Last summer, twelve faculty members became the first group to complete the recently established, one-year Academic Career Leadership Academy in Medicine (ACCLAIM), a School of Medicine program that provides leadership and career development opportunities to junior faculty members, with an emphasis on those underrepresented in medicine.
One of the central requirements of ACCLAIM is that each participant propose an idea that they will work on that advances research, strengthens teaching, and improves the health care system. For Paul Godley, MD, PhD, MPP, executive associate dean for faculty affairs and faculty development, the timing of the kickoff of ACCLAIM couldn’t have been better. With the changing landscape of health care and medical education, Dr. Godley sees a system ripe for new ideas.
“I try to communicate to participants that this is a huge health care system, and it’s getting bigger,” says Dr. Godley. “There are lots of opportunities for leadership, so being ready when the moment arises is a big benefit for the system and the individual.”
The projects proposed by faculty members at the end of their time in ACCLAIM are designed to span boundaries and connect disciplines at the hospital and medical school, and they should also improve efficiency or effectiveness. The ideal end result for a project is the implementation of new ways of working that are in keeping with the missions of the School and Health Care System, while improving and streamlining the organization of care for patients.
Dr. Godley believes that the mix of cross-department communication and exchange of ideas has the potential to shape future leaders at UNC and make them positive agents of change.
“We want participants to see that they can have an impact on the medical school and the health care system – that we’ve invested in them and that this is a place that they can build a career,” he says.
The first ACCLAIM graduates proposed a wide range of improvement projects now in various developmental phases; several months after participants completed the program, some projects are near implementation, while others demonstrate promise and require further research and consideration. Regardless of the project stage, ACCLAIM participation helps individuals learn more about themselves and further develops their leadership skills.
“We’re catching people early in their leadership experience and giving them additional leadership training,” says Dr. Godley. “Because many participants have already supervised people as division chiefs and section chiefs, we’re really enhancing what they possess and revealing to them what’s possible for the system and their careers.”
The idea for ACCLAIM was based, in part, on the model established by the Public Health Leadership Program (PHLP) in the Gillings School of Public Health. David Steffen, DrPH, clinical assistant professor of PHLP, serves as facilitator of ACCLAIM. His experience has been invaluable in pushing participants to examine their personal and professional abilities and limitations, communicate more effectively with others, and broaden the way they think about the growing health care system. So far, Steffen has been impressed with the participants.
“They have incredible curiosity and ability to absorb and apply things in their own area,” he says. “And they have a thirst for knowing individuals on a personal basis. Leadership is a series of microinteractions – it’s about relationships, and everything else is derivative. Both the more introverted and extroverted persons have been willing to get to know other people and situations and connect with them for the goal of making their practice and their area for their patients safer and better.”
To produce change, it’s necessary but no longer sufficient to be technically competent. According to Steffen, a key to producing boundary-spanning projects is generating interdepartmental contact by getting participants out of their individual silos and helping them understand the increasingly complicated integrative health care system.
“In today’s health care environment, logic and algorithms can’t be relied upon to solve all problems,” says Steffen. “Interactions with different kinds of people matter, and with team-delivered and patient-centered care becoming increasingly important, developing the kinds of collaborative skills we do in ACCLAIM is necessary for the physician to make change.”
Nearly two years since the pilot program launched, Steffen has witnessed participants evolve as they’ve developed new awareness of themselves as physicians, scientists, and leaders.
“Before they start the program, individuals have a more limited conception of who they can be and how well they can lead the change they can affect,” he says. “ACCLAIM takes them from having a purely clinical, scientific, or technical viewpoint and expertise to a broad, interpersonal and systems-building perspective, one of synergistic connections among people working for patient health in the medical school, hospital and health care system.”
Read about three innovative projects that have resulted from ACCLAIM
Kevin Biese – A geriatric emergency room
When Kevin Biese, MD, associate professor of emergency medicine, thinks about improving care for geriatric patients, he returns to one moment. It occurred when he was a resident in Boston. As he was leaving the ED one day, he passed by an elderly woman lying on a cot. Seeing someone on a cot, waiting for care, wasn’t unusual, he recalls thinking, but when he returned 12 hours later, he saw the same woman in the same spot. Had she eaten? he wondered. Had she been able to use the restroom? He felt that something had to be done.
“I’ll never forget it,” he says. “It was a sense of, ‘We’re hurting her and that’s not okay.’ My training hadn’t been in geriatric medicine – at that time I didn’t know anything about it – but that’s when I started advocating for improved care for older adults in the ED. We, as a profession, have to take better care of the elderly.”
Dr. Biese has since returned to Chapel Hill, where he received his MD, and broadened his focus from emergency medicine to include geriatric medicine. When he joined the first group of ACCLAIM participants in 2012, he knew that he wanted to implement a geriatric-friendly area of the UNC Hospitals’ emergency department.
“I had the broad sketch of the idea from the get-go, but what developed over my time in ACCLAIM was a better sense of how it could go about being implemented, and how to work with leadership and colleagues to develop it in a way that was sustainable and within the goals of the institution,” he says.
Having visited geriatric EDs at other institutions, Dr. Biese sees the ED at UNC Hospitals as well suited to contain an area dedicated to older patients. A key problem in geriatric medicine nationwide, he argues, is what to do with patients who aren’t ready to be sent home but who don’t have a problem serious enough to be admitted to the hospital. Too often, he says, patients are admitted to the hospital because physicians don’t have a proper space to evaluate them, a complication that leads to bad outcomes for the patient and raises costs for the institutions.
“We need to work on what I call the ‘size medium’ cases – those cases that fall in between the clear-cut size small cases when we can send someone home and the size large cases that require hospitalization,” he says. “We need to make sure that patients don’t just get what they need when they’re here, but that they get the care they need downstream, after they leave, and that takes some additional observation.”
With the aid of ACCLAIM, Dr. Biese is pushing to create a transitions unit for elderly patients within the ED – a place where they can be observed until they’re cleared to leave and where the necessary phase of follow-up care can be devised.
Although the ED doesn’t currently have a transitions unit, it has already infused a series of interventions to improve care for older patients. Dr. Biese believes that the next logical step will be the transitions unit.
“If we can find safe ways to send these patients home, we’re both helping the patient and helping the sustainability of our health care system,” he says. “So it’s better for both the patient and for the system. But what needs to happen to do that is a change of processes in the ED and better integration of care between the ED and the rest of the institution.”
Dr. Biese credits ACCLAIM for helping the development of the project. The exercises that participants go through have helped him learn more about himself and how to communicate with others. And being surrounded by thoughtful colleagues in other disciplines has been key.
“One of the challenges of working in academics is that it’s easy to get trapped in your own silo,” he says. “We don’t see a lot of the rest of the institution, except for in a clinical setting when we’re all busy and advocating for patients. But that doesn’t facilitate meaningful conversations, during which we find out what we share in common and how to move things forward. ACCLAIM is fantastic because we make those cross-department connections, and we hear concerns from other departments. We form effective collaborations, and that’s important not just in the School of Medicine but within the wider institution.”
Samuel Jones – Reducing infections in the most vulnerable
Sam Jones, MD, treats patients at their most vulnerable, after life-threatening burns. Sometimes the patients arrive at the Burn Center ICU immunocompromised, at risk of becoming sicker, or even dying, from a simple infection. Because the patients lack fully functioning immune systems, they often require the application of specific expertise to treat infections.
“This is a cohort of patients that needs specialized infectious disease attention,” says Dr. Jones, assistant professor in the Department of Surgery and assistant director of the Burn Center.
During his year in ACCLAIM, Dr. Jones developed relationships with people across UNC Hospitals and the School of Medicine, among them infectious disease specialist David van Duin, MD, associate professor of medicine at UNC. His goal was to learn how to advance this understudied area and find improved methods of care for his patients.
After working closely with Dr. van Duin and others, Dr. Jones introduced a research plan that, he and his collaborators believe, can ultimately lead to infection-reducing implementations in immunocompromised patients in the Burn Center ICU. According to Dr. van Duin, their partnership has great potential.
“Sam is a very smart, ambitious, and driven guy,” says Dr. van Duin. “He has done great work in the lab trying to figure out what it is about these patients that puts them at such a high risk of infection.”
If their research leads to new ways of treating patients within the Burn Center, it could translate to other ICUs at the hospital and become a model for immunocompromised burn patient treatment everywhere.
“If we can determine the number of incidents of infection among this population in the Burn Center, as well as the reasons for the incidents, then we can reduce how long these patients stay in the Center, which impacts the health care system in important ways,” says Dr. Jones.
Dr. Jones acknowledges that infectious disease in immunocompromised burn patients is not well understood, which can present challenges. But he’s eager to write a new chapter in the care of his patients. So far, the Burn Center has implemented interventions such as frequent line changes and educational measures for nurses, among other modifications to their care. Within a year, Dr. Jones expects to have data on the success of the interventions.
Meanwhile, the Burn Center is in the process of determining infection rates among patients, creating a registry of all the infections that occur, working on first papers from the information they gather, and applying for a grant so that they can continue their work in a systematic way.
Even with the effective collaborations he has created with Dr. van Duin and others, Dr. Jones knows that challenges lie ahead. What works for other immunocompromised patients, such as solid organ transplant or bone marrow transplant patients, may not be as effective for burn patients.
“There aren’t direct translations among such patients,” he says. “Dr. van Duin and I are learning from each other how to deal with those challenges that are unique to burn patients.”
As their work continues to evolve, Dr. Jones appreciates the role ACCLAIM played in shaping his project into something that makes sense to a broader audience.
“ACCLAIM helps you think on a global level, outside of your specialty, and it encourages you to consider ways to make a bigger impact,” he says. “Part of making a bigger impact is understanding the system in which you work. By working with mentors – in my case Marlene Rifkin – you learn more about the hospital and medical school, gain a better appreciation of why decisions are made, and produce realistic ideas that can change the system.”
Reaching out to other colleagues through ACCLAIM has helped bring down barriers that sometimes prevent progress in a large organization.
“It’s incredibly helpful to work with infectious disease doctors like Dr. van Duin who have experience working with immunocompromised patients,” he continues. “It’s easy to get stuck in your own little world. You often have ideas for improving care that make sense to you and to the colleagues in your specialty, but maybe not to others. Through ACCLAIM, you get a chance to interact with colleagues from different specialties, learn how they think, and talk to them in ways that help you communicate your ideas effectively.”
Peggy McNaull – Centralized scheduling for the Pediatric Pain Sedation and Consult Service
When Peggy McNaull, MD, assistant professor of anesthesiology and pediatrics, accepted a spot in the 2012-2013 ACCLAIM class, she knew what she wanted to accomplish. As a pediatric anesthesiologist, she’d been through the 2010 implementation of the Pediatric Pain Sedation and Consult Service (PSC), the first service of its kind in the region and a much-needed program for improving safety, efficiency, and oversight in pediatric sedations, while also providing better inpatient pain management in children.
Despite the improvements created by the service, Dr. McNaull and several colleagues felt that one more change needed to be explored: a centralized scheduling system. With so many different areas of the hospital using the service – an average of 45 outpatient and inpatient sedations are carried out weekly, including MRIs, CT scans, LPs, EMG studies, and PICC line placement – scheduling patients often proved difficult.
“Ultimately, we’re all here for patient care and to make sure that the patient has the best experience possible,” says Dr. McNaull. “When you have parents taking time off work and children going through serious illnesses, the last thing you want to do is complicate their lives due to scheduling mix-ups across departments. We knew we needed to build a template that would bring everyone together.”
Dr. McNaull understood that affecting change wouldn’t be easy. She and her colleagues would need to receive buy-in from leadership and from the various departments that use their services. It was also recognized that additional physician resources would be necessary to improve efficiency in MRI and meet the needs of the new schedule template - a pediatric anesthesiologist would need to be in MRI every day rather than just on Monday and Fridays. She confirms that negotiation was critical to helping the new scheduling system come about.
“It was central to the whole process,” she says. “We had to get groups to come together for a common goal.”
Last July, as her time in ACCLAIM was coming to an end, implementation of centralized scheduling moved from an idea to a reality. And the results have been positive. Scheduling for pediatric sedation has gone smoothly, giving patients and their families peace of mind when they come to UNC Hospitals – giving them one less thing to worry about.
Meanwhile, other departments have found that scheduling sedations by using one email address, one phone number an invaluable advancement.
“When other departments experience how easy it is to schedule their patients with the PSC now, they’re relieved,” she says. “When before they may have spent a significant amount of time trying to schedule the sedation, now it’s quickly taken care of and they’re able to spend more time on care for their patients.”
Dr. McNaull reports that the PSC business is growing because they’ve made it so easy to provide sedation. She puts into perspective how much has changed in just a few short years.
“Years ago, when we first started building the scheduling system, we were going to other children’s hospitals, asking, ‘How are you handling pediatric sedation?’” she says. “And now we’re receiving calls from others who want to know how we’re doing it at UNC. It’s fun to see the evolution of what we’ve built.”
Although she’d been working to build a centralized scheduling system for the service before beginning ACCLAIM, she credits the leadership program with developing her skills and her self-awareness and for helping her to push the project through.
“ACCLAIM was a catalyst for me,” she says. “I learned about my strengths and weaknesses, how to critically take apart a problem and tackle that problem with them in mind, and how to set goals based upon them. That allowed me to communicate better with my colleagues and leadership.”
ACCLAIM broadened her perspective, and the experience will impact her interactions in the School of Medicine and at UNC Hospitals in the future.
“In pediatrics, it’s not always easy to get to know someone from emergency medicine, hematology, infectious disease, or pathology,” she says. “We may see their names in an email but never associate names and faces. Meeting these people has been huge. I have a new appreciation for different specialties and the struggles physicians face to advance care.”
by Zach Read