of ourselves. But what becomes incredibly important is that all of these things have to exist in the same space. So you can imagine me standing in the middle of this room, this is my cockpit, where each one of these individual technologies consumes me, right? So if you don't hone these and use these the way that they're supposed to be used, you actually can be buried in it. It can be a distractor. Doesn't actually lead to improvements in care. It actually can be a problem for your care, and all of this happens quite quickly, as you can imagine. But beyond just the technology, what we aren't doing well in medicine is just the simple processes. So this is a depiction of what I like to consider the standard of care versus what I could envision to be the new care, right? So standard of care says I bring a patient into the hospital. The intention is for them to undergo surgery. They undergo a preformed surgical insult, but it turns out they never get back to their baseline recovery. So they're actually less of a person when they leave that hospital than they were beforehand, but the whole point of them coming in was for us to fix the problem. Well, you could envision that there might be some new opportunities, some new intervention. Where not only do you reduce the surgical insult, but you actually get those patients to a new and improved state, and that's what I thought we could potentially do with this space. So what I began to envision was the idea that we could engineer perioperative health care. So how do you do this? You need a road map of sorts. I Just wish there was a, wait, there is a road map of sorts. So this became my mantra. Some version of this I know is presented in virtually every class in the curriculum. I cannot tell you how important this was for me, and I know that over and over I'm hearing instructors in my head say that this is not a formulaic thing, so that you can't possibly use this as a road map. But I have to tell you that if you want to take this and translate it to my colleagues every day, you have to give them something. So what we did was we put together this framework. As you can see, it's adopted from that former one. It shows the engineering V, which I love to say out loud anyway, but it really helps you to conceptualize this and drive it forward. Help your counterparts understand that you're developing a system, you're implementing that system, and by the way, it doesn't live in and of itself as an isolated point in time, you have to feed it back, so you have to improve that system as well. Again, this is a mantra that I've come to appreciate, but when you're trying to tell it to my colleagues, it's a harder thing to do. So what I did was, I went through the coursework and I applied in a serial fashion each one of these pieces. So I took systems conceptual design from Dave Flanigan, he not only reinforced the piece that I mentioned about your technological opportunities in your various deficiencies, but he basically said, if you want to figure out what the problem is, you have to go to the source, you have to talk to your users, you have to look at your current operations, you have to understand what those things look like, and that's affectionately considered your needs analysis. Well, it turns out we have lots of needs, and I've only outlined a couple of them here. But in medicine we have problems because we forget the patient is our patient. We forget that there are outcomes that we are not speaking to. We think we're doing a good job, but we may not. We have technology that hasn't been incorporated seamlessly. We have administrative issues in terms of gross negligence, in terms of lengths of stay. We have cost problems, and then at the end of all of this, we have providers that are ragged out and don't understand what kind of impact they can have. This is an approach that can allow us to address each one of those things. Dave Flanigan also told me later on in this course that I needed to think about this as a black box, a gray box and a white box, which at the time sounded like I don't even know what language he was speaking. But what it really helped me to understand is that when I'm trying to figure out where my system could go, I have to understand where it is today. So what that meant for us was that we needed to look at our care pattern. What are the things that we're doing for our patients that we should be doing, and what are the things that we shouldn't be doing? So we went back to the literature, and I know this sounds perfunctory, but we went back to the literature. We found those individual pieces, those care processes that we needed to incorporate every day. It turns out there's a lot of this information, but I don't know if you guys know this or not, but physicians are overwhelmed. They don't know how to read those literature, they don't know how to incorporate those pieces, and often times, despite the fact that it's out there and we theoretically know about it, we don't operationalize it. We got into this as well, and we decided we were going to look at all of the literature that exists in this space, and go even a step further and we were going to look at each of the individual care processes that are incorporated successful programs. Turns out there were more than 200 of them, this is just a smattering example. But we literally looked at the individual pieces that needed to be applied in the perioperative space, and decided whether or not they should be in our program. But as you guys know, that's not enough. You have to identify the scope of your program. So this is that famous black box where you look at all of the external entities and determine whether or not they have impact on what you're doing every day. You have to create processes that account for those things. So we did that exercise as well. I'm proud to say that we did even more granularity, we did process mapping. We went through each individual process and we had all the people in the room that needed to inform that. We literally put sticky notes up and explained how is it that I'm supposed to do this thing, that thing and the other thing, and who's the person who's doing it. We color coded it. We were able to inject some various interesting thoughts into that. We then went forward and looked at things like concepts of operation. We specifically looked at whether or not we could do these new procedures. Is there a way for us to incorporate this into our current workflows? What are our current workflows? It turns out this exercise was actually pretty challenging as you guys know, and such a simple thing as getting a medication to a patient bedside was something that became a really untenable task for any one individual. Which is why this exercise, as you guys know, is so important. System design and integration taught by Steve Biemer, for me was also incredibly important because it helped me to understand that as you design that system, you're reducing risk. Now, if I were to say that to a physician right now, they'd have no idea what I'm saying, but this is something that's become second nature to me now. The idea behind this, as you guys know, is to articulate this system even more apropos. In this case, I've removed what the headings are, but you can see I've actually outfitted the individual components of my system. This is one individual medication making it to a patient, but we had to look at each individual component and how that happens. We've been able to articulate that, I think in a really interesting way. But pragmatically, what this says is, if I'm going to envision a new care pattern for my patients, I've got to not only look at the needs, what are the outcomes that I'm intending to address? What are the pieces that go into that? One example of this is if I want to reduce the amount of opioids that I use, this is a hot-button topic in the United States right now, I not only have to think about the medications that I want to employ or the potential regional components, these are things like nerve blocks. I have to be thoughtful about what the provider is that's doing that, where those dollars and cents come from, what's the procedure on getting it to the bedside? That's the implementation piece that we in medicine don't do well. We do it on an ad how fashion. Anybody here who has a daughter or a son who's a physician, can attest to this. So then it turns out that that's not enough. You can't just envision the system, and this is the disappointing part. You have to actually make sure it works. This, by the way, is also something that medicine does. Stas Tarchalski in system testing evaluation was the one who taught me a lot about design verification. Turns out that we just needed to make sure that what we were designing we were actually being effective. I'm happy to report that we've looked at this from every different angle you can imagine. Based upon HCAHPs scores, which is a patient satisfaction survey, our patients are happy with this project. We have less organ injury depending upon the kind of organ that you're referring to, we have shorter lengths of stay, we have a more efficient practice at lower costs, but the part that I'm also really excited about is that our providers find this to be useful. It has reinvigorated their sense of wanting to be around these patients and our retention rates have gone up dramatically as a result of that. Again, directly related based upon surveys to what we've done here. Another way to look at this is to envision how those outcomes relate specifically to the measures you've incorporated. So this is a depiction of how our opioid use in one of our major surgeries was affected by the installation of various medications. So depending upon the individual injection points over time where we added on non-opioid medications, we saw a concomitant drop in those opioids. Now, the reason that's important, as you guys know, is it proves that the thing we're putting in place has some measurable outcome benefit. Just as importantly, we want to make sure we're sustaining those enterprises. So what we're seeing as a result to the program you put in place is not only is the length of stay reduced, but it's sustained as a reduction over time. Over the course of the last year, we've had a very stable reduction at length of stay almost to the point where we ask ourselves are we sending people out too early? Importantly, that relates directly to the measures we're putting in place. In a step-wise fashion, basically a dose-dependent response. The things that we're doing for these patients are leading to better outcomes. That's an obvious important statement. But again, not enough. So as you're thinking about these projects over time, as Joann Saunders mentioned, we have to be thoughtful of performance schedule and cost. There is a routine maintenance program that needs to be done for each one of these projects. So we have to install individual scheduled maintenance periods, but also times for you to work on some of the casualties of that entire exercise. What we noticed was that we had a problem with something called the outliers. These were patients that weren't enjoying the same benefits as everybody else. We had to tackle what was happening with those specific patients, go back to the system, re-articulate the pieces that we're speaking to those specific patients, and try to get them the benefits everybody else was enjoying. That's what we did. We actually found that those patients were staying longer than everybody else for a number of different reasons. We mitigated those issues, and those patients now are enjoying very similar lengths of stay to their counterparts. As you may also know, the patients that stay the longest, the outliers, are the ones who absorb the most of the costs. That's a big teller for us. Then as you guys also know, iteration is king. As we've done over time, we've gone to individual measures and made sure that we're improving upon them. So examples, that purple bar at the top is one measure that we use in the operating room. It's one that we do quite well. We do so well in fact, that we've operationalized it and automated it. The point is that we don't necessarily need to track or put extra resources toward is it this point. So it's fallen off our grid, is being something we're focused on. Instead, we're injecting ourselves into other areas. So for example, the bar there this is dexmedetomidine. It's a medication that even though it was part of our pathway, we just were not able to get it to the patient. We injected ourselves into that space, and as you can see it's now the process measure that we do the second-most commonly. Again, a success factor because we've iterated this program, re-envisioned what this should look like, and tailored the program even more specifically. At the end of all of this, I would love to say that we can do any of this except for the freaking humans that are there. If it wasn't for humans, this would all be perfect. Importantly, what I felt was I needed to do that foundational work in human factors. Foundations in human as seen, Maggie Beecher for the longitudinal course, we looked at a traffic accident actually and what was the root cause around that traffic accident. I cannot tell you how important this was for me as a clinician to understand this exercise. It reminds me an awful lot of one of my mentors examples, which is something called the Swiss cheese model, where every system is perfectly designed for the outcome that it engenders. Which means that every fault that's in that system is leading to a perfectly designed endpoint. It may not be the end point you wanted, but it's an endpoint nonetheless and so you have to design that system very strategically. Integrating humans and technology by Kathy Straub. Again, I can't tell you how impactful this was because what I realized over the course of time is that we can do everything with grit and determination to a point. You have to be smart about how you envision your technologies in supporting those endeavors. Here, we started looking at things like patient reported outcomes, where they can actually use mobile devices to give us information. We've looked at wearable technology, where people can have the classic fitbit and give me information about how they recover. Now electronic health record, which is also a four-letter word in every hospital, it's something that we've had to outfit in a very strategic way to work for us and not against us. Lastly, one of the ones that I was actually not expecting to love is the social organizational factors of human systems engineering, Nathan Bos and John Gersh. They went through the concept of social networking and I thought, "what is this? This isn't something that'll be useful," until I decided to do it myself. This is an outfit where we literally, we took our program and we did a before and after snapshot of the social network that was created around the perioperative providers. What we found was, if you focused on the key players, the degrees of centrality, you could actually outfit a program that increased your output, got better outcomes and improve satisfaction scores, all simply related to its association with who the key players are. This is a publication that we've actually brought to publication in the past year. Then more recently I've started down the masters thesis line. My advisor has been Matthew Montoya, I've been lucky enough to have a committee with Larry Strawser and Alan Ravitz. One of the things that came up poignantly in this thesis work is that it's not enough just to simply look at workflow and technologies, there has to be a culture around us. That if you don't have the right people doing this work who are all like-minded in this respect, you will fail. For us what that has meant is every durable system improvement that we put into place, has to have a technical intervention component. The pieces that I've described, but also an adaptive cultural one, where we build teams of people that work together and we support them in ways that are softer not nearly as technical. In fact, this has been paid forward. We recently got a grant that has allowed us to do this work throughout the United States in an estimated 700 hospitals, and the only reason they allowed us to have that grant is because we have the adaptive component built into it. Without that piece, we're just another group of people doing a bunch of technical stuff. As I close, what I want to articulate for your two case scenarios, which are recent to me but important ones. This is a gentleman who underwent something called an LVAD procedure, which is where they take a mechanical device and they support an entire side of your heart with it. These are people who can walk around like everyday humans, but half their heart is mechanical. In this room, if you see him surrounded, he at this point is conversant but intubated, that means he's on a breathing machine. He has, as you can see a host of medications, in fact there are 12 infusing here, but that doesn't include the ones that aren't infusions. He has the mechanical device at his bedside and in fact his kidneys are also failed so he's on a kidney machine. This man is able to interact with us, he's able to write on a board with us and two days after this picture was taken, we were able to take his breathing tube out. Four days later, we were able to get him off of all other mechanical support devices and today he walks around amongst us as everybody else, and this has been two weeks since this picture was taken. We're doing incredible things. Another woman, this is Harriet. She had a heart failure. She got a heart transplant six hours before this picture was taken, I did her procedure and then was lucky enough not only do the anesthetic for her, I was actually able to take care of her in the ICU the very next morning, which just happen to have it work out that way. We were able to take her off of the breathing machine, but she has surrounding her a host of medications including special infusions, some other respiratory support devices, a whole host of tubes, etc. On the right-hand side is her walking around the unit. It's common place for us to have these patients who are being supported by multiple different devices walking around the unit. I cannot tell you how important that is for them to adjust experience everyday life. The reason that she's able to do that is because we have incredibly thoughtful people, engineers, and incredibly thoughtful people, physicians, who've come together and literally done miracles. As I think about this going forward, I think about all of the opportunities that we have before us, and it incorporates some level of cohesion between these two groups. I've seen it in my training through this program, I think you guys are touching people in ways you can't imagine and I can only see that it will continue to grow as we go forward. So with that, I really thank you for having me to speak today. I'm hopeful that Michael will answer a few questions. Yeah. Epstein, was last name in the book. I think it was called Trends, I've got the name wrong, but it started off comparing Tiger Woods to Roger Federer and how there's Tiger parents and there's parents like Federer because Federer didn't start playing tennis [inaudible] 17. But the real focus was on basically people like you that cross professions, and how people like you are critical to problem-solving in our world, sort of cutting through the problem of specialization. So you're in two fields, that's a tremendous level of specialization. Right. So I'm just curious what you have to say about that. Yeah. So I think it's a great starting point for the conversation because actually we were chatting about this at our table. One of the key features around problem-solving in either one of these spaces is that I was trained in my medical training to approach problem-solving in a completely different way than what I do through this work. What that really was, and again I mentioned this to them, is that we're taught to jump to the solution. So time is of the essence, I need an answer in medicine, or at least we're taught that that's the case, and so we tend to think that if that's the case in harrowing situations, then we must have to use that same approach with everything else that we're doing. As you guys know, engineering is just not like that. In fact, one of the things you are often taught in this program is you shouldn't jump to the solution, that's like the opposite of what you're supposed to do. I will tell you that having people in both spaces attack a problem is incredibly telling and the kinds of conversations that stem from these things are also really very interesting. One of the things that I often find is that I'll sit in a room and I take certain assumptions from my medical training into that space and I say, "we can't because of, " and there's some constraint. Then the engineer will say, "what are you talking about? That's not a constraint." There's no way for us to have had that conversation with that literally having it. I think one thing that you're speaking to is that not only is there a difference in the vernacular that we're using. I mean, we could talk all day about how I learned literally a whole new language by doing this coursework, but the fact that these people are starting from just a very different space when they're tackling a problem, I do think that that's a big part of the "issue" but an opportunity going forward. So for people who cross these boundaries, I think it's just that they're sensitive to those realities. So I was somewhat surprised to see the many tubes that were emanating from these patients, and I'm just curious, is anyone looking to see, are each and every one of these interventions frankly necessary? I mean, could you do equally well or perhaps better with less? I love this question. One of the areas of my particular interest is, do we have monitors that we have in place that are unnecessary? Do we have interventions that we provide that are unnecessary? Unnecessary meaning do they lead to outcomes that we expect? Are they just expensive and just fun as opposed to being helpful? What we're seeing are some of the lines and tubes that you're referring to are actually things that we use as crutches in medicine. So physician will say, I've only ever done this procedure in this fashion and I use this thing, and because of that, it's actually incorrect; it's not only dogmatic, but it's incredibly hard to push somebody off of that position. So instead, what we're seeing is that the younger guard are coming through and there's this wave of energy that goes in a different direction. It's very hard, I think, to prove the absence of something. So it's hard to understand that if I remove that thing, that people will do well because you feel like you're injecting risk into that space. I will admit that this is something that's very hard to study but something that I'm particularly interested in, and the short answer to your question is, absolutely. There are a host of these things that we just simply don't need and it's probably another wave of medicine going forward. I just want to say one last thing, you guys, I know this was already said earlier, you cannot understand how important this program has been for me personally. I also cannot tell you, projecting forward, how many people this will touch immeasurably in the medical space. So I just want to thank you all for your efforts.
