Patient Care and Patient Safety
Lucy Guerra, MD
It’s in Dr. Lucy Guerra’s genes to be completely drawn in to the team-based patient care offered at USF Health. Her own Latino heritage includes a close-knit family that is involved in nearly every aspect of life, including each other’s health.
Knowing she is living true to who she is, she practices team-based medicine every day, putting her patients first, reinforcing the concept to medical students and residents she teaches, and watching the students, in turn, practice it as they provide free care to the local underserved community at the BRIDGE Clinic.
Dr. Guerra wears multiple hats in her career as a physician. She is associate professor, director of the Division of General Internal Medicine in the USF Health Morsani College of Medicine, co-faculty mentor for the BRIDGE Clinic, and associate director of the Internal Medicine Residency Program.
She doesn’t see them as multiple roles, but as one job, she said, a testament to her preference for working at an academic medical center.
“We all need to change our concept of what medical care is and to think of it as having evolved to a very patient-centric model,” Dr. Guerra said. “It’s more about working as a team to provide the best care and realizing the patient is part of that team. It’s a trend we call value-based care. When patients come to a place like USF Health, they’re going to always meet with the physician and other health care providers – a nurse practitioner, social worker, pharmacist or physician assistant – and it’s always going to include medical students and residents because we are an academic teaching institution.”
But an academic medical center is more than patient care and Dr. Guerra is emphatic in her efforts to incorporate USF Health’s other missions into her world.
“Our other missions – research and teaching—are equally important to patient care because you really can’t do one well without the other,” she said. “If we don’t have the research component then we can’t find better drug therapies and better behavioral therapies to treat patients. And sometimes I think this needs to be emphasized more because patients don’t necessarily realize that. The research part is very ethereal – you just don’t see it in action. Patients think of research as being done in the lab. But when you’re coming here, to an academic institution, you have the opportunity to participate in research studies and get involved. If patients realize they can participate in some kind of research study that will make a difference for the next generation of patients that come after them then wow, what a contribution they’ve made to medicine, as well to the future of their own grandchildren.”
For the teaching mission, Dr. Guerra said that, beyond the science of medicine, she tries to remind her students and residents why they chose medicine as a career.
“People who are learning and in a learning environment sometimes get caught up, just like I did, in studying or trying to get good grades or trying to pass, and you have to keep reminding them why they chose this profession,” she said. “For a physician, a nurse or anyone working in health care, it really needs to be a commitment. You’re making a commitment to somebody else – the patient. If you can ground a student in that, then they’re going to be the better health care provider for it.”
HARRY VAN LOVEREN, MD
Over and over again, Harry van Loveren, MD, walks through a surgery in his mind before actually cutting open the brain of his patient, perfecting every step and accounting for everything he will encounter, the expected and the unexpected.
Dr. van Loveren is chair of the Department of Neurosurgery in the USF Health Morsani College of Medicine, senior associate dean for Surgical Subspecialties at USF Health, and chief medical officer of the USF Physicians Group. Along with a brilliant mind and capable hands, his visualization technique has made him an accomplished and much sought after neurosurgeon.
“To prepare for the kind of operations I do you have to mentally do the operations a number of times before you walk into the operating room,” he said. “And you have to understand it all – the anatomy, the surgical instruments, the surgical techniques – so your mental experiments are valid, that what you see in your mind is what you will see in the patient’s head. That these things you see in your mind are true and that if it works in your mind it had better work in the operating room. And if I can’t see that in my mind’s eye, I go back to the (training) lab, go back to text books, and review videos and figure it out until I can create a paradigm in my mind where I complete the surgery successfully.”
How does someone decide to become a neurosurgeon? For Dr. van Loveren, it was because it’s considered the most difficult area of medicine and requires the longest amount of training.
“To be honest, I don’t know why other people go into neurosurgery but I know why a lot of us do – because we’re so egotistical and because we want to be the best,” he said. “As we’re going through medical school we look around and ask what would be the hardest thing I could do? What would be the biggest challenge? But I don’t think we’re the only ones who do that. For instance, look at people who go into the police force and say ‘I want to be on the SWAT team’ or go into the military and say ‘I want to be a Navy SEAL.’ There’s an element of that to becoming a neurosurgeon. We’re looking for the greatest challenge.”
In fact, when he joined USF Health about 10 years ago, he set a goal for his Department to become the go-to neurosurgery department in Florida. Starting with only six neurosurgeons, he has built the Department to about 30 surgeons and nine PhDs, becoming a hub for the most complicated cases.
“My practice is a little bit unique,” he said. “It’s called complex cranial so I do the more complex side of brain operations and a lot of my practice is taking care of patients for other neurosurgeons in the state either for those things they don’t want to do or don’t feel they ought to be doing. That can be a bit of a lonely and frightening position to be in. But nobody wants to see any lack of confidence in us and we don’t really want to feel that lack of confidence.”
His other reason for choosing neurosurgery is because he saw it as the one specialty in which he would never stop learning.
“I chose it because it looked like my learning curve would go on forever,” he said. “When I looked at neurosurgery, I saw older neurosurgeons still making great contributions and the acquisition of experience is so valuable to neurosurgery. So the finish line is, wonderfully, always just beyond our reach.”
He admits, though, that the real reason he chose neurosurgery might truly be because he thinks “the brain is cool.”
“The brain is who we are, it’s what we think, it’s what we believe,” he said. “The ability to affect a person’s life by manipulating that organ is profound and extremely interesting. And we really get some insight into brain function when we’re operating on someone while they’re awake and speaking to you. And with certain stimulation you can bring back very specific old memories for the patient, you can play music, you can run videos. It’s all stored in the brain and you can recall it and make it come out for the patient.”
With a laugh, he added “It’s just a really satisfying career. You should try it sometime.”
Karen Bruder, MD, FACOG, Guides USF Health into EPIC
Karen Bruder, MD, FACOG, was straight out of her medical residency when she saw firsthand the impact data could have on improving patient safety. As an invited member of the patient safety committee at American Congress of Obstetricians and Gynecologists (ACOG), Dr. Bruder was privy to national trends for problems and part of the effort to implement change for improvement.
Today, she is extending that reach directly into the patient care settings at USF Health. As Executive Physician Champion for USF Health’s transition into the Epic electronic health records (EHR) system, Dr. Bruder is the lead for guiding every health care provider at USF Health into the new EHR system.
To understand the true impact of that role, you might first know that Epic is a national leader in EHR and the same system used by Tampa General Hospital, the primary teaching hospital for the USF Health Morsani College of Medicine. This transition means patients will no longer need to collect and transport their records as they go from one partner institution to the other.
But more than that, Epic will help USF’s health care teams see up-to-the-minute records of patients at both institutions. It’s that real-time data – giving as complete a picture as possible of every patient – that is Dr. Bruder’s true target because that component directly correlates to patient safety.
“There’s one great benefit with Epic to patients, which they may or may not realize, and that is a reduction of medical error,” Dr. Bruder said. “A great deal of errors happen when information is transferred from one place to another. Epic gives us the ability to have one chart for one patient. No longer will we have to have one electronic record for the USF practices and one electronic record at Tampa General. Instead they will be all the same. With Epic, we now have access to their entire health record, particularly about medications, recommendations from other physicians, and abnormal test results. Now those issues can be immediately recognized and addressed.”
Epic offers a way to more closely track care across the entire USF Physicians Group and Tampa General, providing a constant watch for contradictions, contraindications, and uses of standardized care. This ongoing analysis goes beyond strong team-based care, Dr. Bruder said, and gives the opportunity to truly impact and improve care.
In addition to her title with the Epic transition, Dr. Bruder is also associate professor, director of the USF Division of General Obstetrics and Gynecology, medical director of the Genesis Women’s Center at Tampa General Healthpark, and chief of Ob/Gyn at Tampa General Hospital. She is also active in the Florida Perinatal Quality Collaborative, a state-wide initiative aiming to improve the quality of health care quality and patient safety for mothers and their babies.
Her day is full of patient care and teaching medical students and residents. The passion she has for her career is easily seen by those around her – she clearly loves her job.
“Being an obstetrician is the greatest job in the world,” she said. “We get to experience the power of women who are carrying their babies, protecting their babies, then bringing their babies into the world and starting a new family. Some of my days I spend in labor and delivery, delivering new babies, doing cesarean surgeries, teaching residents how to do those deliveries, working with the nursing staff. Some days I’m at the Genesis Clinic. Every day is a little bit different and that’s what keeps it fresh and exciting for me.
“But I’m definitely the student as well as the teacher. I learn things from patients every day. I learn things from students and residents and the nursing staff every day. The teaching aspect of it for me is continuous. And because of my interest in quality, I’m able to share that with the residents and students and bring them into those conversations. We actually start teaching students at the medical school level about medical error and patient safety and best practices so that when they come to their residencies, those concepts are already familiar to them.
And the basis of those lessons is rooted in standards.
“Patient safety is really about developing standards of care and looking at processes in detail so we can avoid medical error,” Dr. Bruder said. “That is sometimes difficult to achieve, because there are so many parts of what happens to a patient from day to day. A lot of people are involved, a lot of steps happen between the patient and doctor conversation, the doctor ordering a test, the patient having the test, and then interpreting those results. Everything comes full circle, but anywhere in that process there can be an error that can affect the care of the patient. So our job with patient safety and quality is to look at national standards of care and then examine our processes to be sure we’re following those standards of care, and then making changes, piece by piece, until there is very little room for human error. The electronic health record helps a great deal with that.”
“I went to medical school to become an obstetrician gynecologist,” she said. “I’m one of the fortunate doctors who knew what I wanted to do before I got to medical school. And I’ve never changed my mind. It’s always been a great choice for me and a real source of joy and pride in my life to be able to take care of patients and to teach residents and students.
“When I was a young physician, just out of residency, I was invited to join the inaugural patient safety committee at ACOG, our educating and professional body of obstetrics and gynecology. That’s when I became aware of the Institute of Medicine report that was issued in 2001 and all the patient safety issues that were occurring in the United States. And since that time, wherever I’ve practiced, I’ve been very aware of patient safety issues, quality of care, how important it is for everyone on the patient’s care team to work together.”
And that’s where Epic comes into play again for Dr. Bruder. But only to a point.
“With all this new technology we still need to remember as individual physicians and as a team of caregivers, the most important thing is to be kind to the patients,” she said. “It’s always about the patients. It’s always about how we matter in their lives, it’s always about improving their lives, and it’s always about having a connection between them and us.”
Terri Ashmeade, MD, MS, CPHQ, on Patient Safety
Neonatal intensive care units (NICU) have some of our most vulnerable patients, babies in need of expert critical care. Because every interaction, every touch, with these newborns must be precise, with little margin for error, these NICUs must be a paragon of optimum patient safety.
Terri Ashmeade, MD, MS, CPHQ, embraces every aspect of that realm. She is associate professor of pediatrics in the USF Health Morsani College of Medicine and the Chief Quality Officer for USF Health. Her experience in NICUs and her active roles in defining best standards for patient safety helped pave the way for the new position, a job that aims to elevate quality care and patient safety across USF’s hospital partners and inpatient and outpatient facilities.
What defines a health care provider’s best approach to care, the one thing that ensures the best outcome for patients? Dr. Ashmeade boils it down to one word: data.
“In order to improve we need data,” said Dr. Ashmeade, adding that data rules in the TGH NICU environment. “Measurement is very important and we try to measure everything, from how long it took us to take a baby from the delivery room to the NICU to the temperature in the delivery room and how that temperature relates to the baby’s progress.
“As Chief Quality Officer, I’m able to help others understand our data, get the data they don’t have, understand it, use it to help us improve, and then measure our improvements along the way.”
Dr. Ashmeade said she realizes that patient safety can seem vague for a lot of us, a term that can bring to mind obvious scenarios of incorrect prescriptions and surgical procedures. But true patient safety is more than just preventing accidents.
“The most obvious forms of patient safety are what we hear in the news – a patient has an operation on the wrong body part or a patient gets a medication they weren’t prescribed,” Dr. Ashmeade said. “But there are many more subtle things that can go wrong. People who come into a hospital and get an infection related to a catheter or the overuse of medical treatments and X-rays, for example. It’s the more subtle things we do for patients, or don’t do for patients, that we need to pay attention to.”
Enhanced training for resident physicians and incorporating safety into the medical school curriculum are a couple of the ways Dr. Ashmeade aims to fill the pipeline with health care providers who are proficient in patient safety, which will improve patient outcomes.
“When I was a medical student we rarely heard the words ‘patient safety’,” she said. “We all assumed the care we were delivering was safe and thought that, if we were smart and if we were careful, all our patients would get the best care possible. But since then we’ve learned that, even with the best effort and the best intentions, we’re human beings and we can make mistakes and we can miss things. Learning about the science of patient safety and the science of quality improvement will help move us to the next level. At USF Health, we will train our medical students, nursing students, pharmacy students and public health students from the beginning so it becomes part of their everyday work and not something that’s an extra or an additional task. It has to be engrained.”
Building teams that center their efforts round safety will likely be the most effective approach. But that comes with a caveat: humans are reluctant to change habits and assume they already have good practices. And that’s where data steps in again.
“It’s hard to be measured; it can be shocking at first,” Dr. Ashmeade said. “Sometimes we have difficulty believing the numbers. So, my job will be to make sure I have the numbers right so people can trust them and use them effectively to improve. The first step is getting used to measuring our performance and being OK with ‘this is where I am’ whether we’re at the top or middle or bottom. Knowing where you are on that scale is critical, and data drives that.”
There are many tools for building that data, but Dr. Ashmeade noted that USF Health’s transition to Epic electronic health record system will be instrumental in tracking true improvement.
“With our Epic implementation, we’ll be able to pull good data out,” she said. “I’ve used Epic for a long time at Tampa General so I know it’s a good system and will help us move forward in terms of collecting information on our patients, monitoring and tracking their progress and helping us improve safety across the board.”
Good data is what sparked Dr. Ashmeade’s drive for optimum patient safety and care, like that found in the NICU.
“When I became medical director of the NICU, it was the first time I really felt driven to understand what types of outcomes my patients were having,” she said. “And for the first time I had data I could look at that compared our performance to that of other similar neonatal units across the country and across the world. When I looked at those numbers, I saw that we were doing OK but weren’t at the top yet. That’s when I started training in quality improvement and patient safety to learn the techniques I could implement in the NICU to make changes that could get us to the top.”
Story and multimedia by Sandra C. Roa, USF Health Office of Communications.