Brian Wong Profile picture
Sep 24, 2020 9 tweets 4 min read Read on X
I often hear people say that we should apply what we know from #QI to the #COVID19 response -- the concerns around COVID testing and trying to increase our testing capacity serve as a good example where knowledge of systems can be helpful. A thread.
I often teach #QI with @kgshojania.

He uses this analogy of a Rube Goldberg machine to describe complex systems in healthcare.

Rube Goldberg machines are intentionally designed to perform a simple task in an indirect and overly complicated way

E.g., a pencil sharpener
A: Open window
B: Fly kite
C: Pull pulley
D: Lift cage door
E: Release Moths
F: Eat coat
G: Raise boot
H: Flip switch
I: Turn on iron
J: Burn shirt
K/L: Smoke out opossum
M: Jump out of tree
N: Land in basket
O/P: Lift cage
Q: Reveal woodpecker
R: Sharpen pencil
We often jump to the first and most obvious solution without fully understanding the very complex set of processes that lead to the thing that we are trying to improve (in this case, improving our capacity for COVID testing)
So it might seem obvious to sharpen pencils faster to add a second woodpecker. And yet without addressing the various other steps in the process that contribute to the COVID testing capacity, we will not achieve
Adding pharmacies as testing sites for COVID is like adding a second woodpecker -- makes sense on first glance, but as some have pointed out, may only marginally improve test capacity but might actually worsen test turnaround time

I'm not a lab medicine specialist/public health expert so don't presume to know what the right answers are -- but wearing my #QI hat, the way to increase testing capacity requires detailed examination of the various steps of the process and targeted interventions to address them
For example, if we are overwhelming our testing capacity by testing low-risk individuals, then changes that prioritize rapid turnaround for higher-risk individuals makes a lot of sense
Also reminds me that there are "No Magic Bullets" in #QI -- as written about by @kgshojania and @GrimshawJeremy in this nice piece a number of years back amjmed.com/article/S0002-…

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More from @Brian_M_Wong

Sep 23, 2020
I have set my clock to 10:30 AM to get @jkwan_md's amazingly informative updates on Ontario's #COVID19 situation.

Want to take this opportunity to thank her immensely, but also reflect on 4 #COVID19 curves that really worry me.
The first is the fact that we have no known Epi-link for 50% of our new cases -- @IrfanDhalla points this out repeatedly as a major barrier to properly #TestTraceIsolate Image
The 2nd is the fact that our testing turnaround time is getting longer -- for the first time since early April, we have more pending test results than reported test results (a whopping 48,000 tests pending) -- which means a delay to identifying cases and proper #TestTraceIsolate Image
Read 6 tweets
May 25, 2020
The inaugural @NEJMres360 resident #QI challenge was launched this year. Received 90 submissions.

Of these, 59 invited to prepare and post a poster -- can view them here: resident360.nejm.org/groups/qi-chal…

I'm thrilled that FOURTEEN posters are from @uoftmedicine cc @UofTMedDean @UofTPGME
Would like to highlight these amazing #QI posters from resident programs in medicine (@UofT_DoM), pediatrics (@SickKidsNews) and family medicine (@UofTFamilyMed)

cc @UofTPGME @SalSpadafora1 @UofTDoMChair @LennoxHuang @ronald_cohn @CQuIPS @tara_kiran @kgshojania
1) Let 'em breathe -- submitted by @Aditijain8243 @leechristiem et al from @ccmtoronto @SinaiHealth (critical care) -- increased rates of spontaneous breathing trials in the ICU from 53% to 71% resident360.nejm.org/posts/21339
Read 17 tweets
Mar 13, 2020
Today, as the Director of the Centre for Quality Improvement & Patient Safety (@CQuIPS) at the University of Toronto (@uoftmedicine) sent a message to all of our members -- a call to action to mobilize now to support health system efforts to respond to #COVID19
"Our focus at @CQuIPS will be to mobilize as many of our members, graduates and current students and direct them towards their local QI efforts to respond to the #COVID19 pandemic."
I urged each and every one of them to strongly consider whether any non-COVID related initiatives can be put on hold for now, and direct their time and energy to help our health system respond to the #COVID19 pandemic
Read 6 tweets
Feb 11, 2020
Are you an academic clinician or trainee with a career focus in #QI?

Are you interested in implementing QI initiatives in an academic teaching hospital/clinic settings?

Apply for EQUIP - QI certificate program offered by @CQuIPS
(Deadline Mar 27, ‘20)

cpd.utoronto.ca/equip
Program format:

1) Two 3-day in-person sessions in Toronto, Canada
2) Longitudinal #QI project
3) Webinars for participants to receive feedback on their projects
4) Personalized coaching from expert program faculty Image
Learn from the best — here are just a few of the expert @CQuIPS faculty you will interact with if you enroll in EQUIP

cpd.utoronto.ca/equip/faculty/…
Read 14 tweets
Dec 6, 2019
We are now accepting applications for EQUIP for 2020-21, our #QI certificate course at @CQuIPS that prepares faculty & senior trainees to lead QI in academic environments. Pls retweet & encourage others to apply. Deadline for applications is March 27, 2020 cpd.utoronto.ca/equip ImageImage
Read 4 tweets
Nov 28, 2019
An important thread for how we as GIM/hospitalists can communicate more effectively with our primary care colleagues at the time of discharge — @AM_Cressman we should send to our trainees on CTU right now. #MedEd
My 2 major takeaways:

1) I need to spend as much or more effort confirming the patient’s primary care provider (who likely sees patient regularly) as I do figuring out who their specialists are (who might only see patient 1-2 times per year)...
2) In a discharge summary, when listing follow up instructions that involve the patient’s primary care provider, address them by name — I’m definitely guilty of typing “Family doctor to check patients BP in a week...”
Read 4 tweets

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