E02 Morad Hameed on Process-Mapping in ACS

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Chad Ball  00:15

Welcome to Cold Steel, the Canadian Journal of Surgery podcast with your hosts Ameer Farooq and Chad Ball. The goal of the CJS podcast is threefold. The first is to highlight the best research currently being completed by Canadian surgeons. Second is to offer educational topics for both surgeons and trainees alike. And most importantly, the third goal is to inspire discussion, thoughts, creativity and career development in all Canadian surgeons. We hope you enjoy it.

Ameer Farooq  00:51

I’m honored to introduce Dr. Morad Hameed. Dr. Morad Hameed is a trauma surgeon an intensivist at the Vancouver General Hospital, and an Assistant Professor of Surgery at the University of British Columbia. He completed medical school and surgical residency at the University of Alberta, graduate studies in public health at Harvard University, and fellowships in trauma, surgery and surgical critical care at the University of Miami. He spent three years on surgical faculty at the University of Calgary before moving to Vancouver. His research focuses on systems of trauma care, and acute care surgery. Once again, Dr. Hameed, thanks very much for the privilege of having you on the podcast. Let’s just let’s jump right in. We wanted to talk about your paper that you actually identified, which was “Process mapping as a framework for performance improvement in emergency general surgery.” Can you take us through this paper, and why you like this paper so much, and how this work that you’ve done could be extrapolated elsewhere?

Morad Hameed  01:51

Yeah, first of all, Ameer and Chad, thank you so much for the privilege of having me on my first podcast, and it’s a thrilling thing to be here. And thank you for asking about the paper we wrote on process mapping. So, my background is, is trauma surgery. And as you know, trauma surgery is a very process-driven specialty, the way that trauma is able to adjust for uncertainty and complexity is by developing standard processes for everything. And so that’s always my perspective on uncertainty, complexity, chaos has always been standardization, and so very much the philosophy of trauma care.  Trauma providers, trauma care providers, tend to see the patient journey as a long, linear process or a continuum of care that starts even before the point of injury, but then spans the injury and the prehospital care, the acute care, surgery, critical care, rehabilitation, etc. And we wanted to apply this type of process perspective to acute care surgery, which is similarly has a certain amount of complexity and uncertainty and unpredictability. And we decided to map the process of a standard emergency general surgery encounter. And we picked small bowel stretching as a common emergency general surgery diagnosis. And we selected about 100 patients with small bowel obstructions who presented to our emergency department, and we mapped their process in detail, and to see if we could identify variations in process or variations in practice or bottlenecks in the process. And it was fascinating to see that even something that we’ve seen thousands of times before, like small bowel obstruction, there’s a tremendous amount of variability inherent in the process. And so, for example, a time to CT scan could have a standard deviation of like plus or minus six hours to get to CT. So, for a standard test for a common condition, why is there so much variability? So that’s what the paper was about. It was just trying to introduce the notion of or the perspective of process mapping for complex processes. And what we didn’t know at the time is that there’s an entire field of industrial engineering that is dedicated to a careful analysis of process and reduction of variability in process, and we discovered the work of Shewhart and Deming, who are early industrial engineers and statisticians, and we sort of examine a concept that, if you take a complex process and divide it into micro-steps and measure variability, there is a certain amount of unnecessary variation in each step, and if variation can be reduced at each step, the process becomes better, and then the outcomes become better. And so, starting to look at health care as a series of micro-steps, each with inherent variability, maybe one can start to optimize the process of patient experience, and most importantly, the outcomes. So, there’s a strong link to industrial engineering, which we found to be very fascinating.

Ameer Farooq  05:46

Can you walk us through the paper? How did you design it? Who were the patients that you chose? And just walk us through the paper a little bit.

Morad Hameed  05:57

Yeah, well, it’s a simple paper, very simple. We just picked 100 patients with small bowel obstruction requiring surgery and then a cohort that was managed nonoperatively. And my resident, who was the lead author of the paper, Kristin DeGirolamo, she then with a team that we put together, that includes one of our new surgical residents, Karan D’Souza, started to measure the steps, started to first break down the experience of a patient with small bowel obstruction into discrete steps. And then we started measuring time intervals to each step, and essentially created a process map for an individual process map for every patient. And we represented those maps graphically. And basically, with that sort of, the visual presentation of data, we could start to identify variations and process bottlenecks and gaps in process. And then we start to quantify that just using some simple statistical analyses. And then, essentially, the conclusion was that something so common as small bowel obstruction has a tremendous amount of inherent process variation. And our hypothesis moving forward is that, that represents a significant opportunity to improve patient care and perhaps even patient outcomes, because if we can reduce variability, we can improve the process and improve the outcomes.

Ameer Farooq  07:51

That diagram that you have, in the paper, is a really beautiful diagram, and it’s striking how much variability there is, for all these different patients with, you know, for all these various steps in the process. What do you think is driving all that variation? And why is there so much variation in something, you know, we expect all our medical students to know how to manage?

Morad Hameed  08:22

Yeah. That’s a great question, and that really strikes to the heart of this whole endeavor is, why do we have so much variation in things that should be straightforward, and I think it’s because surgical care has become so complex. And it’s become really a multidisciplinary effort, and I think surgeons are our team leaders, but our teams are multidisciplinary, they’re complex, and our systems are complex, because these systems have evolved to care for patients that are increasingly complex. And so, I think the level of complexity in our systems is so high that we might not have, our processes might not have evolved sufficiently to cope with these complexities. And so, when a patient presents with an unknown diagnosis, with a variable set of comorbidities, with potentially with physiological extremes, then we have to somehow, each time, reinvent the wheel to develop a care plan that’s targeted to those patients and that that’s why we need to assemble these multidisciplinary teams and there’s so many complexities in these interactions. And so, I think that the diagnostic and therapeutic efforts just, you know, just become, you know, almost unmanageably complex. So, the question is, can we recognize this complexity? And then can we create some order in it? And I think that’s a really fun opportunity for acute care systems.

Chad Ball  10:24

Morad, you’ve published a lot for a number of papers, in the Canadian Journal of Surgery over the years, specifically in regard to acute care surgery or emergency general surgery. Why do you have such a passion for this subspecialty in this area of greater surgery.

Morad Hameed  10:45

You know, I love emergency general surgery, because there’s so many things, I love about it. I love the urgency of the physiology. And I love the beauty and the complexities, the anatomy. I like that we have to be thoughtful and strategic. And I love that we have to bring in teams that contribute their talents and integrate them in a seamless way. It’s also a privilege to confront vulnerability and a great opportunity to restore function and good outcomes. I also love emergency general surgery, because it’s a close proxy to trauma surgery, which is my first love. And both of those specialties give us the opportunity to restore order from chaos in a small way. And I think that one of the most exciting things is that emergency general surgery has a long and interesting history. But now it’s being reimagined in a new way. And so, there’s so much opportunity to reimagine it and, and to sort of, to evolve it into new directions that incorporate innovative thinking. But I guess, you know, that the most exciting thing to me about emergency general surgery and trauma is that we get to work in teams, and we get to work with some of the best and brightest and most idealistic people around. So, to me, all of these things make this specialty a huge pleasure and privilege to be a part of.

Ameer Farooq  12:34

As you move forward trying to reimagine this old but new specialty, how do you think we’re going to improve our care for emergency general surgery patients as well as trauma patients?

Morad Hameed  12:48

Yeah, you know, I recently encountered a paper in Harvard Business Review that talked about the three waves  in health care safety. And the first wave that we’ve come to in the last few decades is technological advances. So surgical care has been improved by the adoption of new technologies, such as minimally invasive surgery, for instance. And so that drastically improves surgical care and surgical safety. But eventually that improvement curves tech to plateau and there’s some diminishing returns from the introduction of new technologies. And then, according to this article, the second big wave of quality improvement and safety has been standardization. And we’ve talked a lot about opportunities for standardization and reduction of variability and standardization using strategies such as, ERAS, for instance, shows big benefits in patient care and safety. But again, standardization only goes so far. Our patients are unique, and every process can’t be standardized. And so again, you get some diminishing returns on standardization. So, the third wave of safety, which I think we’re at the cusp of right now in surgery and emergency general surgery is the optimization of surgical culture, and the creation of high reliability in surgical care. And so, this is how do teams come together, how do surgeons communicate effectively? How do we create planned and execute plans within multidisciplinary teams? How do we address complexity? And this all comes back to surgical culture, which I think we’re only just beginning to understand. And I think that the future in, the next big opportunity for a quantum leap in surgical care is to really create high reliability organizations and strong and effective teams or, in other words, excellent cultures of surgical care.

Chad Ball  15:03

That’s, I mean, it touched on a whole bunch of really interesting and innovative concepts there. But can you, can you take those really beautiful and nuanced concepts and tell us how you begin to apply them into your local environment? I.e., whether that’s a primary or a secondary or tertiary or quaternary care facility, for example, like, like VGH? How do you get buy-in? And how do you excite people around you, whether it’s your immediate colleagues or greater multidisciplinary colleagues or nursing staff? How do we make that transition?

Morad Hameed  15:45

Yeah, thank you, Chad, that’s a great point. I am, I recently had the privilege of becoming the head of the Division of General Surgery at the Vancouver General Hospital and also for the University of British Columbia. And this is a job of a lifetime. And the most important privilege that I’ll probably ever get, and I spent the first year just thinking about how to take the first step. And it took me some time to think about what the identity of a general surgeon is, and what the identity of the Division of General Surgery is. And it took me some time to think about what our values and our mission and our vision should be. And I know that, you know, sometimes with general surgeons, we do have trouble kind of crystallizing our identity because, as a rule, general surgeons are multi-system thinkers. And we think of patients in the big picture. We deliver holistic care, we support multi-system trauma, multi-system organ failure, and we, our specialty has developed multiple subspecialties. And so, in some ways, people sometimes thought that the diversity of general surgery results in a lack of identity. But one of my colleagues, who’s our current one of our current residency program directors, Ahmer Karimuddin, he kind of encouraged me to think about our diversity, the diversity of our specialty is actually our strength. The fact that we’re, we’re venturing off in all these directions as subspecialists is actually a strength because it brings back new knowledge and new strategies back to our core, which is general surgery, which is our fundamental identity. The way we trained, the way we train others, is as general surgeons, and so kind of flipping this notion that our diversity is a weakness into the idea that our diversity is our true strength creates so many opportunities to share ideas, to scale ideas, to evolve with confidence. And so the first thing that we realized is, let’s embrace the diversity of general surgery, let’s think about ourselves as being a strong, but diverse, group, and to learn from each other and to organize each other and to organize in such a way that creates a lot of cross-fertilization of ideas. And I guess that’s a pretty abstract answer, Chad. We’ve tried to operationalize this in different ways. But the main point is just to recognize that out of many, we’re one. We’re, our fundamental identity is general surgeons, who embrace the notion of diversity.

Ameer Farooq  19:10

That’s a super cool vision for the department, and I’m getting excited just listening to it.

Morad Hameed  19:20

Chad, introduce me to — Chad, I think he was an economist — Scott Page in Michigan, who talks about diversity and complexity, and says that diversity is not just a moral imperative, or something that’s nice or idealistic. Diversity is something essential for the success of complex adaptive systems. And the more diverse, the more ideas come up, the more solutions to complex problems come up. And so how do we harness that diversity? That’s an organizational challenge for general surgery, don’t you think, that we’re beginning to embrace across the country.

Ameer Farooq  20:01

We wanted to switch gears a little bit now and talk a little bit about you and your journey to this point. So can you tell us a little bit about what drove your initial interest in surgery when you were starting out?

Morad Hameed  20:13

Yeah, it’s the origin story. My father, who is my biggest, my life’s biggest role model, he had to have a CABG. And he went to UCLA and was operated on by a surgeon named Dr. Laks, and Dr. Laks was with my superhero, like, from the time I can remember, he saved my father’s life. And I initially started out life wanting to be a cardiac surgeon. But I kind of forgot about that dream for a while. And in medical school, I met two of my mentors on my surgical rotation, Dr. Merv Laskin, who was a legendary surgeon in Edmonton. And Grant O’Keefe was my chief resident, and he was like a gold medalist in his class and a brilliant surgical thinker. And I just by chance, had the privilege of working with them, and the amazing thing is that they actually welcomed me onto their team, and, you know, every day, they let me know, in some subtle way, that they cared that I was there, and that they had high expectations for me, and the work was amazing, the patients were inspirational. And I just sparked my interest in general surgery. And I loved it for all the reasons I told you: the acuity and the complexity and that’s really what brought me in is, I just felt so welcome in such a privileged environment.

Chad Ball  22:02

Morad tell us synonymously about your voyage into essentially research, or more than that, academic surgery. In other words, what does it mean to you to be an academic surgeon? What interested you in it initially and what do you see it going? In Canada in particular?

Morad Hameed  22:25

Yeah, I didn’t start out life or start out my surgical training thinking that I would be an academic surgeon and I, I still, I still don’t feel that I am an academic surgeon that, when I think of academic surgeons, I think of some of my mentors, like Garth Warnock, or Steve Cohen or Ori Rotstein, there are many, you know, brilliant, powerful thinkers in Canadian surgery, who advanced the fields and do so with rigorous science. But, I guess, when I started working as a fellow and then as an attending two of my mentors, Steve Cohen, and Janice Pasieka, picked up on something that I actually cared about deeply, which was public health, which is sort of big picture thinking and in health systems, and they encouraged and empowered me to find connections between surgery and public health. And that’s really been my angle for the past 20 years. The other thing about academic surgery is something that I love even more, which is the opportunity to see residents transform their intelligence and idealism and energy through this miraculous process of surgical training into this incredible skill and judgment of wisdom of becoming excellent surgeons. So, I’m a fan of, like, finding ways to connect your individual passions to surgery, and also helping or seeing your trainees do the same. And I guess my perspective on academic surgery in the future of academic surgery in Canada is that it’s going to be something that allows ideas to come from anywhere and that picks up the best ideas from any field, whether it’s, you know, basic science, education, global surgery, literature, media, you know, and finds ways to make things that people are passionate about, advance the frontiers of surgery. So, I think I feel like the next era in academic surgery will be just to embrace the ideas that come from surgeons that are entering specialty. And I think it’s our job to ensure that people can have opportunities to express what they’re passionate about. And in so doing, realize their full potential.

Ameer Farooq  25:16

It almost seems like an oxymoron to talk about surgery and public health. Can you tell us a little bit what that means to you?

Morad Hameed  25:25

You know, it’s funny that you say that it seems like an oxymoron, Ameer, because so many people, so many surgeons do masters in public health now, but it wasn’t always the case. Like 25 years ago, surgeons didn’t really even know what public health was. But the point is that I think that surgery always has been a driving force in public health. Like, for instance, when you think about trauma, which is a foundational specialty in general surgery, trauma deals with injury control. And the way that the world or the way that society confronts the pandemic of injury is to create systems of injury prevention, systems of trauma care, building trauma centres, building inclusive trauma systems, adapting helicopters to fly patients. And then, building all of this sort of a systems approach on the continuous collection and analysis of data to optimize the process. And this whole idea of taking a societal approach to a problem, trying to identify determinants, trying to measure its properties, and trying to optimize the processes that respond to those determinants — that’s all-public health. And surgeons, like surgeons in the American College of Surgeons or the Trauma Association of Canada, they drive that process, because they’re on the front lines of these pandemics. They have access to data, they see the human cost of injury, and they are the ones that were inspired to create these sorts of system-wide or society-wide approaches to a surgical condition. So, it’s, I think, fundamentally, surgeons are public health champions. And I think we’re recognizing that and formalizing that more and more.

Chad Ball  27:38

I think you’re so so right and dead on there, Morad. I agree. And in the 20 plus years I’ve known you, there’s certainly been an explosion of focus on public health. And I think a lot of that, certainly in Canada, has really been led by you. And it’s been remarkable to watch and remarkable to engage in on occasion. And you should really be proud of that. I think forever. I was wondering if you could talk to us not only about the T6 project specifically, but also that journey, or that voyage into the entrepreneur side, from the, you know, the busy surgical side that’s foreign to, certainly, most of us.

Morad Hameed  28:18

Yeah, Chad, thank you so much for asking about it. So, I had the opportunity to be a founder of a company T6 Health Systems, which essentially designed a digital user interface that is optimized to collect data in real time, at the point of trauma, resuscitation, and trauma surgery, and collecting data in real time and putting it in a digital format opens up so many opportunities for data analytics. And if you’re collecting data, you can trigger practice guidelines and checklists. And you can measure processes and measure variation in processes. You can measure outcomes, you can create maps, geographic maps. And all this work just really stems from the idea that real-time data capture in data rich environments, such as the point of acute health care coupled with near real-time data analysis, has the potential to transform health care and health systems and even public health. And I think all of us recognize the importance of data in driving or at least informing health care. But we also know that there’s still wide gaps between knowledge, action and performance. So, we started up this whole journey — me and a few of my colleagues, Eiman Zargaran, who’s a trauma surgeon in Vancouver, and Nadine Sherman, who’s a health geographer at Simon Fraser University, we started this idea to bring trauma registries, to low-resource settings, and last year, trauma environments. But the idea has grown broader, into a broader effort to harness technology to advance analytics, to ensure that point of care data can actually empower individuals and systems and cultures to improve performance. Regarding the startup company, then that whole area of endeavor that may, one thing that may be worth mentioning is that the launching a startup, especially for someone who’s not a businessperson, or who’s ever thought about business, can be difficult. And it’s mainly because a startup navigates a series of failures. And its failures that actually guide the way forward. And it, the idea of repetitively failing to accomplish what you hope to accomplish, reinforces everything that we know about, everything that we hear about getting up off the canvas every time you’re knocked out. It makes you humble, and it makes you committed to the idea. And what we’ve learned through failing in this whole startup process is that failures create new opportunities and new avenues for exploration. And that exploration will continue as long as it’s guided by idealism and by people who share the same values. So, I found it to be true that the values and the people in any venture are more critical to the success of venture than the specific idea or business model. And so, the startup experience has taught me to take a long view on success and failure.

Ameer Farooq  32:13

And as a former general surgery residency program director and current chief, do you have any advice for current trainees? For myself, as someone who just has to write a small quiz at the end of the year? Or people who are starting out or even medical students?

Morad Hameed  32:30

You have a small quiz coming up?

Ameer Farooq  32:32

Yeah, as an R5. Small quiz.

Morad Hameed  32:35

Yeah. Well, yeah, I think I don’t have any wisdom or any good advice. But I just say that I think the main thing I’ve kind of learned is that, at all levels, I would say that every surgeon should constantly remember that their unique identity and perspective or passion is the source of our collective strength as a specialty. And, you know, I used to worry sometimes that whatever is unique about me, or whatever is unique about my residents would get crushed by the demands of surgical training and practice. But I think over time, I’ve realized that what’s unique about us, our unique spark, it’s not, it can’t easily be extinguished. And, in fact, our unique perspectives and passions and background are actually the source of our success as surgeons and teachers and researchers. And so, whatever it is that, you know, motivates you and inspires you, it’s important, I think, to bring it forward into the discipline, and in so doing to move our discipline forward. So, for example, one of my colleagues told me that she wanted to work on climate change, or another told me that she wanted to mentor high school students to pursue careers in science and medicine. So, the possibilities are, just by those two examples, they’re endless. And I think it’s, as I said before, it’s our duty to ensure that we all pursue these possibilities and support each other to reach our full potential. And, finally, one piece of advice that I’ll just pass on  from one of my mentors, Richard Simons, that I wish I would have thought of this idea that when I asked Dr. Simons how to prepare, how to plan for my career in five- and ten-year plans, he told me that in this in this surgical life, it’s nearly impossible to predict the future, ten years from now, or even five years from now, because the job or the title that you think you want in five years from now, like, for example, being a staff surgeon at an academic centre or being a program director, even being a department head, it may, that opportunity may simply not be available when you’re ready for it. And what’s infinitely more interesting is, you might find opportunities five years from now that you had never previously imagined. So, the best thing that one can do to prepare for an uncertain and, promising future is just to do one’s best and to be aware in the moment. And Dr. Simon’s advised us to live according to our ideals, to stay healthy, to be mindful and to be creative at our clinical practices every day, to pay attention to our patients, to pay attention to our students and our residents, and remember that we’re their role models. And I think that if we approach each day with this attitude of excellence, it just opens up unforeseen opportunities that we might not ever have imagined. So, I guess the idea is just to stay in the moment and keep exploring and to keep making choices that inspire you. And I think that that creates a world of opportunities.

Ameer Farooq  36:34

You’ve been listening to Cold Steel, the official podcast of the Canadian Journal of surgery. If you’ve liked what you’ve been listening to, please leave us a review on iTunes. We’d love to hear your comments and feedback. So, feel free to email us at podcast.cjs@gmail.com, or connect with us on Twitter @CanJSurg. Thanks again.