CHOP Residents Apply Quality Improvement Frameworks to Improve Global Child Health

Children’s Hospital of Philadelphia (CHOP) has one of the top-ranked pediatric residency programs in the United States. This is due in part to the hospital’s commitment to providing quality professional education and to proactively tailoring that education to meet current and emerging health priorities. Today, global health is increasingly a priority, and CHOP leaders in both the Department of Pediatrics and the Pediatrics Residency Program believe that pediatric global health is a valuable component of the training of future pediatricians.

In addition to offering a Global Health Track in its Residency Program, CHOP works with all residents who are interested in global health to build global health experiences into their training plans. In the 2018-19 academic year, 18 residents — the most to date in a single year — participated in global health experiences. Among them were Leonela ‘Lela’ Villegas, MD, and Nadir Ijaz, MD, who completed rotations in the Dominican Republic and Pakistan respectively.

Learning to provide care that knows no borders

As a Peruvian-American, Dr. Villegas finds that her drive and passion for global health stem from interactions with the healthcare system here in the United States and Peru. While the system in the United States is far from perfect, she recognizes the significant gaps in health services that exist for many people in global settings. She is grateful to be completing her residency training at CHOP, where she is honing her clinical and quality improvement skills while taking full advantage of opportunities to immerse herself in global health experiences.

Dr. Ijaz, who was born in Pakistan, knew he wanted to become a pediatrician during his third year of medical school, partly because he loved working with children and partly because he recognized and admired the unique role that pediatricians can play as advocates for children and families. At CHOP, he found not only a leading institution in pediatrics, but also one that was happy and willing to support his global health interests and those of his fellow trainees.

CHOP and the Global Health Center recognize that building long-lasting relationships with global partners is key to creating sustainable health and health system improvements around the world. Global health experiences for CHOP residents are designed to allow residents to spend extended periods at the same global health partner site throughout their residency training. As a result, residents develop relationships with their in-country colleagues, learn about the healthcare system in a particular setting, and have the opportunity to contribute through small research or quality improvement (QI) projects.

During residency at CHOP, trainees have two opportunities to use their elective time for experiences in global settings. In her second year, Dr. Villegas spent one month in Consuelo, Dominican Republic (DR), providing comprehensive pediatric clinical services at CHOP’s Niños Primeros en Salud (NPS) clinic. As a third-year resident, she is set to travel to the DR for another month-long rotation. Dr. Ijaz has completed rotations in Pakistan at the Children’s Hospital and Institute for Child Health (CHICH), Lahore, a government-funded hospital that provides free care for children. Dr. Ijaz is one of the few residents in several years who has had the opportunity to go abroad during each year of residency. While at CHICH, he completed three-and-a-half weeks of clinical rotation in the emergency department (ED) in his first year, a month in the pediatric intensive care unit (PICU) during his second year, and this year he spent two months working on a QI project in the PICU.

Supporting Dominican moms to improve breastfeeding

Dr. Villegas (back, R) with colleagues including NPS Lead Pediatrician, Dr. Japa (front row, 2nd from L) In her first rotation in the DR, Dr. Villegas observed that breastfeeding initiation and continuation rates were strikingly low in the community. This was supported by data collected by the World Health Organization (WHO), with only 38% of mothers initiating breastfeeding within the first hour of birth and only 5% of babies still exclusively breastfed at 5 months. Dr. Villegas also learned that mothers had little knowledge about the importance and benefits of breastfeeding for their child and themselves. It was an eye-opening experience that prompted Dr. Villegas to ponder how those benefits could be effectively framed within the sociocultural norms of the DR. Given that improving breastfeeding rates is one of the main objectives of the NPS program, Dr. Villegas started thinking about how she might help.

Upon returning from her first rotation, Dr. Villegas discussed the topic with NPS team members Ingrid Japa, MD (head pediatrician), Ramona Cordero, RN (head nurse), Global Health Center Medical Director Andrew Steenhoff, MBBCh, DCH, and Manager Adriana Deverlis. She also connected with Diane Spatz, PhD, RN-BC, an internationally recognized breastfeeding expert who has developed and conducted breastfeeding training around the world. Thanks to support from the Pediatrics Residency Program, the CHOP Global Health Center, Dr. Spatz, and partners in the DR, Dr. Villegas is now preparing for her next monthlong rotation in Consuelo. She will launch a breastfeeding training program for NPS’ health promoters, who extend the clinical program by serving as trusted health advocates in the community. Dr. Villegas has developed a modified breastfeeding curriculum using the World Health Organization’s Breastfeeding Counselling Training Course, which she will use to train all the NPS health promoters. After they have been trained, the health promoters will teach community members in each of their neighborhoods. 

To date, Dr. Villegas’ global health experiences have been incredibly valuable. “I have learned that different cultures approach medicine in different ways and in their own timeframe,” she says. “It has been a learning curve for me to immerse myself in the DR and learn their approach for handling sensitive topics.” By participating in community visits to NPS patient homes, Dr. Villegas gained a different perspective and understanding of her patients and their families. “You truly can’t understand someone until you visit their home and see how they live,” she reflects.

Improving pediatric sepsis management in Pakistan

Children’s Hospital and Institute for Child Health, Lahore In Pakistan, Dr. Ijaz was based at an inpatient hospital. Through his clinical rotations in the ED and the PICU, he observed areas where processes could be streamlined to improve care. He understood that no system works perfectly, but also knew there was a standard methodology that could be applied and used to improve a hospital system.

“I wanted to empower my local partners to define the problems in their system and then work systematically to address them using Plan-Do-Study-Act (PDSA) cycles,” he says. Dr. Ijaz worked with CHICH Assistant Professor Nighat Sultana, MBBS, FCPS, and PICU Senior Registrar Ghazala Shaffqat, MBBS, FCPS, to identify gaps in the management of sepsis. Dr. Ijaz then worked with CHOP PICU Attending Physician Heather Wolfe, MD, to review the Institute for Healthcare Improvement’s approach to quality improvement along with his colleagues in Pakistan. 

Together, the team introduced a one-hour sepsis bundle in the PICU. Sepsis guidelines state that within one hour of identifying sepsis, clinicians must draw a blood culture, give broad-spectrum antibiotics and fluids, and initiate vasoactive medications if necessary. Their bundle packaged all of these actions in a way designed to make it easier for clinicians to accomplish them promptly.

However, soon after introducing this framework, the team learned that even the simpler interventions in the bundle would be difficult to implement. One challenge that Dr. Ijaz had not anticipated was with stat orders: “When I place a stat order for antibiotics at CHOP, the order is carried out promptly,” he says. “I incorrectly assumed that using this approach would have the same effect in Pakistan — but the systems are different with very different staffing resources.” In Lahore, stat orders were used only for one-time medication doses, not for new, standing medications. Therefore, when new antibiotics were ordered for septic patients, nurses — each of whom was caring for a large number of patients — would administer the antibiotics at their preset medication administration times no matter what time the order had been placed, resulting in variable timing to antibiotic administration. With time, the team was able to change this and other aspects of sepsis care as part of a sepsis huddle checklist, a tool that Dr. Ijaz and his CHICH colleagues adapted from CHOP’s sepsis huddle framework. Since Dr. Ijaz’s return to CHOP, the CHICH PICU faculty and staff are continuing to implement this checklist and collect data on its use and effects on patient outcomes.

A supportive learning environment

Both Dr. Ijaz and Dr. Villegas have found CHOP to be an incredibly supportive environment both to grow their global health skills and to nurture their emerging careers as globally focused pediatricians. They credit Adelaide Barnes, MD, Assistant Program Director of the Pediatrics Residency Program, for her guidance and mentorship. “Dr. Barnes has been my mentor since day one at CHOP. She was the one who called me when I matched at CHOP,” says Dr. Ijaz. “I shared that I wanted to continue to build partnerships in Pakistan during residency, and she helped make it possible.”

Additionally, all residents are connected with the CHOP Global Health Center, where they have the opportunity to meet individually with Dr. Steenhoff, the center’s Medical Director. Dr. Steenhoff helps the residents conceptualize their global health projects and, along with Dr. Barnes, helps them debrief following each global rotation.

Although Dr. Ijaz and Dr. Villegas were not formal participants in the Global Health Track, they were able to participate in meaningful, career-defining experiences during their residency. This underscores CHOP’s commitment to crafting a global health experience that is rich and fulfilling for all.

“CHOP has done a great job integrating with the local community in the DR through a long-term relationship that I haven’t seen in other places,” says Dr. Villegas. “That level of care and commitment takes decades. This means that the families, communities and our colleagues trust us. This example is also helping me plan for my long-term goals of working in Peru and how to establish and maintain relationships in my future work.”

Learn more about CHOP’s Pediatrics Residency Program.