Episode 1: Team within the team
Just 10% of patients develop sepsis, but it contributes to as many as half of hospital deaths across the United States. In 2014, new faculty Dr. Kencee Graves and Dr. Devin Horton decided to save these patients’ lives at the University of Utah. In the first Practicing interview, Chrissy Daniels and Mari Ransco learned about their challenges leading value improvement and the importance of their partnership.
(Abridged transcript below)
Start with Devin and Kencee's "why"
1. What made you want to become a doctor?
[Kencee:] I wouldn’t be happy doing anything else. I love people, I have loved being with people my whole life. Medicine gives me the intellectual challenge of thinking about a problem, lets me help someone make their life better. I started out in college as a biology major, and then I wondered, “am I doing this for the right reasons? Is this because I want to do this?” I changed to a psychology major for a year and I realized I didn’t like it. I thought about doing a masters in biology, I thought about nursing, but I didn’t fit there. So this has been the most compelling thing for me in the last 15 years.
[Devin:] I arrived much more circuitously. I never planned to go into medicine. In my family growing up, my sister was the really smart person who got straight A’s, and I was the social kid. The people person. At the end of my senior year, I went to a job fair. I saw my friends interviewing at banks or selling wines or in the ATF (Bureau of Alcohol Tobacco and Firearms)—and I didn’t want to do any of those. I had played rugby in college and I thought I might want to go into athletic training, so I took physiology and anatomy. I really excelled in them and I really liked them. I ended up graduating and then coming back to take some post graduate pre-med classes.
2. Has medicine been different than you expected?
[Kencee:] I grew up hearing how terrible medicine is; how it will rob you of your life, how it’s the worst mistress. I haven’t found that to be true. I have a lot more flexibility in this job than people in other jobs do. Medicine is a hard job. It’s emotionally draining. It takes years and years to get here. But now, I’m in a spot where I do have control over my hours and I can make it home to put my little guys to bed and that means a lot to me.
3. You both trained here [University of Utah], what was it like to join the faculty after residency?
[Kencee:] I started as a full time hospitalist on July 1, 2014. My office is next door to Devin’s and I started out [as an attending] in this group who I had trained with. I did med school and residency here, Devin did med school and most of residency here. To me this group of doctors [the hospitalists] were just legends. They were all super smart, and there was no way I was ever going to be one of them. Bob [Pendleton], Mike [Strong], Stacy [Johnson], Nate [Wanner]. I was like, oh no, they’re going to figure out I’m an idiot really quickly!
“That’s a big issue for new physicians joining our group. Really, you’re joining these amazing people and you think, 'Wow, how am I ever going to be that?'”—Kencee
[Devin:] As a med student, Bob Pendleton was my first attending ever and Stacy Johnson was my senior resident. It was intimidating to join this group that you have respected for so long. So for the first year, I didn’t speak in meetings. I continued to call Bob “Dr. Pendleton” and Mike, “Dr. Strong.” I basically didn’t talk. I felt very out of place. I wrote a column for Today’s Hospitalist my first year of practice and one of the articles, “Walking with Giants,” was focused on Bob.
[Kencee:] I think it took me a year to realize that those people are not the giants I had made them out to be. I think it took me a year to realize that I was hired for a good reason. I trust Nate’s judgment is solid—he doesn’t hire idiots. That’s a big issue for new physicians joining our group. Really, you’re joining these amazing people and you think, “Wow, how am I ever going to be that?”
Learning by leading improvement: The Sepsis Challenge
4. How did you get involved in leading quality improvement?
[Devin:] This is a reoccurring theme in my life. I don’t plan, seemingly, for my life. I never thought, “Gee, what I’m really drawn to is quality improvement and sepsis, and what I really want to do is work on a huge hospital initiative.” No, not at all.
[Devin:] Things started to percolate when I would see patients who had been decompensating for days. One thing I will give myself credit for is that if something bothers me, I have to take action. I was so frustrated seeing these decompensating patients. I thought, there’s gotta be a better way to do this. Instead of complaining, I wanted to sort out a way to do it. Then I heard a talk identifying Sepsis as the Number 1 cause of hospital mortality, and it came all together for me. I said, "holy cow, I can’t believe no one is working on this.”
“I was so frustrated seeing these decompensating patients. I thought, there’s gotta be a better way to do this.”—Devin
[Devin:] I didn’t even know what I was doing was quality improvement. About seven months later, Kencee and I were asked to go to this quality improvement class that Bob teaches (Value Improvement Leaders). “Why would I go to that?” I asked. It was a great class. I finally learned the ideas and names of the stuff we had been doing.
[Kencee:] I did a chief year in Internal Medicine at the University of Utah. I spent the year terrified that everyone would think I was a terrible chief. I worked really hard and had my twins in my chief year. I knew I was going to be a hospitalist and knew I couldn’t work 100% clinical time with 5 month old twins. So when I got offered a position as the residency program quality improvement program director, my response was “Great. I don’t know a thing about quality improvement, but I’ll take it because it helps me offload a little bit.” I was figuring out how to get my Quality Improvement seminar up and running and Devin wanders into my office one afternoon and says, “want to work on sepsis?” I thought, the best way to learn QI is to freakin do it!
[Kencee:] My early involvement was hanging out, not knowing what do. Then we started to get data, and I thought, “I know what my role is.” I can do details and analysis—that’s my strength. I don’t have the vision or creativity that Devin has. I can look at an excel spreadsheet for an hour and be in Zen.
[Devin:] I knew Kencee was smart and a hard worker. I wasn’t sure she would really be interested in this, or maybe she would just help out with a little part and then move on. Instead, she just dominated. She did amazingly well; she was totally organized. I give kudos to me because I said, “Kencee, you’re dominating, go for it.” I give kudos to her because of her 100% ownership. That’s how we became a partnership.
[Kencee:] We had to learn how to work together. I was working really, really hard and Devin was coming up with all these great ideas. I was going around and around executing the details, and then he’d say – what about this? I finally had to tell Devin he was driving me crazy. I stewed on that for two months before I did it. I was prepared for him to say, “Kencee you’re such a jerk. This is my project.” Instead, he was great. He asked, “What do you need from me? Let’s talk more openly.” Now we talk every day about what’s going on, how we can address it, whose strengths are whose.
[Devin:] There was a part of me that was selfish, that wanted to continue to be the owner. I told her that. But you have to honest with yourself. I don’t have the skill set that Kencee has. Ultimately, its either going to be me saying goodbye, being stuck with a project that fails or admitting I needed a partner.
[Kencee:] Knowing that there are two physicians has softened the blow for both of us. This has been a huge project and we’ve both felt overwhelmed. I can’t imagine what that feeling would have been like if there was just one of us.
5. What have you learned about your leadership?
[Kencee:] I mentioned before that I can sit in my office and just look at spreadsheets. I border on introvert, and I think Devin is more introverted than me. I’ve learned how to sit down and talk to people. I would never have sat in someone’s office and had them yell at me for an hour about our ideas; Devin taught me that. One of the things that’s mattered most to people as we go across the hospital is the time we’ve spent with them in their office and discussing the problem.
[Devin:] We have some strong personalities in our group who can chew a person up in meetings. These are people I really respect and are a little bit scary. I learned to just talk with them. I do not like small talk, it makes me anxious. On the flip side, I’ve always been good at one-on-one conversations with a person. I have zero fear of cold calling. I’ve been known to cold-call famous scientists, famous authors. I’m not afraid to walk into someone’s office and say, “Can we talk about this?”
[Devin:] These big personalities are really good doctors. They care about their patients. Their strong opinions come not from arrogance, but a positive ownership of their patients and the system. When you can talk to them and hear them out they just really want the best for patients. What they don’t want is some bright-eyed knucklehead coming in with ideas that are going to hurt their patients. With Kencee’s data analysis, we were able to powerfully show what we were trying to do. Maybe they didn’t believe all our findings, but we got comments like, “Wow, you guys have put a lot of work in this.” Just seeing how seriously we took our analysis put them at ease.
6. What was different in your approach that allowed your efforts to be successful?
[Kencee:] First, it was getting the strong personalities on our side. People trust and respect those more senior people. Second, to give them a really good argument. We said, “this is our data, this is what you guys know for sepsis, this is what our treatment times are, and this is what happened to this patent.” It’s really hard to argue with data—especially if you are a physician whose brain works that way. People couldn’t come back and say “we don’t have a problem,” because our data clearly showed that we did.
“I learned there is a lot to be said for tenacity.”—Devin
[Devin:] The third thing is persistence. After one presentation to an intensivist team, I got a text that this provider said, “They have a cute idea but they’re going to fail.” It was a cycle that I noticed over and over in every single group. The first time they kind of got mad and yelled. And then the second time they said, “this sounds ok.” And the third time, “yeah, sounds pretty reasonable.” The fourth time, “what do you guys think?” I think the persistence and the tenacity was something that helped us. They saw we weren’t going away and that we were going to do a good job.
[Devin:] I learned there is a lot to be said for tenacity. I was never a very gifted athlete, but I was small and I was mean. I would not give up. I was the little guy biting someone’s shin. Tenacity helped me in medical school, in residency, and now this. I wouldn’t stop biting ankles and they realized I wasn’t going away.
[Kencee:] Persistence is also why it was really helpful to have two of us. Because Devin can take a beating, and then he can take a break, and I’ll take the next beating. It gave us emotional resilience to be able to do that. Value Improvement Leaders taught me that what looks like resistance is really misunderstanding.
[Kencee:] That is the difference between meeting #2 and #3. The first meeting is spent talking about everything that has been bothering this person, even if it has nothing to do with this project. We listened and they realized, “Oh wait, these guys care.” Meeting #2 is when the barriers come out, “I don’t want you guys alerting on all my patients.” Devin’s response to that resistance is, ok, let’s model what would happen. We actually have a column that turns color based on the MEWS score. That really helped. People could see that not every patient was alerted. It helped them understand how often this really happened.
[Kencee:] I don’t think that we understood how powerful the column would be. There is a nurse manager who logs in every day when she gets to work to see which patient has the highest MEWS score. We did not anticipate that at all. To me, it was just like, “Gee…as a resident I would look at my patient list and I had no way of knowing who was sick and not sick.” So it occurred to me that I could see this color on this column for pain, what if we did that for MEWS? That’s where the column came from. I stole the column idea from Nate [Wanner].
7. What was your plan to roll out the project to other areas?
[Devin:] We rolled out to the hospitalist group first, with great trepidation. We had our predictive alerts, but we could have very well failed if everyone hated it. An Ortho provider started the idea of the column. They said, “We just got done with 10 years of trying to teach our residents not to do blood cultures and chest x-rays on everyone, and now you’re asking me to do that.” I said, “Let’s just put the column on, and you just sit with it for six weeks and if it’s a problem, let’s talk about it. If it’s too much, you don’t have to do it.”
[Devin:] This ended up being a strategy, putting the ball in their court. Providers don’t want to be told what to do. We would build our case, show them the data, and then leave it up to them. “What set of vital signs worry you? Does a heart rate of 140 with a resting rate of 35 worry you? You tell me. When do you start to get that feeling in your stomach that the patient sounds scary? Look at it for a month. If you don’t want it, we don’t have to go that far, no pressure.” A month later, it was a one sentence conversation. “You’re right I’ve seen nothing but green, go on.”
[Devin:] It’s a great idea to add the column, but it is also an extra step. I’ve gone to the provider’s office and waited 20 minutes to install their Epic column. It only takes three seconds to put the column on, but that extra step is sometimes a barrier for people.
Assembling the team
8. You assembled a larger team of nurses and pharmacists, and many other roles. What was different about leading that interdisciplinary team?
[Devin:] Early on, some people were strongly opposed to this. They said it was bad idea. That we were both “deer in headlights,” not knowing what to do. Now those people are our allies, but early on they came with concerns and with a vengeance—to vent.
[Devin:] I remember one meeting in particular. An important nurse administrator laid into us, “You haven’t gone through the right authority, you haven’t told us, you haven’t told the right people, you missed this meeting, why don’t I know about this? You missed this and that committee. You can’t change the nursing flow.” I had never even heard of those committees, but I was happy to go present. If you tell me who to talk to, we’re all ears. But man, I walked out of that meeting upset.
[Devin:] Part of my total naiveté was not knowing who is who in the hospital. I didn’t know who Tom Miller [CMO] was when I started this. I didn’t know who Margaret Pearce [CNO] was. One day, Russell Vinik wrote out the nursing structure of our hospital on a piece of paper so I’d know who was who. That paper is still on my wall.
“I remember being so thankful that we had a value engineer.”—Kencee
[Kencee:] At first, I remember being so thankful that we had a value engineer because at least those guys know how to lead meetings. Nobody ever taught me that. I know how to lead a [medical] team because I spent the last 7 years on one. But I’ve never spent time in that kind of meeting. I didn’t know what an agenda was. I learned a lot from our value engineer and our quality consultants. Watching them gave us a good start. I remember the first time Devin led a perfect meeting. I was like, “WOW! We learned that!” I can run a meeting now but it took us a year to learn that skill.
[Kencee:] We started with this core group of 20 around the table. No one was engaged. No one was interested. Those were painful meetings. Our value engineer and I decided, “let’s break into sub meetings. Let’s give them some power.”
[Devin:] That was a huge turning point in the project. Before, no one was giving deliverables. That was another word I learned. It was basically just Kencee and I running our mouth every meeting, and everyone just watching us. Once we broke up and gave them deliverables—by a date—things just started cranking. Within 5 months, we had a product.
[Kencee:] Going into that, it felt like herding cats. I remember being really frustrated thinking, I don’t know how to get these people to do anything. We just had to empower them. We said, “You’re accountable, do your thing, and come back in a month.” And they did. The secret sauce was giving our subgroups the power to run and trusting that they would. It was scary. I thought the project would fail right there.
9. How did that feel when the first life was saved?
[Devin:] When we started, I had told an intensivist that, based on guidelines, we should be giving antibiotics within one hour. At the time our response was closer to 7 hours. And he said, “you want to go from 7 hours to 1 hour? You will never do it. Maybe 6 hours, maybe 5 hours, you need to take a more incremental approach.” I listened, and said to myself, “I want one hour.”
“If you wanted to call something perfect, this was perfect sepsis care.”—Devin
[Devin:] When that first case happened, it was awesome. The patient got an alert, the providers were called to the bedside, and they followed the protocol. It was 30 minutes to a lactic acid, 45 minutes to a blood culture, and like 53 minutes to antibiotics. After working so hard and being told it wasn’t a good idea, it felt like redemption!
[Devin:] The patients deserve it. We’re talking about patients with severe sepsis whose cells are dying. One hour, or three hours, is not too much to expect from a system. That first day, when we saw the system could coalesce and respond within an hour, it was like, “See – it can be done.” It was a relief. If you wanted to call something perfect, this was perfect sepsis care.
[Kencee:] It gave us someone to talk about, too. When we went to other floors, we would talk about a case that didn’t go well. Then we would talk about our protocol, and we would talk about our first patient, and say “we’d like to do this for everyone.” Being able to show that we had done it was really powerful motivation to do it again.
10. You mentioned that there was a CNA that surprised you with their sepsis knowledge…
[Kencee:] Full disclosure, I was a CNA [certified nursing assistant] through college. The CNAs I worked with were people that would call in sick 5 minutes before a shift. It’s considered an entry level job, despite being one of the most important jobs in the hospital. Vital signs are vital. In our posttest we had an HCA [health care assistant] who wrote, “this patient has sepsis because they have a UTI, they have a lactate of 3, and they have flank pain. They need antibiotics—fast.” It was beautiful. A CNA with a high school degree gave us a better single definition of sepsis than any attending did. That to me shows the difference between what someone in a nursing position can and will learn, versus at a physician level. So many nurses came up to me and said, “I’ve got learn this.” And no physician ever did. I’ve learned that the nurses are more motivated to learn what they don’t know.
Hindsight is 20/20: What we wish we knew before...
11. What is the most important lesson you wish you knew 2 years ago?
[Devin:] That they will come around. While it’s easy for me to cold call someone, I actually don’t like getting yelled at. I don’t want people to think that I’m stupid, irresponsible, or dangerous. Those comments really affected me. When you walk away from talking with a physician you really respect and you trained with thinking, wow, that person thinks I’m reckless and irresponsible. Those were hard conversations. When I knew I had a meeting coming up, I would become despondent for like 4 days before, because I knew what was going to happen. I just had to tell myself, “this is part of the process, it will be ok.” The worst thing that they can say is that they don’t want it and no. And to know that probably by the 4th or 5th time, they’re going to say yes.
[Kencee:] I think the thing I would have told myself two years ago is “you’re going to be okay.” We all perceive physicians to be these smart, strong resilient people. And in truth, I’m worried what people think about me—especially when you have trained here. I had multiple things that I would go back and do differently, but the project didn’t suffer. I don’t know if I would believe me, but I would have told myself “I’ll be okay.”
[Kencee:] It’s also okay if they don’t come around. If they don’t want to come on board. You can’t win every battle. Even this far in, I worry that in five years, people won’t care about Sepsis anymore.
[Devin:] I lose sleep that we are going to drive up antibiotics. I lose sleep that this is a bad project. But my logic tells me that if your heart rate is 130 and you’re breathing 35 times a minute, you should be seen. You should have infection ruled out.
12. What has this taught you about the people that you work with?
[Kencee:] I looked at jobs throughout the city. I knew I wanted to be a hospitalist. I knew the U would be a dynamic place. I made a conscious decision to come here. I have been so impressed with our system’s support, responsiveness, and empowerment of us. We could have been shut down at a lot of different levels, but we weren’t.
[Kencee:] At the U, we had the support of our quality office and value engineers. We got to attend the Value Improvement Leaders course. We were given IT support to help us develop in EPIC. Despite the fact that people balk at Epic, this project would not have been possible without Epic alerting us when someone is sick. We had a lot more support than we would have had in other systems. I really have to commend the U for saying, here you go, and this is everything you need.
“I have been so impressed with our system’s support, responsiveness, and empowerment of us.”—Kencee
[Kencee:] Even though Devin and I volunteered for the first year, we got support that meant more. I would rather have the team support than have my salary covered. Whatever we asked for, we essentially got. That meant a world of difference. This hospital has been fertile ground to for this project. They do a good job making feel people valued, recognizing talent, and moving it forward. We’ve had a lot of support, a lot of mentoring, and a lot of great ideas from people who are not physicians. Having those people as part of our team has been worth so much.
[Devin:] I’ll echo Kencee, despite getting fairly painful pushback on the individual level, the physician and hospital leadership blew my mind. The administrators, Nate Wanner, Russell Vinik, Bob Pendleton, and on up, really have the patients in mind.
[Kencee:] Our executive administrators have given us face time too. I’ve met with Margaret [Margaret Pearce, CNO] for an hour, with Laura [Laura Adams, Acute Care Nursing Director] for an hour, Tom Miller [Chief Medical Officer] for an hour. I don’t know if every hospital would have done that – “Oh sure, hospitalist 2 years out of residency, come spend an hour with me.” With them, it only took an email.
[Devin:] There were a couple of times that I emailed Bob [Bob Pendleton, MD CMQO] at 9:00 p.m. to say, “I want to quit. I got beat up today and I’m done.” Bob would email that night or call me to say, “Let’s meet tomorrow.” Only 4 months ago, I texted Mike [Mike Strong, MD Chief Medical Informatics Officer] at 7:00 a.m. to say, “I need to talk. I’m scared we’re not doing the right thing.” It was an hour on the phone while he was driving to work saying, “Devin, I think this is ok. You guys are in the right direction.” This kind of support from our leaders has meant a lot to us as junior faculty.