The Theme of the Week is "Collaboration"

Northern California KP visits Southern California to share innovations

In a meeting a couple weeks ago one of our doctors told me she didn't think we should share information with one of our sister regions."I don't like xxx person in that region" she said adamantly, "and I don't think we should partner with her. She will just steal our ideas and take credit for them." So I gently reminded her that we always share our work openly and freely because, in the end, it isn't about who gets credit, it's about improving the lives of our patients and our communities. When you think about it, Kaiser Permanente exists because of a collaboration that began over 60 years ago between Henry Kaiser and Sidney Garfield. That journey continues today because of internal collaboration within our three entities (Hospital, Health Plan, and the Medical Group) who have come together to build a partnership all aimed towards one vision and goal - Providing high-quality affordable care. 

Interestingly enough, the work theme for the past couple weeks for me has been all about collaboration.  Starting with a meeting with our Southern California Complete Care Leaders where we shared ideas for improving care for patients with rare diseases, diabetes, asthma,  etc. The meeting opened with our Southern California Medical Director over Quality and Clinical Analysis and our Foundation Hospital Senior Vice President for Quality and Patient Care Services Patti Harvey who spoke of their appreciation towards this group for coming together to improve outcomes, to improve quality, and improve lives.  The collaboration theme was echoed by our Southern California Permanente Medical Group Business Leader, Judy White, who spoke about replacing the competition that we have with each other across service areas to a culture of collaboration to improve care for all patients.   

Three days later I met with consultants from Community Partners to go over our plans to deploy our Proactive Encounter program in surrounding community clinics throughout Los Angeles area... work sponsored by our Kaiser Permanente Community Benefits grant program. This work aims to improve the quality of care delivered to patients across our communities by teaching clinics quality improvement strategies, implementing standard workflows, and sharing clinical guidelines. When I was approached by our Community Benefits team last year about the idea of sharing and deploying Proactive Office Encounter (POE) across our community clinic partners I didn't need any persuading to get me on board. "Count me in!" was my ecstatic response.

Wednesday we spent almost two hours on a conference call with Northern California KP explaining how we developed and implemented a Proactive Encounter program for our Obstetric patients that provides prompts in our EHR to remind staff to stage orders for providers so based on what each individual patient needs according to gestational age. If depression screening hasn't been completed, labs are missing, or a RH- patient hasn't had Rhogam given by her 28th week a care gap will remind the staff to place the order. Sharing strategies, programming logic, technologies, and thought processes helps us deliver outstanding care to both the mother and child.

My last call today was with a group of physician leaders from our Colorado region who were in the process of rolling their version of Proactive Care out to their specialties and shoring up the work already accomplished in primary care with a Successful Opportunity Report much like what we use in Southern California to monitor the effectiveness of our Proactive Care program by measuring how often patients came in to our health care system with a care gap and whether that gap was closed within 30 days. I shared with them some of our strategies for engaging specialties and how we used the report to identify areas for improvement and celebrate successes. After the call, I had a side conversation with one of their project leads who had more questions of her own. She thanked me for taking the time to talk with her offline. What they don't get is that this is one of my greatest joys... Sharing successful practices to improve the patient care experience. 

I'm grateful every day that I work for an organization that allows open collaboration. Together we save lives... one patient at a time.


"Every day is Collaboration Day when you have friends on Twitter and other social media platforms" KA

When The Stars, The Moon, and Planet Align

Our church has a Visiting Teaching program where the women (or as we call each other "sisters") are assigned another female in our congregation to visit on a monthly basis with the purpose of watching out for them and their family, befriending them, and helping wherever needed. I recently asked our leaders if I could be assigned to visit a specific sister in our ward. She and I often sit next to each other in Sunday school and, even though there is a 10 year age difference, we have similar interests. She is a Kaiser member who also happens to be a diabetic and, like me, struggles with weight issues. In our last visit, after a discussion about how hard it is to get out and exercise after work, we made a pact to walk together instead of sitting and visiting. Using a Dr. Sallis tone, I reminded her that "Walking, even if in small increments, is the single most important thing she(we) can do to improve her(our) health."  She promised to try and walk whenever possible.

Recently, her PCP left KP and she was sent a letter saying she would have to find another. She asked me if I could recommend someone from the Pasadena clinic. I told her I wasn't sure if Dr. David Morris's panel was open or not, but that was who I would choose. Last Sunday she shared with me that she had gone on to KP.Org to use the Find a Physician feature and found that Dr. Morris' panel was indeed open. She selected him and was VERY surprised when his nurse called within 10 minutes to say "Dr. Morris would like to schedule an appointment to meet you and review your medical history." 

Just a few short days later, she went in for her appointment. "The nurse asked me if I was exercising and I was really happy to say that I was walking for a total of 30 minutes a day 5 days a week!" she said with great satisfaction. She told me that the nurse showed her on the computer screen that she needed to have a mammogram and a diabetic foot exam then she helped her book an appointment for a mammogram and asked her to take off her shoes and socks before leaving a "cute little poker thing" on the keyboard for the doctor.  When Dr. Morris came in the room he went over all of her medications with her. She is still on Actos so Dr. Morris explained that we were trying to move patients off of Actos because of the bladder cancer issues. She told him she was aware of the concerns but felt like she had really good control of her numbers and didn't want to come off yet. She commented to me that she appreciated having a conversation about her medications instead of being told what to do. They talked about how she will eventually need to start insulin and she told him she didn't think that she would EVER be able to do that so she was going to do whatever she could to avoid it. He asked her about exercising and she said "I walk because Kristen Andrews made me promise I would try." It surprised me when she said this because I didn't know I was one of the reasons she was walking which reminds me just how important it is that we speak up to our friends, neighbors, colleagues, and family about importance and simplicity of walking whenever and wherever possible. She also asked him if she should get a shingles immunization (something else I may have gently suggested because of her medical history and age). He told her she was just the right age to get the immunization and ordered it for her. She rolled up her sleeve to show me a little red mark. "See... Proof! That sucker hurt!"

After scheduling our next walking visit for the next day we opened up our hymn book to start our Sunday School session. Right before the conductor raised her right arm to lead the music, my dear friend leaned over and whispered "You didn't tell me Dr. Morris was so darn cute! That was a real plus!" What can I say... we aim to please.

Tim Ho has a phrase that he uses to describe a visit where everything goes right. He says it is like the "Stars, moon, and planets line up and the agenda of the patient, the agenda of the physician/staff, and even the agenda of the organization provide an opportunity for change." Dr. Morris and his staff created a moment like this for their patient... my friend. It's these kind of stories that make my heart beam with pride. This is how we make a difference and help improve the lives of each person that comes through our door. Saving lives... together... one person at a time.

Through the Eyes of a Patient

For years my husband and I have been Saturday morning regulars at a little restaurant nestled in the foothills of Monrovia. The term "regulars" takes on a deeper meaning here. It means you are part of a family connected by the owner who knows you by name, where you like to sit, and who you like to sit next to. One of my favorite people to sit next to is a lovely lady named "Doreen".  She is a pistol of a woman who reminds my of my late grandmother. Doreen is seventy-two years old and has wonderful stories to tell about coming from Scotland be an RN in the states, stories she will share with anyone who will listen. If Doreen comes to our table, my husband has learned to just eat his food instead of waiting for the conversation to finish because there is a chance it will be cold before she leaves. 


One Saturday morning Doreen's story was about her new primary care doctor who was younger and didn't seem to like being personal with her patients. She told me how much she missed her old doctor who took an administrative position. Curiosity got the best of me and I asked Doreen where she went for her health care. When she replied, "Kaiser Permanente" my husband and I both smiled. Twenty years ago I would have kept my employers identity a secret because our reputation wasn't that great, but now, I said with pride in my heart "I work for Kaiser." "Really?"... Doreen perked up with excitement. "Oh dear..." she said with her Scottish accent, "I wish I had my old doctor back. I understand she has a wonderful new role now, but I miss her dearly. She took the time to listen to me. My new doctor is very good, but she likes to look at the computer and type, which, I must say... she is very good at typing." Hearing Doreen find the good in every situation garnered another chuckle from me. I asked which one of our facilities she went to and who her doctor was then and is now.  When I told her that her last doctor is a good friend of mine, she bubbled with joy and said, "Isn't she lovely dear! I used to be able to call her with a question and she or someone from her team would call me back.  Will you please tell her I said Hello? I'd love to talk to her sometime. My new doctor said she prefers to communicate through email so I had to have my son show me how to use the computer so I can talk to her. " As she spoke, I couldn't help but make a mental note "what happened to the patients preferred communication?" I listened to my friend describe a couple things she would change if "she was running things." At one point she said, "Oh dear, I'm talking too much. Tell me what you do for Kaiser?" I said, "I run a proactive care program that is meant to improve your care experience." Doreen's eyes got big and she laughed "Now I've gone and got myself in trouble. Don't get me wrong, my doctor is good, she just is too young to want to listen to an old bird like me." I assured her that no one was going to be in trouble and that her insight was valuable to me. From that day on, Doreen has been my secret shopper. Each Saturday amidst the tables of other regulars, we sit for at least 10-20 minutes as she gives me the scoop. "Employees parking in the Emergency parking lot causing patients who need easy access to park in a remote lot. Why did Kaiser move that department to a different location without telling the patients? Do you know that area has just been empty for months? Isn't that a waste of money?" I don't try and provide excuses, I just listen. On Monday's, when I'm back at the office, I go over all of my mental notes and reach out to the administrators who need to know what their patients see, hear, and say. Sometimes I am able to come back to Doreen with answers to her questions and other times I have resolutions to share.


In the spring of 2011, after taking a few weeks off from our regular Saturday routine, my husband and I walked in to the Peach to find Doreen on her way out. Was it just me or were there tears in her eyes? I stopped to hug her and she broke down in my arms. We stayed in that embrace until we could both gather our composure. I didn't know why she was crying, but I cried with her. Then she whispered, "I have breast cancer." My heart sunk. I am estranged from my mother and my grandmother passed away two years ago so Doreen is like my mother and grandmother rolled up in one beautiful being. She told me she had gone to Rhuematology and they reminded her to get her mammogram done. (Thank goodness for Proactive Care) When she did, they found the tumor and biopsies confirmed it had spread to 5 of her lymph nodes. My mind raced with questions about stages, but I knew I needed to let her guide the conversation. She would tell me what she was strong enough to tell. Doreen seemed disheartened as she explained to me that she wasn't sure if she would be able to go through with the treatment because she didn't drive and she wouldn't be able to get to her appointments because the location was too far away. "There must be options. Our social workers should know about resources available" I said. She told me she checked with the Social Worker and her Oncologist and both had no solutions to offer. I asked her if she would mind if I helped her handle this one and she gave me permission to ask around. We spoke for a few more minutes before she left to get some rest, still recovering from her biopsies.


A phone call to one of my doctor friends, who also happens to be the Assistant Medical Director for Quality and Clinical Guidelines for KP SCAL and, more importantly, an Oncologist, and I learned that our Los Angeles Medical Center had apartments nearby where patient's could stay while they were undergoing treatment. Why our Social Worker didn't know about this vital program was something I would fix later, my first priority was helping Doreen. She would spend the week at the apartments and the weekends at home. Her dispair turned to hope. She started her own walking club with other patient's who, as she put it, "Seemed so sad - I knew walking would make them feel better." Even on bad days, she carried her sense of humor with her, teasing the nursing staff and other patient's. On Saturday's, she would confide in me about how she was really feeling and in true Doreen fashion, share with me her ideas for improving the care experience. "Everyone is very good on an individual basis, but it doesn't seem like they talk to each other. It would be nice if there was a case manager who could help guide you through the process. The social worker is good, but this doesn't seem to be her expertise", she would say. "I found out they had support groups offered by Kaiser from another patient." 


On another Saturday morning, Doreen was quiet and not as talkative as normal. I asked her what was wrong and she told me her Oncologist had retired and she had a new young doctor. The medication was really making her feel horrible and she just wasn't sure she wanted to continue with the treatment at age 72. She tried to talk to her new doctor about it, but she just seemed to be in "I can save you from this disease" mode. Doreen wanted to have a real conversation with someone that would help her explore ALL options, including doing nothing. In her sweet Doreen way, she said "I'm sure she is a wonderful doctor, but I wish I had someone who could understand that I am old and tired. I've done some research of my own and there are some studies that say treatment at 72 isn't always the best choice." Once again, I asked for her permission to consult my Oncologist friend, Dr. Schottinger, who also happens to be in her late 50's and perhaps more relatable.  I arranged for the two of them to talk.  Dr. S reviewed her chart and assured Doreen she was in very good hands and agreed with the treatment recommendations, but suggested she talk to her doctor about the extreme fatigue she was experiencing and ask to switch to a different medication. She spent 45 minutes on the phone with Doreen... consulting, reassuring, and listening. Doreen called me afterwards and said she felt like a weight had been lifted and that Dr. S allieviated so many of her concerns. Doreen spoke to her doctor at her next visit and together they made changes to her medications which she didn't cause the fatigue she felt before.


Doreen continues to go through treatment and has good and bad days. She is still walking every day and living life full of hope, but ready to stop the treatment if she feels the quality of her life is diminished in any way. She speaks up. Sometimes to her doctor directly and sometimes through me, but she has a voice nonetheless. Doreen continues to be my secret shopper and I know she loves it as much as I love her for doing it. In fact, she is the perfect kind of secret shopper because she knows how to highlight the good while looking for opportunities for improvement. She always apologizes for "carrying on", but I cherish every moment with her. She has taught me so much about improving care just by reminding me to see things through the eyes of a patient. We all have something we can learn from the Doreen's of the world and it's time for the world to listen.


I am grateful to Doreen for allowing me to share her story so others can learn from her too.

The Push-Away Moment

"The importance of the "push away moment" cannot be overemphasized.  It is when the agenda of the patient, the agenda of the physician/staff and even the agenda of the organization aligns and provides an opportunity for change.  It's when the the stars, moon and planets line up.  When it comes down to it, it is a tragedy when the opportunity passes because the physician/staff keeps pecking away at the keyboard." Timothy Ho M.D. 

Electronic Health Records are an amazing innovation. They allow physician's to record and view pertinent information to guide their patients along the right care path. They allow electronic decision support to provide recommendations based on the patients medical history. An EHR gives us the ability to send orders to our labs and pharmacy electronically and appropriately bill for the services provided while allowing us to capture vital data for reporting agencies. The downside, and biggest provider/patient complaint, is it steals away eye contact time with the patient and, if not balanced with a personal touch, may make the encounter feel very impersonal.  The challenge for physician's is finding that right balance and knowing when to push away the computer and just listen to the person sitting in front of them. 

Last year I wrote a blog about overcoming chronic insomnia in which I described a moment  where the Sleep Neurologist was taking a detailed medical history to uncover what brought me to him. For most of the intake, he would look at me quickly to ask a question then turn to the computer to type my answers. Eye to eye contact was minimal. I explained how my health had deteriorated to where I was having migraines 3-4 days out of the week because I wasn't sleeping and the Ambien I had become dependent upon was causing me to sleepwalk and do crazy things I couldn't remember. He asked me to describe a couple of sleepwalking episodes and as I did, he typed. He typed and typed and typed... until I, choking back some tears, started describing the latest episode where I had taken a pair of scissors and cut my hair - in my sleep. It was at that moment that he experienced what my doctor friend Timothy Ho once referred to as a "Push-Away" moment. That, as he described it, is a moment where you realize that the most important thing you can do for your patient is to stop typing, look the patient in the eyes, and just listen. 

When I finished spilling out what was a very embarrassing and scary episode for me, my doctor looked me directly in the eyes and with great assurance said "I can help you, if you are willing to make a lot of changes, starting with stopping the Ambien." That was the moment for ME, the patient, when this visit changed. I went from feeling alone and desperate to feeling heard. It was the concern in his eyes and voice that reinforced the fact that my situation was as serious as I believed it to be. It was the confidence in his words that made me feel like he really could help me. If we didn't have the push-away moment connection, I probably wouldn't have taken his strategies for overcoming my insomnia to heart. 

If providers practice listening for clues and learn to take advantage of push-away moments, patients may feel more committed to complying to medical advice and recommendations. Push-away moments may even lead to better medication adherence, people exercising more, giving up tobacco, and completing important screening tests. Why not push away your computer and give it some thought?

White Coat

Artist: Regina Holliday "Listen To Me"

Sitting across from you as you wear a white coat of armour 
Backed by your training and elite medical degree
My hope lies in your knowledge, skill, and training
While my world lies painfully dying in room 603
As I stare at your family's portrait behind you
Hanging protectively in an expensive wooden frame
I wonder if you know your patient has children too
If you care to know the soul behind the name?


Stethoscope stuffed deep in your white coat pocket
Tools to help you hear how every heart beats
My heart is breaking as it races with desperation
Distractions interrupt us, forcing me to compete
This time you set aside as office hours
That I thought would be dedicated to me
Has been stolen by conversations with others
Not one concern for the patient in room 603


I beg you for explanations and definitions
Of words too complicated for me to even spell
Searching for answers to the numerous questions
Needing a partner to help us through this hell
With you I get no answers... no compassion
So we transfer care to another white coat team
The medical record I had to fight you for
Granted so easily to them, as if part of some crazy scheme


I stand here with memories to keep me strong
Sharing our experience with others on Capital Hill
Voices, faces, and stories painted on jackets
So others can learn and remember them still
Supported by others who join the fight for change
Politicians, patients, family members, and doctors too
Today I'll be painting one more story
On the back of a white coat to remember you


Dediciated to Regina and Fred Holliday

To participate in the Walking Gallery Event on June 4th, 2012 click here

For more information on the Walking Gallery and Regina Holliday's Medical Advocacy Blog click HERE

It's All About The Patient

When I was hired by Kaiser Permanente over 21 years ago, my father, a lifetime KP employee, told me to always let one thing guide me.  He said, "No matter what you hear, the work we do is ALL about the patient. Sometimes you will have to fight to give the patient a voice, but as long as you do what's right for the patient, everything will turn out in the end." Having had my own voice diminished at one time, his words resonated deep within my soul. I took my fathers words to heart and as I've made my way up the career ladder that advice has helped me stay strong through some very difficult battles with well meaning people who simply forgot to see the patient as a person. Sometimes, I learned, you have to throw away the clinical guidelines and evidence and simply ask the patient how they want us to care for them. When their voice isn't being heard, you need to speak up for them.


Four years ago, I was sitting in a hospital room in the midst of a 6 month battle to help a very special patient fight for her life, my daughter Amanda.  Amanda, who was 12 years old at that time, went from being a happy, healthy, and active 5'2 103lb pre-teen to an 80lb lifeless, hopeless, and very sick girl. 


Her symptoms started off as nausea one morning. No big deal, I thought, I'll keep her home from school for the day and she'll be fine. After three days and a new symptom of persistent itchiness, we took her to the doctor.  "Must be a food reaction" her doctor said. Not really sure which food may be causing it, her doctor suggested we stop the one thing Amanda ate all the time - Special K cereal.  With a change in diet and some over the counter Benadryl, we left hopeful things would settle down.  Two days later, however, the nausea turned in to bouts of vomiting and the itching had intensified. Another doctors appoint and an after visit summary that listed a diagnosis of a stomach flu and we were back at home trying to keep her hydrated. After two more days of vomiting we took Amanda in to the ER for IV fluids. The ER doctor ordered tests, gave her medicine to stop the vomiting and calm the ridiculous itching that was driving me crazy. "Looks like she may be allergic to Gluten." With some basic instructions on how to avoid Gluten, we were sent home. Three weeks, two more PCP visits, and three more ER visits later, Mandy's symptoms increased to the point where she was throwing up between 4-6 times a day even with a gluten free diet. The itching continued, and now she had severe joint pain and headaches. All her labs, except for electrolytes and potassium, were coming back completely normal. Her illness was a mystery. Her pcp, finally admitting she was at a loss, sent in a round of referrals to Allergy, Rhuematology, and Gastroenterology. The allergist found nothing wrong and the rhuematologist told my husband that maybe it was depression or Amanda was "doing this to herself" and referred her to pyschiatry. Amanda, the patient, my beautiful little girl, growing tired of being poked, prodded, and doubted, became quiet and distant. She tried to go to school on the days she felt well enough, but was always sent home part way through the day.  My nerves were fried and I just couldn't take one more call from the school nurse telling me my daughter "looked like death". After a battle with the school to get her records I enrolled her in an independent study program so she wouldn't fall behind. Fortunately, our older daughters who were 19 and 20 at the time skipped a semester of school so they could take turns staying home with her. I honestly don't know how we would have made it through this nightmare without them. I felt like I had let her down. I mean, how could her mom work with all of these doctors and not one be able to fix her? 


Amanda and I paid a visit to the ER at least 2-3 times for IV fluids. They had admitted her twice, but sent her home the next day with the nausea under control no closer to a diagnosis than the first day we took her in. On top of all this, Amanda had developed a new symptom. Sometimes, she would be talking to you and then for no reason, just start staring off in space. Eyes open, but looking at nothing. When I took her in to the Pediatric Urgent Care clinic to have the new symptom evaluated, the doctor came in the room, quickly examined her and, without reviewing her history, said, "She is on drugs." I was floored.  After a very heated argument with the doctor, she said "If you don't be believe me, take her to the ER and they will test her. You'll see." We went across the street and the ER doctor reviewed her chart, came in and talked to us, ordered a CAT scan AND a drug test.  While he was in the room with us, she had one of her staring episodes and he said "she is NOT on drugs, she is having seizures." With a referral to Neurology entered into our EMR, a round of IV's for dehydration, another after visit summary, and a print out of all her lab results for our growing collection, we were out the door.

Nearly three weeks later, we were sitting in the exam room of Pediatric Gastroenterologist Dr. Fredrick Watanabe, a man, who would become our "Dr. House".  By the time we saw doctor Watanabe, Amanda had withered away to 84 lbs. Her tiny bones pushing against her pale skin as if they would poke through with any quick movement.  Throughout all of her other specialist appointments, the doctors directed their questions to us, but Dr. Watanabe sat down across from Amanda and looked her in the eyes and spoke directly to her.  He told her that he believed that she was really sick and he was going to help her get better, but she had to make a deal with him.  She would have to eat, even though she would probably throw it up, he told her to eat anything she wanted, "Just eat." He made her pinkie swear that she would keep her end of the deal.  He put her on a medication to increase her appetite and another to help with the nausea, and scheduled an endoscopy for the following week. The endoscopy showed scaring in her esophagus, but no reason for the vomiting. I was so worried that he was going to give up like everyone else, but instead, Dr. Watanabe became our advocate. 


While at work one day one of my older daughters called me in a panic saying that Mandy had thrown up about 10 times and she couldn't get her off the bathroom floor. I rushed home to find her lethargic and with a barely palpable pulse. I carried her to the car and raced her to the ER again. Her blood pressure was so low they couldn't pick up a reading and she was so dehydrated they pumped 8 bags of fluids. She was admitted to the hospital for the fifth time a little over 3 months into this ordeal. Dr. Watanabe not only came to see her, but went to see the Chief who was going to discharge her once her vomiting had stopped and convinced him that she needed to be kept in the hospital while they coordinated all her care.  He had them assign her to a teen medicine doctor who would meet with me after each of her other appointments to help us understand what was going to happen next. Working on a hunch, he called a friend of his who is a Pediatric Neurologist at Children's Hospital of Los Angeles that specialized in something called "mitochondrial disease".  About 3 weeks later and an extremely thorough consult with his doctor friend who was picking up some shifts at KP to help with some vacancies in neurology, we had his hunch confirmed. After 4 1/2 months, Amanda was officially diagnosed with Mitochondrial Disease.  Finally, after a month of a treatment her symptoms went away as quietly as they came. 


Amanda is now a lively 16 year old sophomore who's looking forward to getting her driver's license in a month. She has her weight back up to a healthier 98 pounds. She had some scary episodes where the mini seizures turned in to tonic clonic seizures, but those haven't occurred for over three years now. This whole experience changed her though. She is more grown up and thoughtful. She has no problem speaking up for herself when she goes to the doctor or the dentist. She tells them exactly what's going on and what she expects to happen. 

When I think back on our journey I can't help but feel blessed that our EMR had already been implemented and each of her physician's, as well as myself, had access to her full medical record.  I am grateful that we belonged to a health plan that understands the importance of integrated health care and that we didn't have to beg for insurance authorizations and approvals. No... every visit wasn't perfect. When her care was sub-par I sent emails to the chief and department administrators and when it was great, I did the same. I became Amanda's voice when she wasn't heard. Though there were times when I doubted we would ever find a diagnosis, we never stopped fighting. Every time I fought for her, I could hear those words my dad told me so long ago... "It's all about the patient".  

The Proactive Encounter program I run for Southern California Kaiser Permanente is so much more than a preventive care program. It's about saving lives and remembering to give our patients a voice in the process. The phrase, "I will not stand idly by" pushes me to be the best person I can so no one is forgotten and everyone is heard. Regina Holliday recently asked me to send her three paragraphs to describe my soul and my tipping point so she could paint my story on the back of a jacket for the Walking Gallery event on June 4th in Washington D.C. This was a tough request for me because my soul is a cumulation of all my experiences, good and bad.  As a domestic violence survivor, I vowed to never let someone steal my voice again. It's in my nature to fight for the weary and be strong for the weak. I've learned that although I work for an amazing organization, it is made up of humans who are flawed just like me. Sometimes I have to fight for the patient just like I did years ago for my daughter. I proudly wear a button to work every day that reminds me that the work we do is ALL about the patient and that together we save lives. I used to cringe inside when someone would share with me a bad encounter with us, but now I sincerely want to know from them how that experience could have been better and I become their voice sharing their story in hopes to improve the care experience and those become a part of me too.  When the right thing to do seems blurred and confusing, I think about what I would want as a patient... What I would have wanted for for Amanda and then I fight for it. All of these experiences are woven together to make up my soul.

Mentors in Social Media

Back in March of 2011, Dr. Ted Eytan from The Permanente Federation, came to Southern California for a 3 day visit to see how we cared for each patient using a Proactive Complete Care philosophy.  After his visit, Ted sent our team a link to a blog he wrote about what he observed and what he heard.  I was fascinated to see blogging used to tell a different kind of story.  I had a personal blog outside of work that I used to keep me company on nights when I was plagued with chronic insomnia, but  Ted's blog was a way to share successful practices, observations, and ideas with others who had a similar interest.  In Ted's case, his blog is medical related, but with a focus on providing successful strategies to improve patient centered care.  Giving the patient a voice and improving the care system in the process.  When I followed the link to Ted's blog, it took me to our employer's internal sharing site called Ideabook.  While in our Ideabook site, I found out that we had a Complete Care page hosted by my friend and Complete Care Physician Co-Lead, Timothy Ho, MD. After reading through the many blogs posted by Tim Ho and other contributors, I thought about the possibilities of what writing a Proactive Care blog from my perspective might do to help facilitate what I've learned with others across our region and, because my role had expanded to helping other KP regions implement and deploy our Proactive Care system, what it might do to help answer some of their questions.  Without another thought, I took a leap and joined Ideabook myself.  To be honest though, I was extremely intimidated by the thought of blogging for work. I mean, what if no one reads my blog? What if what I wrote didn't matter? I was plagued with "What if's..." so for a couple months, all I did was read the writings of others.  Then, Ted Eytan invited me to attend a Health Innovations Summit in our Nation's Capital, Washington, D.C.  Before I left the event Ted had convinced me that it was time to open a Twitter account and get working on my blog.  In fact, I opened a Twitter account and tweeted the link to Ted that day and wrote my first blog on the plane ride home to California.

Since that time, I have written close to a 100 blog posts on our internal site.  My writings are about the work that we do, the care that we deliver, the system's we use, and what I like to call "the heart of why we do what we do". I was worried at first that since my clinical experience is only through osmosis and not by profession that I would not be able to add value to a physician or nurse who read my blog. That's when I realized, my blog didn't have to be clinical because my blogging and Twitter doctor buddies, Tim Ho or Ted Eytan, could add a comment to my post to share the clinical side. What do I have to offer then? Well... to start with I have over 20 years of combined experience with Kaiser Permanente on both the Health Plan and Medical Group side. I determined that I would do something that I haven't seen as much in doctor blogs.  I could share my vulnerabilities. Whenever I thought it would get the point across better, I would keep it real by adding my personal experiences to the topic.  There are times when my blog posts are short and sweet, just sharing a brief article that I read, and there are posts that are technical and explain why an alert or care gap may be triggering the way it is. Sometimes there are rants about something that set me on fire and sometimes there is a piece of my soul that is opened up and poured out through key strokes with a hope that someone will be inspired to do the right thing.  

Tim and I have had a couple of conversations about whether or not all of the time it takes to blog is actually worth it. Sometimes it feels like such a thankless task, especially when a blog post only gathers a couple of hits. Then there are other times when a post gets hundreds of hits. Go figure! He and I have developed a relationship of encouragement through blogging that, at least for me, has helped me see the world a little differently.  Tim Ho is the master of analogies and story telling, which is funny because he doesn't believe that comment to be true. Ted Eytan has been my Twitter mentor. Re-tweeting and asking open ended questions that have helped me understand how to be a better tweeter.  I also follow a few other blogs like Regina Holliday's Medical Advocacy Blog, who, without knowing it, has inspired me in different ways.


To Tim, Ted and all the others out there who have helped me become a better blogger and social media user/advocate, thank you.

No More Sleepless Nights

After dealing with chronic insomnia for nearly 5 years, I can honestly say for the first time in a very long time, I have "no more sleepless nights." Many of my co-workers suffer from the same insomniac issues I did, so when I mention that I am sleeping now, they tend to lean in close, eyes glistening with hope, and ask me "HOW???" They want to know the magic cure. Is it a pill? Is it a tea? Is it meditation? That's when I laugh and tell them to be patient and I'll share everything. Truth is, I can give them all the answers and remedies, but if they aren't ready to take a inventory of where they are and assess whether they are ready to make a change, it won't work.

"You can't push anyone up the ladder

unless he is ready to climb himself" - Andrew Carnegie

The Five Year Fog

Insomnia means different things to different people depending on what type of sleeper they are and what type of insomnia they experience. For me, insomnia was triggered by medical & medication issues, physical surrounding, racing thoughts, and really poor sleep hygiene. Every night was like ground hog day happening over and over again. I had no problem falling asleep around 10:30 or so, but I couldn't stay asleep. By 11:30 I was wide awake again and I would stay awake until just about the time I needed to get up for work. Four to five nights out of the week, I would sit up surfing the internet or answering work emails - awake - while everyone else in my house slept. Unfortunately, the lack of sleep sent my other medical conditions like fibromyalgia and migraines in to full gear. Eventually, I had to increase the dose of those medications because relief could not be found on previous doses. Working the day after a night without sleep was like dragging myself through quicksand. I just felt myself weighed down in a fog, my body moving slowly through the day to day movements. 


After having two near accidents falling asleep at the wheel while driving, I finally went to my doctor for help. After a long discussion about the pros and cons, she prescribed me Ambien. We started with a prescription for 10 tablets to see if it would help. I was very selective about taking the Ambien. I would look at my calendar and think, "what meetings do I need to function really well", and then I would take the Ambien the night before those meetings. Fridays and Saturdays were nights were my "awake" nights because my precious Ambien could not be sacrificed for personal sleep. All I knew is this stuff really worked. I was sleeping! I still felt tired during the day, but I didn't remember being awake at night, so that must have meant I was sleeping. Right? Not necessarily. Studies have found that patient's who took Ambien failed to fall in to the deep sleep cycle where your body works to repair and restore itself to maintain good health.

I've played the medication adjustment game for some time. Adding new pills to the arsenal when needed. One night while filling my pill container, I counted 9 pills, not counting the other 3 I took during the day for a total of 12 prescription pills.  Twelve pills - Seven prescriptions. (This number didn't include the Advil I popped like candy during the day.) Still, my migraines were seriously out of control, my fibromyalgia never seemed to get any better, my energy was zapped all the time, and I had lost all hope for ever having a normal pain free life. I had gone from taking Ambien 1 or 2 times a week to taking it 5 nights a week because it was the only way to get any sleep. I was starting to believe that this was all there was ever going to be for me. 

Ambien had side affects for me. One of which was sleepwalking. Strange things happened during these sleep walking episodes that I either don't recall or have mild flashbacks of what feels more like dejavu than my reality. To my family, most of those incidents were funny. Heck, hearing them tell me about the night I waved incense through the house to rid the bad spirits or told my daughter I saw someone's head get chopped off and blood squirt out while watching "storage wars" made me laugh too. My husband even had to put a lock on our door high enough for me not to reach and hide my car keys at night because he was worried I would try and leave the house. But the scariest moment came when I took some scissors out and cut my hair...while sleep walking. That moment and my increased migraines led me back to my physician again. 


June 6th, 2011 
After explaining to my doctor that there was just no way I could go on living THIS life, we discussed my plan to get off as many medications as possible. I was ready to make a change in my life... a change FOR my life. After some discussion we agreed that I would stop taking the pain killers opting to fight through the bad fibromyalgia days and would begin tapering off my everything but my Qvar.  Before I could stop taking the Ambien, she wanted me to see a Neurologist who dealt with sleep disorders. 

"The best cure for insomnia is to get a lot of sleep." - W. C. Fields

June 23rd, 2011
I had my initial consult with Dr. Prasanth Manthena who is the director of the sleep disorder clinic at our Los Angeles Medical Center. After going through my medical history and discussing my sleep concerns including the sleepwalking episodes Dr. Manthena pushed away the computer and looked me directly in the eyes and said "I can help you, if you are willing to make a lot of changes, starting with stopping the Ambien." I was terrified at the thought of going back to not sleeping again, but I knew I needed to stop taking it. In fact, if I was only allowed one word to describe how I felt at that point in my life in regards to medical and sleep issues, I would have to say "despair". Dr. Manthena saw the fear in my eyes and reassured me that he would help me gain control over my sleep. Control... that is a feeling or word that hasn't come to mind when thinking of my sleep patterns in the last 5 years. With a VERY detailed set of instructions including cutting the dose of Ambien down to half a pill for the following two weeks before stopping completely, an appointment for a sleep study, and an assignment to read a book called "No More Sleepless Nights" by Peter Hauri, I left his office with a new feeling... hope.

Two days after attempting to cut that tiny little Ambien pill in to half, I decided to just stop taking it completely. The first few of nights were tough, but I followed all of the instructions provided - except for wearing sunglasses at night while watching tv. Forty minutes of exercise a day, no caffine after 10am, no more tv in the bedroom, alarm clock under the bed, hot shower at 9:30, go to bed at 11:30 after completing my "scheduled worry" journal. Up at 6:30, even on weekends. I did it all. After one week of following these instructions, I started to see the benefits of my efforts. I was sleeping! Without medication. Not only was I sleeping well, I felt good. After just a couple weeks, I started feeling GREAT. I had energy to exercise, my migraines have reduced significantly, the fog in my head was gone, my spirits were up, my fibromyalgia was better, and I was able to reduce my medications from 12 pills a day to 5 (two medications).

July 28th, 2011

When I went back to Dr. Manthena for a follow-up visit. He was pleasantly surprised at the change in my countenance. I truly am a different person than the one that sat in his exam room two months prior fighting back tears. Dr. Manthena expressed that many people don't follow the instructions and they don't always get to see positive outcomes like mine. We also discussed his ideas about getting patient's in to an insomnia health education program BEFORE they feel the need to turn to prescriptions or over the counter medications to get sleep. I am living proof that these programs could work.

Together... Dr. Manthena and I have given me back my life. Together... we saved a life.

I am forever grateful.


June 23, 2012 ***UPDATE***
It has been a year since my first visit with Dr. Manthena and I am happy to report I am STILL sleeping well. I go to bed every night at 11:30 and get up every morning at 6:00 - I don't even need an alarm clock, my body just knows when to sleep and when to wake. I am off ALL prescription medication with the exception of my Qvar and Albuterol for my asthma.(I tried to stop those too against my doctors advice and found that it just plain sucked not being able to breath) My fibromyalgia flair ups are manageable and less frequent. I still get a monthly migraine around my menstrual cycle that usually sends me to the nurse clinic for a Toradol injection. I do have occassional nights when my mind races with thoughts, but I calm them by picking up a book (nothing exciting though) and reading in very soft light until I am ready to sleep. If I ever feel myself starting to slip, I evaluate what part of the routine I am missing and add it back in and my sleep returns. 


As great as it feels to know I have helped myself, there is an even greater satisfaction in knowing that sharing my story has helped others. At a recent site visit, the Assistant Department Administrator came up and hugged me and said, "Thanks to your blog I am now sleeping", that's when my one of my physician partners, Dr. Timothy Ho, laughed and said, "Did I tell you that I use that blog with my patient's too?" I knew that the doctors in Kaiser Riverside Family Medicine used it, but it meant even more to me that my friend and fellow blogger felt it was worth sharing. Big smile from me! 


Wishing you all a great nights sleep... tonight and every night.

Insomnia Patient instructions (written for me)
-Titrate off ambien 10mg (1/2 tab) for 2 weeks – then discontinue completely
- Read Peter Hauri's Book: No More Sleepless Nights

SLEEP HYGIENE INSTRUCTIONS
Recommended Bedtime: 11:30pm

Recommended Wake time: 6:30

Recommended Hot Shower time 9:30pm

After shower:

• Keep room cool afterwards
• Wear sunglasses till you go to bed
• Scheduled worry (i.e. Keep a diary with the following:
  
  • Write down all concerns/stressors/anxieties
  • After writing them down - cross them out - (there is nothing more you can do tonight)
  • Write down several good things about yourself

Remove TV and any computers from bedroom
Remove ALL clocks from your bedroom (if need alarm keep it underneath your bed)
Wear earplugs each night

If not sleeping: get out up of bed and read with as little as light as possible (don't work, watch TV, etc.). Go back to sleep when you can't remember the last line you read. Does not matter how long you've been reading: get up at 6:30 am and go to sleep at designated bedtime not earlier.

Homeostatic Drive for Sleep
• Avoid naps. If you need to nap keep it short: 10 to 15 minute nap only and not close to bedtime.
• Restrict sleep period to the average number of hours you have actually slept per night in the preceding week. For example, if you feel that you are only sleeping 6 hours at night, make sure you are laying down in bed for just over 6 hours. Quality of sleep is important. Too much time in the bed can decrease quality on subsequent nights.
• Get regular exercise each day, preferably 40 minutes each day of an activity that causes sweating. Stop all exercise after 6 pm.

Circadian Factors
• Keep a regular time out of bed 7 days a week.
• Do not expose yourself to light if you have to get up at night and at least 1-2 hours before going to bed (i.e. no TV, computer). Wear orange-tinged sunglasses inhouse if necessary
• Get at least one half hour of sunlight within 30 minutes of your out-of-bed time (do not wear sunglasses or hat at this time).

Drug Effects
• Avoid caffeine entirely for a four-week trial period. If you absolutely cannot go without caffeine: limit caffeine use to one to two cups no later than 10:00 AM. (I don’t personally drink or smoke so I’m not including those instructions here)
Arousal in Sleep Setting
• Do not eat or drink heavily for three hours before bedtime. • If you have trouble with regurgitation, be especially careful to avoid heavy meals and spices in the evening. Do not retire too hungry or too full. Head of bed may need to be raised.
• Keep your room dark, quiet, well ventilated, and at a comfortable temperature throughout the night. Earplugs and eyeshades are OK. White noise is also OK (Fan is great).
• Use a bedtime ritual. Reading before lights-out may be helpful if it is not occupationally related. .
• List problems and one-sentence next steps for the following day. Set aside a worry time. Forgive yourself and others.
• Do not try too hard to sleep; instead, concentrate on the pleasant feeling of relaxation.
• Avoid unfamiliar sleep environments.
• Be sure mattress is not-too soft or too firm, pillow is right height and firmness.
• Use bedroom only for sleep; do not work or do other activities that lead to arousal
• If possible, make arrangements for care-giving activities at night (children, others, pets) to be assumed by someone else.