I was provided with the distinct honor of being a James IV traveling fellow during 2015. This was a fantastic opportunity and one for which I will be forever grateful. I divided it up in to two three-week segments with the first trip taking me to England and Scotland, and the second trip to Thailand, Singapore, and Australia. Throughout my trip I was able to connect with surgical and anesthesia leaders in Quality and Patient Safety Operations as well as Outcomes Research. I have attached a photographic journal of my trip as well.
Trip 1: Scotland and England, March 2015
The first trip took me to Scotland and England in the United Kingdom. On this trip I was fortunate enough to take my family inclusive of my husband, Nigel, and my daughters, Emily (10) and Sarah (8). As I had earned my Ph.D. in Transplantation Immunology at the University of Cambridge, and my husband was born and raised in England, this trip allowed me to meet new colleagues, as well as connect with old friends and family.
We left Columbus on March 14, 2015 and flew into Edinburgh, Scotland. There we spent our first weekend with Nigel’s family and were able to visit the very best Panda Bear exhibit I have ever seen (who knew Pandas liked Scotland?!). We also visited the Royal Britannia, which was once equipped to serve as a hospital boat for the Royal Navy along with other sites, including Edinburgh Castle.
I was then able to connect for two days with Dr. Andrew Longmate, who is the Strategy Director of Healthcare Quality for the National Health Service as part of the Scottish Government Health Foundation. Andrew was an IHI (Institute for Healthcare Improvement) fellow in Boston, and I was connected to him and his great work through Carol Harden, VP of the IHI here in the U.S. I was able to introduce Andrew to the work we have completed on surgeon engagement using Crew Resource Management and performance management tools for surgeons. Additionally, we spent a great deal of time discussing standardizing mortality reviews, and peer review for surgeons and physicians. Andrew is incredibly passionate about implementing change, including falls prevention and sepsis mortality reduction, and I was able to share best practices both used on a local and national level in America. In particular, I presented balanced scorecards we have used in our Clinical Transformation work as well as approaches to managing surgical patient safety events so to reduce occurrences.
After working with Andrew at the Scottish Government’s St. Andrew’s House, we then travelled to The NHS Royal United Hospital in Bath, England where I visited with Dr. Carol Peden, Ms. Anne Pullybank and Ms. Sarah Richards. Carol is the principle investigator on a national research trial to reduce mortality after emergency surgery. She is a critical care anesthesiologist who has implemented care pathways and algorithms to improve care amongst trauma patients that undergo emergency laparotomy. She partners with Ms. Anne Pullybank, who is the Head of General Surgery in Bath and together they have made remarkable improvements in patients who undergo surgery on an emergency basis. We spent time reviewing the program we had implemented around Crew Resource Management, as surgeon and physician engagement is of utmost importance to their leadership.
I was made aware of additional programs and saw very impressive data around their FAST program (Stroke Alert) as well as the implementation of the Safe Surgical Checklist and difficult airway management across the entire NHS. There is a real push towards transparency of patient safety across the entire NHS where simple visual tools are used to demonstrate falls and on time starts to all members of the care team. The NHS approach to engagement surgeons and anesthesiologists in safe, effective and efficient surgical care is a program lead by Dr. Peden and Ms. Pullybank entitled, “EBPOM: Evidence-Based Perioperative Medicine.”
After having toured Royal United Hospital, Ms. Sarah Richards was kind enough to share with me her work around Emergency Surgical Ambulatory Clinics. Ms. Richards is a trauma and acute care general surgeon who was finding that throughput in the hospital was preventing patients from getting the urgent surgical care they needed. She established protocols and processes to help assess patients in the ED (with consultants rather than senior house officers), triage them and often have them booked in the operating room that day or within 24 hours. She also put in place a process that included using ultrasound at the point of care in the ED and getting patients discharged the day of surgery for those who could tolerate it with appropriate home care or office visits. Her success at Royal United Hospital has now been replicated at other NHS sites and improved the patient throughput, securing patient care in a timely fashion.
After leaving Bath, we traveled to Oxford where we stayed in a lovely English cottage near Broadway, allowing me to travel to both Oxford and Manchester. In Manchester, I was able to meet with AQUA (Advancing Quality Alliance), a NHS collaborative in the southwest of England that brings nurses and physicians together around quality and patient safety. I was a guest speaker for a day-long symposium in Manchester where surgeons and physicians from across the southwest of England travelled to attend. My workshop included mortality review processes, Crew Resource Management training techniques, and performance management opportunities to ensure good patient outcomes. There were more than fifty people in attendance, many of which I stay in communication with as they develop quality programs in their own centers.
I spent several days in Oxford where I was hosted by Mr. McCulloch, Mr. Friend, Dr. Higsham and Mr. Mortensen. I met with the members of the Oxford Patient Safety Institute as well the Oxford Simulation Center which is entitled OxSTAR, and presented, “Engaging the Team in Attaining Zero Defects” at Grand Rounds. Mr. McCulloch’s team was tremendously engaging and his students presented their work on preventing adverse events as well as improving outcomes after emergency and ambulatory general surgery. Mr. McCulloch is the author of many of the IDEALS methodology papers which are focused on evidence based practice algorithms. The Oxford Group has elevated patient safety to really encompass the academic atmosphere of Oxford. I plan to return to Oxford in March of 2016 as Mr. McCulloch is now an advisor for my AHRQ Program Project Grant IDEA4PS which is a 4-year patient safety laboratory grant.
I then spent several days walking the English countryside with two very tired children before we travelled to London for two days where we connected with friends from Cambridge before flying back to the U.S. on March 31.
Trip 2: Thailand, Singapore and Australia (August and September 2015)
The second part of my fellowship started with attending the World Congress of Surgery in Bangkok, Thailand. Unfortunately it was scheduled to begin just days after a bombing at a local temple, but the Congress continued so I decided to make the trip, leaving America on August 21, 2015.
Traveling to Bangkok itself is quite an adventure, but after 15 hours and a layover in Tokyo I arrived safely. The World Congress of Surgery is a tremendous meeting of surgeons from literally all over the world. There were many presentations and I was pleased to see an entire portion of the Congress dedicated to Quality and Patient Safety. Whilst at the Congress I was able to meet with Dr. Pramyothin, the Executive Director of the Royal College of Surgeons of Thailand, as well as Dr. Pausawasdi of the Phramongkutklao Hospital. I also met with and was hosted by Dr. Kelly McDowell who is the president of the Global Surgical Consortium, and who invited me to speak on “Global Quality and Surgical Patient Safety.” The Asian countries, many of which are low income, are very focused on how to provide safe surgery and implementing best practices similar to what we have in America, including the Safe Surgical Checklist and professional escalation of care concerns within the hierarchy of surgery. A particular deliverable was sharing our work around clinical alarms and how low income countries can learn from our research so that only the appropriate patients gets monitored in resource-limited environments.
A particular highlight of my visit to Bangkok was connecting with a large number of members of the Association for Women Surgeons (AWS). We had breakout sessions that focused on women in surgery from across the globe and how to improve mentorship for all women in surgery. There were many social events as well, including breakfasts and a fantastic trip to Jim Thompson’s silk factory which featured dinner and lots of shopping! It was fantastic to connect with so many women surgeons from all over the world. Dr. Numann was presented with an honorary degree from the Royal College of Surgeons of Thailand which was a well-deserved honor.
I then travelled to Singapore where I was hosted by Dr. Tai, an anesthesiologist and previous IHI fellow as well. Singapore still has many roots in traditional Chinese medicine, but their innovation and technology is astounding. Dr. Tai invited me to speak at the SHINE (Singapore Health Improvement Network) on “Attaining Zero Defects: Engaging the Team.” Afterwards I toured KK Women’s and Children’s Hospital meeting with many nurses and physicians and exploring the use of RFID and patient tracking to prevent elopement and improve patient throughput. I was able to visit 5 different hospitals in Singapore. The Singapore health system is similarly concerned with preventing hospital acquired infections and hand hygiene. Dr. Peter Lu (ENT) hosted me at National University Hospital and Changi General Hospital for an entire day where we spent hours talking about maintenance of competency amongst surgeons and human factors in surgery. I also attended Department of Surgery Grand Rounds and heard presentations from 6 different surgeons on topics ranging from ERAS to “Better Colonoscopy Pathways.” Mr. Lam (Urology) hosted me during my visit to Tan Tock Seng Hospital where I presented on “Curriculum Development of Safety and QI in Residency.”
I spent two days with the Patient Safety team and reviewed many of their A3 projects as well as discovered how they have implemented lean training throughout the medical student and resident training. Dr. Wan is a critical care attending that hosted me at the National Heart Center. I finished my time in Singapore meeting with leaders of the SHINE network that work for the Ministry of Health for Singapore.
I then traveled to Melbourne, which was to be my final destination, meeting with Mr. Ian Faragher. Ian is a General and Colorectal Surgeon that I had met at Harvard many years ago when we were both completing a Leadership training course. Since that time, Ian has become heavily engaged in Quality and Patient Safety and invited me as a guest speaker for their Inaugural Western Health Quality Summit. I was honored to be a part of this very special summit that was really focused around patient engagement. I gave several workshops on Root Cause Analysis and Peer Review and I served on panels with other surgeons and healthcare leaders. Mr. David Watters was a part of this summit and as the current present of the Royal College of Surgeons of Australia, shared much around engendering a culture of patient safety so to prevent surgical patient safety events. Susan Biggar was another keynote speaker. She is uniquely positioned to speak on improving the patient experience as the mother of two children with cystic fibrosis and authoring the captivating booked entitled, “The Upside of Down.” A unique experience was meeting Dr. Michael Buist who joined us from Tasmania and is not only a senior leader and proponent for patient safety, but as a patient who suffered from a preventable surgical safety event, is also a keen and colorful Quality champion. The CEO of Western Health in Melbourne is Dr. Alex Cochrane, a physician and kidney transplant recipient. The Melbourne healthcare system has a very personal approach to improving the patient experience. My keynote presentation was entitled, “Value-Base Care Transformation: Engaging the Entire Team.” Melbourne was a fantastic city where Ian and his family hosted me at their home for 5 days.
The opportunity to be a James IV traveling fellow is one that will influence me forever. As I continue on my own personal journey as a national leader in Quality and Patient Safety, I now have an international perspective on how we as physicians and surgeons collectively provide care to patients. I have come to realize, that while there may be geographic barriers, as surgeons, we are all more similar than different in our quest to provide the safest care to patients. Additionally, whilst the training and environment may be different, unsafe systems harm our patient more often than bad surgeons. And only collectively can surgeons be the leaders that will allow for patients, regardless of where they are or where they come from, to get the safest, most efficient and patient centric care every patient is entitled to.
I am forever indebted to Dr. Chris Ellison and the entire leadership team at the James IV Surgical Society who provided me with the encouragement needed to apply for this life changing experience.
Susan D. Moffatt-Bruce, MD, PhD, FACS Chief Quality and Patient Safety Officer
Associate Dean, Clinical Affairs for Quality and Patient Safety Associate Professor, Surgery
Associate Professor, Biomedical Informatics
The Ohio State University Wexner Medical Center
View a PDF of photos here: