October 23, 2025 • 43 mins
A small change at the bedside can ripple across an entire system. That’s the spark behind this conversation with Dr. Khalil Sivjee, Medical Director at Cleveland Clinic Canada and pulmonary–critical care physician, as we explore how data, design, and relentless measurement turn delays into decisions and anxiety into action.
We begin in the ICU, where a simple ventilator-liberation protocol challenged “that’s how we do it” and proved that even a junior clinician can drive measurable improvement. From there, Khalil zooms out to outpatient redesign—mapping the lung-cancer journey from first nodule to treatment and collapsing months-long waits by pre-ordering imaging, biopsies, and consults. Supported by EMR flags that signal when access drifts off target, this work redefines what it means to be data-driven.
We unpack “metrics that matter”—from reducing “scanxiety” through faster imaging turnaround to tracking safety events and service-line dashboards that keep teams focused on what patients actually feel. Then the conversation expands into the workplace, where Cleveland Clinic’s corporate advisory model helps companies build healthier environments through smarter design—air quality, ergonomics, mental-health screening, and on-site “pre-primary” checks that spot hypertension and diabetes early.
Finally, we look to the frontier of access: portable diagnostic kits and AI-enabled triage that bring care to students, remote workers, and underserved communities. The distance between a question and a clinical answer keeps shrinking.
The takeaway: the future of outpatient care is near-home, proactive, and measurable. Put the patient at the center, bring services to them, and measure everything that matters.
If this resonates, follow, share, and leave a review—and tell us the one metric you think every clinic should track.
🔗 Resources & Links
Guest Links
- Dr. Khalil Sivjee – Cleveland Clinic Canada Profile: https://my.clevelandclinic.org/canada/staff/sivjee-khalil
- Dr. Khalil Sivjee – LinkedIn: https://www.linkedin.com/in/khalil-sivjee-a3021a9a/
Specific References Mentioned in the Episode
- Cleveland Clinic Canada — Official site for outpatient and corporate health programs: https://my.clevelandclinic.org/canada
- Tytocare — Remote diagnostic platform discussed in the episode: https://www.tytocare.com
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
SPEAKER_00 (00:00):
Data-driven care is the only way to deliver care.
If you're going to deliverquality care, you have to
continue to measure what you'redoing, how you're doing it, and
how effective it is.
Otherwise, not only could youstagnate at a certain level of
quality, but I think you couldactually get worse at it.
SPEAKER_01 (00:18):
Welcome to Leading Quality, the podcast
spotlighting the people movinghealthcare forward from the
front lines to the C suite.
I'm your host, Jason Meadows.
My guest today is Dr.
Khalil Sivji, medical directorat Cleveland Clinic Canada and a
(00:42):
pulmonary critical carephysician who's turned bedside
frustrations into system levelfixes.
Trained at Brown, University ofConnecticut, Yale, where he
served as chief medicalresident, and Weill Cornell,
Khalil learned early how smartdata can shorten suffering.
First at Kaiser Permanente andlater in Toronto, where he led
(01:05):
respirology at Sunnybrook HealthSciences Center, taught at the
University of Toronto, and builtprograms that move patients
faster from worry to treatment.
Today, he's pairing that ethoswith new care models, metrics
that matter dashboards, EMRflags that catch weights before
they snowball, and embedded nearwork, near-home clinics that
(01:28):
make prevention practical forbusy people.
He also serves as chief medicaldirector for the Royal Bank of
Canada, advising on healthierworkplaces and upstream
screening that spotshypertension, diabetes, and
mental health needs before theybecome emergencies.
He's a fellow of the RoyalCollege of Physicians and
Surgeons of Canada and theAmerican College of Chest
(01:50):
Physicians.
Active with the Ontario MedicalAssociation and American
Thoracic Society.
And when he's not rewiring carepathways, you'll find him on the
tennis court, a golf green, orcheering on his beloved Yukon
Huskies.
Dr.
Sivji, Khalil, welcome to theshow.
(02:11):
Thank you, Jason.
So we've known each other for alittle while, but um even just
before hitting record, having abit of a dialogue about some of
our respective backgrounds.
And I wanted to dive a littlemore into yours.
You've had an interesting careerpath, as I alluded to, uh, both
from in the US and Canada.
When did quality and patientexperience first click for you?
(02:33):
Was that earlier in yourtraining?
Did that come later after youwere in attending?
SPEAKER_00 (02:38):
Yeah, you know, it probably wasn't a single event
that uh where where somethingclicked and I became interested
in quality, was through a seriesof observations throughout my
career where I just looked atthe way something was done.
And when I asked why it wasbeing done that way or why we
couldn't do it a more efficientor safer way, uh, I never got a
(02:59):
clear response to that.
It was always kind of this isthe way we do it.
I think my absolute firstepisode of that was when I was
working as a staff attending uhin California in the ICU, and we
would have patients that wereintubated, and some of our
patients uh were covered byintensivists who were there all
day, every day, all night, everynight.
(03:21):
And then we had a few patientswho were rounded on by
community-based docs.
And those docs would come inafter their busy clinic, three
o'clock, four o'clock, fiveo'clock in the evening, make a
slight adjustment to theventilator, and then leave.
And nothing would happen until24 hours later when they came
back.
And sometimes on the weekends,it would be longer than 24 hours
(03:42):
before they came back.
So these patients were obviouslyon these ventilators for longer
periods of times than thepatients that were covered by
the intensivists on site.
And so I asked, why is that?
Well, why aren't these changesmade either by myself or by
other critical care docs thathappened to be there?
And the answer I got was that'sthe way it is.
(04:03):
And so we developed a liberationprotocol from the ventilator, a
ventilation liberation protocol.
And I proposed it to the docsthat were based in the community
who surprisingly uh had noproblem with it.
They were like, sure, I mean,you're you're actually helping
us.
And we we got it approved.
And I worked for a large uhhealthcare organization in
(04:24):
Southern California at the time,and got it through the
appropriate committees uh and weand we launched this thing.
And all of a sudden, we measureduh a difference in how fast
people were liberated from theventilator.
And that was sort of the firstuh light bulb that went off that
said, wow, someone who is ajunior staff can make an impact
like that.
I wonder what else is out there.
(04:44):
And so every other step throughmy career, I just kept looking
for these opportunities wheresmall changes could have huge
impact.
And you they were essentiallyresource neutral.
It's just taking what you have,rearranging it, and getting
better outcomes.
SPEAKER_01 (04:59):
Yeah, I I think uh so many of us in the quality
improvement space who have foundour way here, one way or
another, have had those kind oflight bulb moments as you
describe.
One thing that's exciting aboutthis and these types of
conversations uh for me is to tokind of show others who haven't
maybe haven't yet had that lightbulb moment or or at different
stages in their QI path torealize that, as you said, a
(05:21):
junior staff member can bereally impactful, that that
people can can often be broughtaround to good ideas if they're
presented well and if we'venavigated the the change
management landscapeeffectively.
But that's um that's reallypowerful.
So you you mentioned you knowworking in Southern California,
and I think you were working forfor Kaiser at the time, if I
recall correctly.
SPEAKER_00 (05:41):
That's that's correct.
SPEAKER_01 (05:42):
What did you learn about integrated data-driven
care um when you were practicingthere?
Or or how has that become aprominent theme for you since
working there?
SPEAKER_00 (05:53):
Yeah, I I've come to appreciate that uh data-driven
care is the only way to delivercare.
Uh, if you're gonna deliverquality care, you have to
continue to measure what you'redoing, how you're doing it, and
how effective it is.
Otherwise, not only could youstagnate at a certain level of
quality, but I think you couldactually get worse at it.
Uh, one example that I uh hadwhen I first joined uh the
(06:17):
current uh hospital system thatI'm in now in Toronto was our
lung cancer data.
And so we would look at patientswho came in with a suspicious
lung nodule, and they would cometo see us, so they'd wait to see
the to the see the pulmonologistor respirologist, as as we call
it in Canada.
And that wait might be days toweeks, at which point we then
(06:40):
see them, of course, do acomplete history of physical,
look at the x-ray order of CT,weight number two.
Uh, once the CT was done andinterpreted, they'd come back
and see us.
We decide do we do abronchoscopy, do we do a CT
guided needle biopsy, do we do aPET scan?
What's the next step?
Weight number three.
Uh, and eventually we would havehistology, we'd prove they have
(07:00):
lung cancer, and we'd send themto the thoracic surgeon or the
radiation oncologist or the nextappropriate specialist.
And when you added up thesesequential weights, uh, it
became months of waiting.
And and uh we know now that infact lung cancer can upstage in
as little as two to three weeks.
And so as we got busier andbusier, these weights just got
(07:22):
higher and higher.
And um, there was no way I couldjust sit and and watch that
happen.
And uh that was one of the timeswhere I said, okay, we've we've
got to change this entire systemagain, completely resource
neutral.
It was just about realigningwhat you ordered and when you
ordered it.
So the the second that thatreferral came in for a
suspicious nodule, I had alreadyordered the CAT scan, I had
(07:45):
ordered the CT guided needlebiopsy, I had ordered the
referral to the oncologists.
I could always cancel those if Ididn't need them, but we showed
that that changed our uh time totreat lung cancer from about six
months, which was really hardfor me to believe, uh, down to
less than 90 days, which stillis a long time and it still
could be an upstage, but it wasa step in the right direction.
(08:06):
And from then I was convincedthat data-driven care not only
is an intelligent thing to do,but it could change people's
lives.
And it was the only way I wasgoing to practice going forward.
SPEAKER_01 (08:17):
Yeah, I do wonder actually.
I first of all, I'm fully boughtinto that approach.
Um, you really can't affect whatyou can't measure.
And this is something that Ifeel like I spend a lot of time
preaching.
And I I'm curious if you'venoticed differences in different
places you've practiced, whetherit be different parts of the US
or the change over to Canada, ifthere was different approaches
(08:38):
or different willingness toreally take a data-first
approach.
SPEAKER_00 (08:43):
Yeah.
I I think that in the end, atleast in North America, we all
got into this profession for theright reason, which is to help
people and uh to make sure thatuh the care that we deliver is
the best care that can bedelivered.
And I I think that transcendsborder borders, I think it
(09:04):
transcends cultures, I think ittranscends economic uh systems
as well.
And maybe I've just been lucky,but I found that anytime that I
come across a system of uhoperations that I think could be
more efficient or working well,uh, and and then introduced a
concept of how to change it tomake it more efficient and more
(09:26):
patient-centered and moreeffective, that I have been met
with uh actu actually verylittle resistance.
The only exception to that Iwould say is in and it was not
in in my current job, it was ina prior uh job, and it wasn't
with Kaiser, so I'm gonna takethem off the off the table here
for a second.
But it was in a it was in aplace I was moonlighting,
(09:48):
actually, and I was seeingpulmonary consults uh to try to
decompress their wait list.
And I would walk in and therewould be a couple of consults in
a in a fax folder for me to lookthrough and decide who I was
gonna schedule to see.
But then there would be twoother fax folders uh with other
physicians' uh names on them.
And I said, Well, what's what'sin those?
I wonder if there's any urgentconsults in those.
(10:10):
And the answer I got back was,well, Dr., and I'll use a fake
name here, Dr.
Jones is on vacation for twoweeks.
He that's his pile.
And I said, but what if there'sa just lung nodule in that pile?
What if there's a I've you knowcoughed up some bloodstreak
sputum in that pile?
And the answer I got was, well,Dr.
Jones will get to it when hegets back.
And that sort ofprofession-centered organization
(10:33):
of medicine in the communitysetting sometimes is a little
bit hard to uh get get over.
Of course, when Dr.
Jones did get back, I said, Hey,I wonder if we should have a
central triaging system suchthat there is a Dr.
Jones pile and there is a Dr.
Sy pile, but there's also anurgent pile where someone with
uh very few rules to followcould identify urgent, what
(10:58):
sounds like urgent consults, putthem in an urgent pile, and the
next person that got to thatpile sketch saw those patients,
not the person waiting to comeback from vacation in two weeks.
A little bit of resistance,obviously, that's fee for
service.
You know, you you you eat whatyou kill kind of thing, and you
have to make sure that thenumber of referrals you get is
sufficient to sustain your yourpractice.
(11:21):
But I think with enough time andwith enough discussion, open
discussion, we were able to getthrough that.
In fact, we did have an urgentconsole pile in the end.
SPEAKER_01 (11:30):
Yeah, that's great.
And I'm sure that was impactful.
Were you able to measure any uhany metrics in terms of the
turnaround there?
SPEAKER_00 (11:37):
Yeah, that so I was I was a pulmonary fellow at the
time.
I didn't want to rattle the cagetoo much.
And uh so I uh yeah, I just I II was satisfied with the fact
that we had an urgent care pile,and I did not delve into what
the actual numbers were.
SPEAKER_01 (11:55):
Fair enough.
And then, you know, your careersaw you in 2005 relocating to
Toronto.
And so I think the cross-bordermoves, although they're
becoming, I think, a lot morefrequent, are are still uh
you're still in a pretty smallgroup of people.
I'm curious what inspired thattransition, how that went, um,
and uh where you find yourselfnow.
SPEAKER_00 (12:16):
You know, I had a knack for leadership even as a
young uh kid, and it wasn'tactually because I sought it
out, or nor was it because I wasappointed such.
And I I came to this realizationactually in Little League, where
I was never captain of my LittleLeague team, but I showed up on
time, I went through the all thedrills the way I was supposed
to, and every day I gave it myall.
(12:38):
And at the end of my lastseason, the coach came up to me
and his son was on the team andwas actually the captain every
year I was there.
But he came up to me privatelyand he said, You know, you know,
you although my son, and I'llsay his name, although my son
Sean has been the captain, worethe C on his jersey, you've been
the captain of this team.
(12:59):
You've led this team.
And I said, What do you mean bythat?
He says, You led by example, youled because you worked hard, you
showed up every day, and yougave it your all.
And so that uh struck a chordwith me.
And I and I realized that youknow, leadership sometimes
chooses you.
And so when I went throughfellowship and I and I
graduated, I knew that I wasgoing to um eventually climb the
(13:21):
leadership ladder.
When I was with KaiserPermanente, I was I was being
groomed to go through theirleadership process.
But sometimes if you have theopportunity to skip a couple
rungs on ladders, you do that.
And in 2005, I was given thatopportunity.
The University of Toronto hasfour teaching hospitals.
Uh, Sunnybrook Health ScienceCenter is one of them.
And the uh opportunity came upfor me to be the division head
(13:43):
there in respiratory, which wasa couple of rungs of the ladder
up from where I was with Kaiser.
I'm also from uh the northeastuh of this of the United States,
and Toronto was a great uh placeto be and much closer to quote
unquote home.
So that that factored in aswell.
But that's what what that's whyI made the decision, and uh uh
(14:04):
it was it was a great one tomake.
SPEAKER_01 (14:06):
Yeah, and I I think there's probably a lot that we
could dive into there in in yourtime at Sunnybrook and beyond.
But taking a another step or twoahead, you actually gave a uh
facilitated a great lecture withone of your colleagues, Heather,
at our CQO community, acommunity of quality leaders
that uh has been convening uhevery month for a few years now.
And um it was talking a lotabout how you so your your
(14:31):
practice now is uh based out ofCleveland Clinic Canada, and
you're a unique organization, asI understand it, in that you are
solely outpatient focused, incontrast to the way the the
model works in the US with theCleveland Clinic, I think being
both inpatient and outpatient.
Yeah.
Your presentation recently wasabout your efforts towards using
(14:52):
metrics that matter and uh howyou measure quality in the
outpatient setting.
So I'm wondering if you can tellme a little bit about that work
specifically.
SPEAKER_00 (15:01):
Yeah, sure.
So you're absolutely correct.
Uh Cleveland Clinic Canada,which has been around for 20
years, is based in twoambulatory clinics in uh
downtown Toronto and MidtownToronto, although we have a
virtual presence and we have uhaffiliate clinics throughout
Canada, as opposed to theCleveland Clinic in Northeast
Ohio, which has you know dozensof buildings and inpatient beds,
(15:24):
and they're also in Florida andLas Vegas and Abu Dhabi and
London.
But we're unique in the factthat we don't have hospital
beds, and that is simply uh afunction of what we are focused
on, number one, and number two,because as you know, with the in
a universal healthcare system,the the government uh owns and
runs the hospitals.
Having said that, there is a uhfocus on the patient and being
(15:47):
uh driven by patients' needs anddelivering patient-centered
care.
So the emphasis on the patientexperience, I would argue, is
equal in our Toronto slashCanada offices as it is on main
campus.
And just because you are beingtreated for a urinary track
(16:07):
infection in Toronto and maybenot on IV antibiotics in a
hospital bed for euros sepsisdoesn't mean that we can ignore
uh your experience.
And the patient experience is isis really important.
So how we handle you when youcome in, when we see you, so
access to our care, how we makesure that you don't have an uh a
(16:28):
drug allergy to the antibioticwe're gonna use, how we follow
you up, how we answer yourquestions, how we let you know
that your urine culture showed acertain uh E.
coli that is sensitive to theantibiotic that we gave you, how
we handle the adverse reactionto the antibiotic.
Um, all of that is, I think,important, not just in terms of
patient experience, but also inuh in terms of quality and
(16:50):
safety.
And so we have an emphasis onthat.
And and the the colleague youwere referencing earlier in your
question, Heather, is our uhsenior director of the patient
experience.
And so her and I meet on aregular basis.
She uh reports to me thePruscani responses from all of
our service lines, and I won'tgo through them all, but we have
(17:12):
seven total service lines.
We also go through our uh safetyevent reporting data.
We look at our root causeanalysis we're done, we look at
process improvement that'soccurred in the clinic, and we
look at those metrics thatmatter that you referenced.
So things like uh how long didit take for our diagnostic
imaging to turnaround?
Because that matters.
When you you have a mammogram,um not that I've had a
(17:35):
mammogram, but you can imagineif you've had a mammogram and
you're waiting for thoseresults, you're staring at the
ceiling for those nights.
And the difference between sevendays and three days in terms of
a turnaround time is massive.
It may not impact the uh overalloutcome, especially if it's a
negative mammogram.
But you know, a week staring atthe ceiling, wondering if you
have breast cancer because youraunt just had uh was diagnosed
(17:56):
with breast cancer is is superimpactful and I believe uh
matters.
SPEAKER_01 (18:01):
Yeah, and I'm seeing an interesting contrast there
between what you just described,which sounds like a very
patient-centered viewpoint tothe kind of the more physician
or staff-centered models thatthat we sometimes see and that
you were kind of uh mentioningbefore, that absolutely makes a
difference.
And we hear that on the frontlines.
We hear people saying, whyhasn't this test or that test
(18:24):
resulted yet when it's been youknow seven days and could
reasonably be done faster thanthat?
So, how do you approachmeasurement, making sure that
these metrics matter, how youchoose kind of which metrics you
you use, and you know, how is itdifferent between the outpatient
world and the inpatient world?
Because I think a lot of of usin healthcare QI are um are
(18:45):
inpatient people.
SPEAKER_00 (18:46):
So that that term about uh wait waiting for your
scan to turn around, I've heardit called scansiety.
But, anyways, we so so we try tolimit scansiety and other other
anxieties really by askingourselves if we were the
patient, and you have to bereasonable, of course.
You can't can't wish that yourscan was read yesterday if it
was done today.
That's not going to be uhreality.
(19:08):
But we say if we were if we werea patient, we ask ourselves a
question like if we were to pickup the phone and want to make uh
an appointment, and I'll justpick on mammography because
that's kind of a hot buttontopic now, especially in the
province of Ontario, wherethey've switched to a
self-referral model.
So you don't need a referral toget a mammography.
But if you were a patient andyou were and your aunt was just
(19:28):
diagnosed with breast cancer andyou were in your 40s and you
want to schedule yourmammography, what would be a
reasonable amount of time youwould want to wait for that?
Um, and then we look at and andtry to benchmark that against
other wait times, both locally,provincially, nationally, and
internationally, and come upwith a come up with a number.
So that's one uh thing that wedo.
(19:48):
Then we look at turnaround timesfor things like mammography, of
course, other diagnosticimaging, uh stress tests, echo
path reports, and again,benchmark it against local, but
not just local, also provincial,uh national, international
averages.
And we try to beat all those.
We try to we try to say, okay,that's the average, we're gonna
(20:10):
be better than that.
Is that good enough?
Uh it's a start, and uh, if wecould offer same-day service for
every service we have, we wouldabsolutely do that.
But at least we have a NorthStar, at least we have a metric
that we are or a measure thatwe're trying to get to, and
always asking ourselves, can wedo better?
(20:31):
Is there a better way of servingthe person so so that they have
the least amount of anxietywhile they're waiting for tests
to get done, consults to beseen, results to be reported
back to them?
I want to piggyback on somethingyou said about
profession-centric versuspatient-centric care.
That's been a pillar of theCleveland Clinic since its
(20:53):
inception.
So 104 years ago, uh theCleveland Clinic in Ohio was
started by four physicians whoactually were practicing in
World War I.
And they were in a mash tenttogether, and the patient was in
the center and they broughtservices to that patient.
When they went back in 1921 toNortheast Ohio, they said that
worked really well.
We should get rid of our officesand start the Cleveland Clinic.
(21:15):
And in fact, unlike other healthsystems, there is no department
of medicine, department ofsurgery, department of neurology
at the Cleveland Clinic.
There are only institutes,institutes around patient care.
So there's the Institute ofDigestive Diseases where you
might have colorectal surgeonsand gastroologists and
nutritionists and psychiatristsand immunologists all working
(21:35):
together.
Again, that mash tent, patientin the center, bring the
services to the patient.
That concept has uh pervadedthroughout all the Cleveland
Clinic sites that I mentionedearlier.
And it's uh also the motive weuse in um in Canada as well.
SPEAKER_01 (21:51):
Yeah, thanks for clarifying that.
It sounds like a really uhreally revolutionary model.
I'm curious when you're you'retalking about you know,
measuring metrics that matter,when you're talking about, for
example, mammogram turnaroundtimes.
I'm imagining each step in thatprocess, if you're mapping that
process, each step has areasonable amount of time that
it takes to complete.
(22:12):
And then there's a waitingbetween step A and step B.
And then step B has a certainamount of time to complete, and
then you know you've got awaiting time or some other delay
between B and C.
When you're all looking at theseprocesses and looking to improve
them, are you getting down tothat level of granularity?
Are you and I and I ask thatpartly because I think having
(22:33):
the you talked about beingresource neutral, cost neutral.
One of one of the challenges cansometimes be having this the
staff and the expertise kind ofall in the same room to be able
to map processes down to thatlevel of granularity.
Is that is that part of theconversation?
SPEAKER_00 (22:46):
Yeah.
Um I I you know, I say resourceneutral because I I consider
patient experience and qualitylead as part of that necessary
part of the of the of the caredelivery pathway.
And so the answer to yourquestion is yes, we do look at,
uh we've got patient flow mapsfor almost every type of
(23:08):
encounter that someone wouldinterface with us.
And we've uh, you know, onceyou've established them, they
they don't change much.
And it's just a matter offiguring out where these wait,
these aggregate wait times falland and how long they are.
And then you set set upautomated systems such that when
the wait time uh exceeds, andwe're when we use an electronic
(23:29):
health record like most everyoneelse does now, and we've built
in systems so that theelectronic health record can
flag when those wait timesexceed what we'd like them to
be.
So if I know that uh pulmonaryconsults are now nine weeks, and
I've said no, they must be lessthan four, the EMR will actually
(23:51):
say, hey, red flag, you'rebooking nine weeks out.
You wanted me to tell you whenyou were booking more than four
weeks out.
And so, yeah, the first timedown the hill in the sled uh is
gonna be a little tough andrequire some investment.
But after that, when youautomate these systems, they uh
they serve you well.
SPEAKER_01 (24:09):
And and that's I mean, that's another really
interesting hill that it soundslike you've got you successfully
climbed.
I know some uh institutions willstruggle with, which is, you
know, once we have a a newprocess, a uh you know, new
policy in place, how do wemeasure when the system is in
spec or out of spec?
And it sounds like you've gotsome real metrics that can that
are tied to your EMR that can dothat.
(24:30):
So that's yeah, I can imaginethat's a huge benefit to keeping
on track once you've once you'vegot those uh processes mapped.
This sounds like reallyimportant stuff when it comes to
using metrics that actuallymatter in the outpatient
setting.
And I wanted to to hear a littlemore about another area where
you're, I think, innovating inoutpatient work, and that's your
(24:52):
your role as the chief medicaldirector at uh the Royal Bank of
Canada, RBC.
Um because I understand thatyou're trying to bring a lot of
these kind of whole patientwellness principles, you know,
maybe traditional and and somealso innovative principles to uh
the corporate workplace.
I'm curious what you can tell meabout about that whole uh that
(25:14):
whole model.
SPEAKER_00 (25:15):
Yeah.
So uh that's correct.
I am the chief medical directorfor uh RBC Royal Bank, but it's
through a contract that theyhave with the Cleveland Clinic,
and there's a service line thatwe have called uh Global
Corporate Advisory Services.
And this really grew uh it itstarted before COVID, but it
really grew once COVID um was uhin its you know full flown uh
(25:39):
full-blown stages.
And it it I think it's born fromthe realization that we people
spend a lot of time at work.
They probably spend a third oftheir lives uh in the office.
And while they're there, they'reexposed to a bunch of different
things.
They're exposed to the commuteto the workplace, they're
exposed to their desk space andtheir office space and the
ventilation and the quality ofthe air and that ventilation,
(26:01):
perhaps some of the radiationthat's uh emitted in the in the
in the workplace.
They're exposed to sunlight, orsometimes not if they're working
in a in a building with nowindows.
They're exposed to printer ink,although that's becoming less
and less of an issue.
They're exposed to the buildingitself, what's in the walls and
things like that.
So, and and then they're exposedto the nature of the work with
(26:23):
all its inherent stresses andand and whatnot.
And so companies started torealize that if they were going
to have a resilient anddedicated workforce that showed
up, was present, and thrived atwork, um, they have to be at
least aware of what makes ahealthy workplace and what makes
(26:46):
a healthy workforce.
Um and so we we've been helpingboth the Royal Bank and now uh
dozens of other companiesaddress issues that affect the
health and one well-being oftheir workforce and not just of
individuals.
Um, so that might be things likeletting them know uh about
(27:07):
ergonomics and uh teaching themhow uh you know you should every
20 minutes you should be lookingup from your screen and looking
20 feet away so you don't getyou know changes to your vision
from staring at the screen uhall day.
It might be um looking at theirbuildings that are more than 60
years old and saying, you know,is there asbestos in the walls?
(27:28):
And what what you know, workingwith their uh corporate real
estate groups um and advising onthat.
Um it might be air quality, andunfortunately, as you know, with
with climate change, we'rehaving more and more forest
fires and you know, in Torontoat least, um the the air is not
such great quality every everyfew weeks.
It's sometimes orange when youwalk outside.
(27:49):
Um, and part of that is fromforest fires from the prairies.
And so, what is that, what's theimpact of that when you have a
part of your workforce that havehas chronic lung diseases like
asthma or COPD?
What should you advise uhpeople?
How should they monitor airhealth quality indices?
So that's been a really uhinteresting part of my career.
I've learned a lot ofoccupational medicine.
(28:09):
Uh I've learned about uh a lotof things about uh buildings and
building materials that I neverthought I would ever uh learn
about, certainly didn't learnabout that at medical school.
But these are things that cansignificantly impact the the
health and well-being of peoplethat work in those buildings.
SPEAKER_01 (28:25):
Yeah, I felt myself needing to adjust my uh my
posture in my chair as you weretalking about ergonomics.
I'm sure you noticed.
And uh and and I I yeah, Icertainly hear that.
I mean, it it sounds like thiswas, you know, in the circuitous
pathways that our careerssometimes follow.
It sounds like this has been onearea where, again, you've you've
(28:46):
learned about buildings and airquality, some of these things
which kind of touch torespirogy/slash pulmonology, but
but also um probably a whole lotof other areas.
And so this model, it soundslike is um, you know, advising
companies on a lot of theaspects you talked about.
Is there also like directprovision of medical care?
SPEAKER_00 (29:06):
Yeah, so it's an interesting question.
Uh, in its original concept 10years ago, I've been the medical
director for Royal Bank.
Uh actually, today is my 10-yearanniversary.
Um Happy anniversary.
Thank you.
The the original concepts didnot have any direct patient
care.
It was mostly being the bridgebetween their human resource
(29:26):
department, their benefitsdepartment, and their uh senior
leadership.
Because often there's a littlebit of a disconnect between
those.
You know, if if a new medicationcomes out, they're deciding
whether it should be on theformulary, well, there's a cost
to that, obviously.
And uh the senior leadershipteam may not be able to or want
to incur that cost this year,and uh employee relations has to
(29:48):
deal with the fallout from thatdecision.
And so I would come in and andbridge those two.
So that was the original uhconcept.
However, because we're havingsuch a primary care access
problem, and this is not uniqueto.
Canada.
I've talked to my friends backin the States, and it is a North
American problem, if not aglobal problem.
We've got lots of aging uhpeople with chronic medical
(30:09):
conditions, and we have fewerand fewer family doctors to take
care of them.
Because of that, we've come hadto come up with some unique ways
of offering at least the basicfoundational primary care uh to
groups of patients.
So, for instance, there's a uhuh delivery company, I won't go
into details, that had all oftheir thousand employees in
(30:30):
their main warehouse, and wewent by and we did some health
screening, some basic healthscreening for them.
Um, point of point of care,blood pressure testing, point of
care, cholesterol screening,hemoglobin A1C checking for
diabetes.
You know, we measure we measuredtheir waste circumference.
And at least we gave them ascorecard at the end for those
thousand employees to say, okay,here's the subset of you that
(30:52):
really should go on toconnecting or reconnecting with
your family doctors and takingcare of these things before they
become a problem.
And, you know, we we includedsome mental health stuff in
there as well, and you know,with the PHQ 9.
Um, obviously these were nursesthat were in private booths that
were uh working with thesefolks, but we were able to offer
(31:14):
some, I don't even know if I'dcall it primary care, I'd call
it maybe pre-primary care tothis group of paid uh employees
sponsored by their employer whoall of a sudden, instead of
having to take the half day offto go see their doctor if they
could get in, at the workplacehad this foundational
information about their healthand could start working on that.
(31:35):
We picked up, well, we picked upbrand new diabetics, we picked
up people in stage twohypertension uh that needed to
get uh you know that addressedfairly quickly.
And it was really uh reallyfruitful.
And other companies have lookedat that model and said, okay,
well, maybe that's that's a wayfor us to contribute to our
employees' health andwell-being, and maybe even
(31:56):
decompress the public healthcaresystem a little bit.
SPEAKER_01 (31:58):
And and it sounds like um something that I've
heard kind of more and moreabout, which is how do we, you
know, how do we innovate inthings that are upst care that's
upstream from the hospitalexperience, right?
We spend a whole lot of timefocusing on the hospital and uh
for for good reason.
And and at the same time, wehave a uh, you know, fewer and
(32:19):
fewer family dogs, as you say,trying to care for more and more
people in more and moredistanced communities.
And so, how do you innovate tocreate new models where some of
these people can be met wherethey are uh in a truly
patient-centered way?
And and I understand also thatone of the other initiatives, so
this big initiative has beenthis Tito Care initiative.
(32:41):
Um, tell me about Tito Care.
What's that all about?
SPEAKER_00 (32:43):
So Tito Care is a company um that developed I
would say user-friendlydiagnostic equipment.
And it is can be can be done bya layperson.
It can include many things, butat its very core includes an uh
flexible odoscope to look in theears, uh, a rhinoscope to look
in the nose, a laryngoscope tolook in the mouth, a blood
(33:06):
pressure cuff, a stethoscope.
Uh it can it can include even athree Lib CG and a pulse
oximeter, depending on whatlevel of title care uh you get.
But it's essentially aself-diagnostic,
self-examination tool that canbe placed anywhere and used by
almost anyone.
Um I think we we even had itdown to like the third grade
(33:29):
level, could could learn how touse this.
And we have gone to places whereit's been can either convenient
for people to use this tool,upload that information either
synchronously or asynchronously,and then connect with a
healthcare provider virtually.
Um, and so we've we've placedthese in uh university campuses
(33:51):
where you know students may notmaybe maybe you want to go uh
get a checkup at two in themorning because that's when
you're done studying, right?
And all the pizza places areclosed by then.
Well, you can do that now,right?
We can we've placed these onFirst Nation reserves where
access to care, as you know, isis very challenging.
We've placed this in um inmining company towns where
(34:13):
there'll be this remote areawhere 5,000 employees are
congregated because they're on amining job site and they have no
access to healthcare, and it'sthree hours to the closest.
Can you imagine that?
Imagine wanting to get a checkupto get your blood pressure
checked.
You leave your work, you drivethree hours, you probably wait
in a waiting room for a bit, getyour blood pressure and whatnot
(34:36):
checked, and then go back towork.
Well, that's your whole day isgone.
The productivity loss from thatis immense, multiplied by 5,000
employees.
We can put a title care clinicin that setting, connect with
the nurse practitioners.
And of course, once in a whilewe'll send out sometimes
physicians, sometimes PAs, uhphysician assistants, sometimes
nurse practitioners, uh, to seeany patients that need to be
(34:59):
seen in person.
But the efficiency of that andthe access that that offers
compared to what they have nowis like night and day, right?
The one thing I didn't uhmention, and I I assume you were
going to ask me this question,but I'll just I'll just prompt
you anyways, is is uh who isinterpreting that data.
(35:20):
And so far it's just beenone-to-one.
You know you get your bloodpressure on tight O, and I have
to look at your blood pressureand decide if you have
hypertension.
Well, as you know, you don'tnecessarily need a physician to
decide that anymore.
AI can decide that, right?
So we are looking at, especiallywith uh the dermatoscope, which
I didn't mention, you know, whenyou put a dermatoscope on a
(35:41):
rash, let's say your your localfamily doctor might have seen
that rash 500 times.
I'm just pulling that number outof thin air.
Maybe your dermatologist hasseen that rash 2,000 times.
Well, Google Images has seenthat that rash 5 million times,
right?
And it's I think it's only amatter of time before artificial
intelligence and deep learningis able to not just take that
(36:03):
data that you're uploadingthrough your own self-examined
experience with title care, butalso interpret it correctly and
give you a little bit of a senseof this is urgent.
You must go see someone nowabout this, or try a little
steroid cream and you'll beokay.
SPEAKER_01 (36:20):
So it sounds like between looking, examining the
skin, examining the mouth andthroat, the ears, the blood
pressure, um, there's a wholelot that you can do in the
stethoscope.
Stethoscope as well.
Yeah, and to the three day threelead cg as well.
So there's a lot that you cando.
And it sounds like with very fewresources other than this this
(36:41):
product itself, and maybe somekind of designated you know
area.
Does it does it involve a lot ofcleaning or or maintenance of
this equipment?
SPEAKER_00 (36:50):
Or is that yeah, it it's well we've we've been using
this for about four years now.
The results have been excellent.
We've had very few, in fact,we're gonna be uh writing this
up fairly soon.
Very few user errors, criticalerrors where we're not able to
get the person to get theinformation.
Um the cleaning isself-explanatory and it's done
after after easy use.
(37:12):
And this is like hard plastic,easy, easy stuff to clean.
It's not it's not cloth oranything of that nature.
And the the amount of space thatyou need uh for this is very
little.
You can you can do this in a youknow a six by six foot uh uh
room.
SPEAKER_01 (37:29):
Well, is embedding care in workplaces and you know
residential towers and miningtowns, I mean, is this like the
next frontier of outpatientquality improvement?
I haven't I can I have to sayI've never heard a presentation
on this at any QI conferences,but it sounds uh sounds pretty
revolutionary.
SPEAKER_00 (37:50):
But I think if we take a step back, uh, you know,
I have I have a um a dischargesummary from the 19s, early
1970s, uh, and it was my fatherthat was admitted.
Um, and he was admitted tohospital to manage his
hypertension, and it wasn'tsevere hypertension, it wasn't
life-threatening hypertension,it was just hypertension.
And his cardiologist said, youknow, uh this this the uh it's
(38:14):
comical to read today, you know,50 years later or whatever.
This man's wife is on vacationfor two weeks, so I've admitted
him to hospital so we canaddress his hypertension.
We've come a long way sincethen.
The stuff that we have we admitpeople to the hospital for now
is much, much, much more severe,and rightfully so.
(38:35):
And the consequence of that isthat the stuff that is less
severe than that, we need to nottake care of in a hospital.
We cannot be doing routine.
I you know, I I have ahospital-based clinic and I feel
bad about it because I see somemild asthma there.
I shouldn't be seeing mildasthma in a hospital.
It's way too expensive a placeto see us.
(38:55):
So I think as things that areless acute, subacute and
sub-subacute are being pushedout to the ambulatory space,
it's only a natural extensionthat some of that stuff that was
traditionally in an ambulatoryspace is being pushed into the
community.
Whether that'll be in people'shomes, whether that'll be at
people's workplace, whetherthat'll be people's schools,
whether that'll be people'sneighborhoods, could there could
(39:17):
there be a kiosk in the cornerof your neighborhood, in the
corner of your neighborhoodwhere you could get your
checkup?
I I think that's the way in thefuture, um, especially as blood
diagnostics become more uhefficient and you can just prick
your finger and get a wholebunch of that information.
Obviously, we have to make surethat that's all legitimate and
and meets standards of uh ofcare and and and is
(39:39):
cross-referenced with goldstandards and things like that.
But I I honestly think there'llbe a day very soon where you
will not leave your house to getyour annual physical exam.
SPEAKER_01 (39:50):
Yeah, so that I mean it's as if you anticipated my
next question because I I'mreally interested in in how um
how you're talking about theseinnovative ideas.
And I I wonder if we fastforward five or ten years, what
do you think will surprise usabout routine outpatient visits?
What will outpatient visits looklike?
SPEAKER_00 (40:11):
I think that the foundational information about
yourself, so your sort of yourbiohacking information that
everyone's after will be easilyattainable by yourself and in
your home, right?
Whether it's wearabletechnology, um, whether it's
something like title care whereyou're gathering that
information.
I think that baseline stuff isgonna be there.
I think what's gonna happen isthat the only reason you would
(40:33):
go to see someone in a in anoffice, one is if you need
advanced diagnostic imaging.
So I don't think you're gonnahave an MRI machine in the
corner of your neighborhood.
I think that's something you'regonna have to go to in to see
someone.
Um minor procedures, obviously,you're gonna have to go in for
if you need them all removed andwhatnot.
Vaccinations.
I don't I can't see a day whereyou're self-administering
(40:55):
vaccinations, unless, of course,they're intranasal, and who
knows?
Maybe, maybe we can do that.
Uh, but there'll still be a rolefor for those type of
intervention or procedure-baseduh visits.
But short of that, you know, Iwould say 75% of the stuff that
we have people come to theoffice to get done, prescription
(41:16):
renewals, uh, education ondiabetes, uh, et cetera, et
cetera, et cetera.
I don't think people will becoming to the office to do that
anymore.
If you look at every otherindustry, and as you know,
Jason, unfortunately, medicineuh is usually lagging about 20
years behind every otherindustry.
But if you look at the bankingindustry, you don't you don't go
to the bank anymore.
(41:36):
Everyone does online banking.
It's it's you want to you knowcash a check, you're doing that
in online, deposit a check, youcan transfer money, pay your
mortgage.
None of that is done in a in theactual facility anymore.
And healthcare eventually willwill follow, whether it'll be
five, 10, 15, 20 years from now,who knows?
I think I think we're stillusing faxes, right?
(41:58):
So go find it.
Faxes and pagers.
Faxes and pages, right?
SPEAKER_01 (42:04):
Yeah.
Um, well, I think that's a greatplace to to end our
conversation.
I really appreciate this.
And I think that gives me andhopefully some others a lot of
food for thought on what'scoming down the pipe in
innovative outpatient care andand even in in areas that we
don't even think about as beingoutpatient care, right?
In these whole new kind ofclinic models that you're
(42:26):
describing and you know,advisory, health advisory within
the workplace.
And and so really appreciateKhalil, you taking the time to
uh to have a chat with me today.
And uh yeah, really appreciateyou.
SPEAKER_00 (42:37):
Thank you.
Thank you very much, Jason.
SPEAKER_01 (42:39):
For listeners who'd like to uh follow your work and
or get in contact with you,where should they go?
SPEAKER_00 (42:45):
Uh well, they're if they're on the uh Canadian side
of the border, they could uhlook up Cleveland Clinic Canada
and uh all of our contactinformation is there.
Otherwise, I guess they would uhcontact you to contact me.
SPEAKER_01 (42:59):
Sounds good.
So we'll uh yeah, we'll we'lllink the uh your profile in the
show notes.
And uh thanks so much forsharing your insights on quality
improvement, measuring metricsthat matter, and innovating new
models of outpatient care.
Thanks so much for listening totoday's episode of Leading
Quality.
If you enjoyed the show, pleasetake a moment to like,
(43:20):
subscribe, and share it withsomeone who might find it
useful.
You can find all our episodes atleadingquality.budspout.com or
in your favorite podcast app.
The show was written and hostedby me, Jason Mellowski, edited
by Milan Millson Village, andproduced by Thrive Healthcare
Improvement.
See you next time.
Data-driven care is the only way to deliver care.
If you're going to deliverquality care, you have to
continue to measure what you'redoing, how you're doing it, and
how effective it is.
Otherwise, not only could youstagnate at a certain level of
quality, but I think you couldactually get worse at it.
SPEAKER_01 (00:18):
Welcome to Leading Quality, the podcast
spotlighting the people movinghealthcare forward from the
front lines to the C suite.
I'm your host, Jason Meadows.
My guest today is Dr.
Khalil Sivji, medical directorat Cleveland Clinic Canada and a
(00:42):
pulmonary critical carephysician who's turned bedside
frustrations into system levelfixes.
Trained at Brown, University ofConnecticut, Yale, where he
served as chief medicalresident, and Weill Cornell,
Khalil learned early how smartdata can shorten suffering.
First at Kaiser Permanente andlater in Toronto, where he led
(01:05):
respirology at Sunnybrook HealthSciences Center, taught at the
University of Toronto, and builtprograms that move patients
faster from worry to treatment.
Today, he's pairing that ethoswith new care models, metrics
that matter dashboards, EMRflags that catch weights before
they snowball, and embedded nearwork, near-home clinics that
(01:28):
make prevention practical forbusy people.
He also serves as chief medicaldirector for the Royal Bank of
Canada, advising on healthierworkplaces and upstream
screening that spotshypertension, diabetes, and
mental health needs before theybecome emergencies.
He's a fellow of the RoyalCollege of Physicians and
Surgeons of Canada and theAmerican College of Chest
(01:50):
Physicians.
Active with the Ontario MedicalAssociation and American
Thoracic Society.
And when he's not rewiring carepathways, you'll find him on the
tennis court, a golf green, orcheering on his beloved Yukon
Huskies.
Dr.
Sivji, Khalil, welcome to theshow.
(02:11):
Thank you, Jason.
So we've known each other for alittle while, but um even just
before hitting record, having abit of a dialogue about some of
our respective backgrounds.
And I wanted to dive a littlemore into yours.
You've had an interesting careerpath, as I alluded to, uh, both
from in the US and Canada.
When did quality and patientexperience first click for you?
(02:33):
Was that earlier in yourtraining?
Did that come later after youwere in attending?
SPEAKER_00 (02:38):
Yeah, you know, it probably wasn't a single event
that uh where where somethingclicked and I became interested
in quality, was through a seriesof observations throughout my
career where I just looked atthe way something was done.
And when I asked why it wasbeing done that way or why we
couldn't do it a more efficientor safer way, uh, I never got a
(02:59):
clear response to that.
It was always kind of this isthe way we do it.
I think my absolute firstepisode of that was when I was
working as a staff attending uhin California in the ICU, and we
would have patients that wereintubated, and some of our
patients uh were covered byintensivists who were there all
day, every day, all night, everynight.
(03:21):
And then we had a few patientswho were rounded on by
community-based docs.
And those docs would come inafter their busy clinic, three
o'clock, four o'clock, fiveo'clock in the evening, make a
slight adjustment to theventilator, and then leave.
And nothing would happen until24 hours later when they came
back.
And sometimes on the weekends,it would be longer than 24 hours
(03:42):
before they came back.
So these patients were obviouslyon these ventilators for longer
periods of times than thepatients that were covered by
the intensivists on site.
And so I asked, why is that?
Well, why aren't these changesmade either by myself or by
other critical care docs thathappened to be there?
And the answer I got was that'sthe way it is.
(04:03):
And so we developed a liberationprotocol from the ventilator, a
ventilation liberation protocol.
And I proposed it to the docsthat were based in the community
who surprisingly uh had noproblem with it.
They were like, sure, I mean,you're you're actually helping
us.
And we we got it approved.
And I worked for a large uhhealthcare organization in
(04:24):
Southern California at the time,and got it through the
appropriate committees uh and weand we launched this thing.
And all of a sudden, we measureduh a difference in how fast
people were liberated from theventilator.
And that was sort of the firstuh light bulb that went off that
said, wow, someone who is ajunior staff can make an impact
like that.
I wonder what else is out there.
(04:44):
And so every other step throughmy career, I just kept looking
for these opportunities wheresmall changes could have huge
impact.
And you they were essentiallyresource neutral.
It's just taking what you have,rearranging it, and getting
better outcomes.
SPEAKER_01 (04:59):
Yeah, I I think uh so many of us in the quality
improvement space who have foundour way here, one way or
another, have had those kind oflight bulb moments as you
describe.
One thing that's exciting aboutthis and these types of
conversations uh for me is to tokind of show others who haven't
maybe haven't yet had that lightbulb moment or or at different
stages in their QI path torealize that, as you said, a
(05:21):
junior staff member can bereally impactful, that that
people can can often be broughtaround to good ideas if they're
presented well and if we'venavigated the the change
management landscapeeffectively.
But that's um that's reallypowerful.
So you you mentioned you knowworking in Southern California,
and I think you were working forfor Kaiser at the time, if I
recall correctly.
SPEAKER_00 (05:41):
That's that's correct.
SPEAKER_01 (05:42):
What did you learn about integrated data-driven
care um when you were practicingthere?
Or or how has that become aprominent theme for you since
working there?
SPEAKER_00 (05:53):
Yeah, I I've come to appreciate that uh data-driven
care is the only way to delivercare.
Uh, if you're gonna deliverquality care, you have to
continue to measure what you'redoing, how you're doing it, and
how effective it is.
Otherwise, not only could youstagnate at a certain level of
quality, but I think you couldactually get worse at it.
Uh, one example that I uh hadwhen I first joined uh the
(06:17):
current uh hospital system thatI'm in now in Toronto was our
lung cancer data.
And so we would look at patientswho came in with a suspicious
lung nodule, and they would cometo see us, so they'd wait to see
the to the see the pulmonologistor respirologist, as as we call
it in Canada.
And that wait might be days toweeks, at which point we then
(06:40):
see them, of course, do acomplete history of physical,
look at the x-ray order of CT,weight number two.
Uh, once the CT was done andinterpreted, they'd come back
and see us.
We decide do we do abronchoscopy, do we do a CT
guided needle biopsy, do we do aPET scan?
What's the next step?
Weight number three.
Uh, and eventually we would havehistology, we'd prove they have
(07:00):
lung cancer, and we'd send themto the thoracic surgeon or the
radiation oncologist or the nextappropriate specialist.
And when you added up thesesequential weights, uh, it
became months of waiting.
And and uh we know now that infact lung cancer can upstage in
as little as two to three weeks.
And so as we got busier andbusier, these weights just got
(07:22):
higher and higher.
And um, there was no way I couldjust sit and and watch that
happen.
And uh that was one of the timeswhere I said, okay, we've we've
got to change this entire systemagain, completely resource
neutral.
It was just about realigningwhat you ordered and when you
ordered it.
So the the second that thatreferral came in for a
suspicious nodule, I had alreadyordered the CAT scan, I had
(07:45):
ordered the CT guided needlebiopsy, I had ordered the
referral to the oncologists.
I could always cancel those if Ididn't need them, but we showed
that that changed our uh time totreat lung cancer from about six
months, which was really hardfor me to believe, uh, down to
less than 90 days, which stillis a long time and it still
could be an upstage, but it wasa step in the right direction.
(08:06):
And from then I was convincedthat data-driven care not only
is an intelligent thing to do,but it could change people's
lives.
And it was the only way I wasgoing to practice going forward.
SPEAKER_01 (08:17):
Yeah, I do wonder actually.
I first of all, I'm fully boughtinto that approach.
Um, you really can't affect whatyou can't measure.
And this is something that Ifeel like I spend a lot of time
preaching.
And I I'm curious if you'venoticed differences in different
places you've practiced, whetherit be different parts of the US
or the change over to Canada, ifthere was different approaches
(08:38):
or different willingness toreally take a data-first
approach.
SPEAKER_00 (08:43):
Yeah.
I I think that in the end, atleast in North America, we all
got into this profession for theright reason, which is to help
people and uh to make sure thatuh the care that we deliver is
the best care that can bedelivered.
And I I think that transcendsborder borders, I think it
(09:04):
transcends cultures, I think ittranscends economic uh systems
as well.
And maybe I've just been lucky,but I found that anytime that I
come across a system of uhoperations that I think could be
more efficient or working well,uh, and and then introduced a
concept of how to change it tomake it more efficient and more
(09:26):
patient-centered and moreeffective, that I have been met
with uh actu actually verylittle resistance.
The only exception to that Iwould say is in and it was not
in in my current job, it was ina prior uh job, and it wasn't
with Kaiser, so I'm gonna takethem off the off the table here
for a second.
But it was in a it was in aplace I was moonlighting,
(09:48):
actually, and I was seeingpulmonary consults uh to try to
decompress their wait list.
And I would walk in and therewould be a couple of consults in
a in a fax folder for me to lookthrough and decide who I was
gonna schedule to see.
But then there would be twoother fax folders uh with other
physicians' uh names on them.
And I said, Well, what's what'sin those?
I wonder if there's any urgentconsults in those.
(10:10):
And the answer I got back was,well, Dr., and I'll use a fake
name here, Dr.
Jones is on vacation for twoweeks.
He that's his pile.
And I said, but what if there'sa just lung nodule in that pile?
What if there's a I've you knowcoughed up some bloodstreak
sputum in that pile?
And the answer I got was, well,Dr.
Jones will get to it when hegets back.
And that sort ofprofession-centered organization
(10:33):
of medicine in the communitysetting sometimes is a little
bit hard to uh get get over.
Of course, when Dr.
Jones did get back, I said, Hey,I wonder if we should have a
central triaging system suchthat there is a Dr.
Jones pile and there is a Dr.
Sy pile, but there's also anurgent pile where someone with
uh very few rules to followcould identify urgent, what
(10:58):
sounds like urgent consults, putthem in an urgent pile, and the
next person that got to thatpile sketch saw those patients,
not the person waiting to comeback from vacation in two weeks.
A little bit of resistance,obviously, that's fee for
service.
You know, you you you eat whatyou kill kind of thing, and you
have to make sure that thenumber of referrals you get is
sufficient to sustain your yourpractice.
(11:21):
But I think with enough time andwith enough discussion, open
discussion, we were able to getthrough that.
In fact, we did have an urgentconsole pile in the end.
SPEAKER_01 (11:30):
Yeah, that's great.
And I'm sure that was impactful.
Were you able to measure any uhany metrics in terms of the
turnaround there?
SPEAKER_00 (11:37):
Yeah, that so I was I was a pulmonary fellow at the
time.
I didn't want to rattle the cagetoo much.
And uh so I uh yeah, I just I II was satisfied with the fact
that we had an urgent care pile,and I did not delve into what
the actual numbers were.
SPEAKER_01 (11:55):
Fair enough.
And then, you know, your careersaw you in 2005 relocating to
Toronto.
And so I think the cross-bordermoves, although they're
becoming, I think, a lot morefrequent, are are still uh
you're still in a pretty smallgroup of people.
I'm curious what inspired thattransition, how that went, um,
and uh where you find yourselfnow.
SPEAKER_00 (12:16):
You know, I had a knack for leadership even as a
young uh kid, and it wasn'tactually because I sought it
out, or nor was it because I wasappointed such.
And I I came to this realizationactually in Little League, where
I was never captain of my LittleLeague team, but I showed up on
time, I went through the all thedrills the way I was supposed
to, and every day I gave it myall.
(12:38):
And at the end of my lastseason, the coach came up to me
and his son was on the team andwas actually the captain every
year I was there.
But he came up to me privatelyand he said, You know, you know,
you although my son, and I'llsay his name, although my son
Sean has been the captain, worethe C on his jersey, you've been
the captain of this team.
(12:59):
You've led this team.
And I said, What do you mean bythat?
He says, You led by example, youled because you worked hard, you
showed up every day, and yougave it your all.
And so that uh struck a chordwith me.
And I and I realized that youknow, leadership sometimes
chooses you.
And so when I went throughfellowship and I and I
graduated, I knew that I wasgoing to um eventually climb the
(13:21):
leadership ladder.
When I was with KaiserPermanente, I was I was being
groomed to go through theirleadership process.
But sometimes if you have theopportunity to skip a couple
rungs on ladders, you do that.
And in 2005, I was given thatopportunity.
The University of Toronto hasfour teaching hospitals.
Uh, Sunnybrook Health ScienceCenter is one of them.
And the uh opportunity came upfor me to be the division head
(13:43):
there in respiratory, which wasa couple of rungs of the ladder
up from where I was with Kaiser.
I'm also from uh the northeastuh of this of the United States,
and Toronto was a great uh placeto be and much closer to quote
unquote home.
So that that factored in aswell.
But that's what what that's whyI made the decision, and uh uh
(14:04):
it was it was a great one tomake.
SPEAKER_01 (14:06):
Yeah, and I I think there's probably a lot that we
could dive into there in in yourtime at Sunnybrook and beyond.
But taking a another step or twoahead, you actually gave a uh
facilitated a great lecture withone of your colleagues, Heather,
at our CQO community, acommunity of quality leaders
that uh has been convening uhevery month for a few years now.
And um it was talking a lotabout how you so your your
(14:31):
practice now is uh based out ofCleveland Clinic Canada, and
you're a unique organization, asI understand it, in that you are
solely outpatient focused, incontrast to the way the the
model works in the US with theCleveland Clinic, I think being
both inpatient and outpatient.
Yeah.
Your presentation recently wasabout your efforts towards using
(14:52):
metrics that matter and uh howyou measure quality in the
outpatient setting.
So I'm wondering if you can tellme a little bit about that work
specifically.
SPEAKER_00 (15:01):
Yeah, sure.
So you're absolutely correct.
Uh Cleveland Clinic Canada,which has been around for 20
years, is based in twoambulatory clinics in uh
downtown Toronto and MidtownToronto, although we have a
virtual presence and we have uhaffiliate clinics throughout
Canada, as opposed to theCleveland Clinic in Northeast
Ohio, which has you know dozensof buildings and inpatient beds,
(15:24):
and they're also in Florida andLas Vegas and Abu Dhabi and
London.
But we're unique in the factthat we don't have hospital
beds, and that is simply uh afunction of what we are focused
on, number one, and number two,because as you know, with the in
a universal healthcare system,the the government uh owns and
runs the hospitals.
Having said that, there is a uhfocus on the patient and being
(15:47):
uh driven by patients' needs anddelivering patient-centered
care.
So the emphasis on the patientexperience, I would argue, is
equal in our Toronto slashCanada offices as it is on main
campus.
And just because you are beingtreated for a urinary track
(16:07):
infection in Toronto and maybenot on IV antibiotics in a
hospital bed for euros sepsisdoesn't mean that we can ignore
uh your experience.
And the patient experience is isis really important.
So how we handle you when youcome in, when we see you, so
access to our care, how we makesure that you don't have an uh a
(16:28):
drug allergy to the antibioticwe're gonna use, how we follow
you up, how we answer yourquestions, how we let you know
that your urine culture showed acertain uh E.
coli that is sensitive to theantibiotic that we gave you, how
we handle the adverse reactionto the antibiotic.
Um, all of that is, I think,important, not just in terms of
patient experience, but also inuh in terms of quality and
(16:50):
safety.
And so we have an emphasis onthat.
And and the the colleague youwere referencing earlier in your
question, Heather, is our uhsenior director of the patient
experience.
And so her and I meet on aregular basis.
She uh reports to me thePruscani responses from all of
our service lines, and I won'tgo through them all, but we have
(17:12):
seven total service lines.
We also go through our uh safetyevent reporting data.
We look at our root causeanalysis we're done, we look at
process improvement that'soccurred in the clinic, and we
look at those metrics thatmatter that you referenced.
So things like uh how long didit take for our diagnostic
imaging to turnaround?
Because that matters.
When you you have a mammogram,um not that I've had a
(17:35):
mammogram, but you can imagineif you've had a mammogram and
you're waiting for thoseresults, you're staring at the
ceiling for those nights.
And the difference between sevendays and three days in terms of
a turnaround time is massive.
It may not impact the uh overalloutcome, especially if it's a
negative mammogram.
But you know, a week staring atthe ceiling, wondering if you
have breast cancer because youraunt just had uh was diagnosed
(17:56):
with breast cancer is is superimpactful and I believe uh
matters.
SPEAKER_01 (18:01):
Yeah, and I'm seeing an interesting contrast there
between what you just described,which sounds like a very
patient-centered viewpoint tothe kind of the more physician
or staff-centered models thatthat we sometimes see and that
you were kind of uh mentioningbefore, that absolutely makes a
difference.
And we hear that on the frontlines.
We hear people saying, whyhasn't this test or that test
(18:24):
resulted yet when it's been youknow seven days and could
reasonably be done faster thanthat?
So, how do you approachmeasurement, making sure that
these metrics matter, how youchoose kind of which metrics you
you use, and you know, how is itdifferent between the outpatient
world and the inpatient world?
Because I think a lot of of usin healthcare QI are um are
(18:45):
inpatient people.
SPEAKER_00 (18:46):
So that that term about uh wait waiting for your
scan to turn around, I've heardit called scansiety.
But, anyways, we so so we try tolimit scansiety and other other
anxieties really by askingourselves if we were the
patient, and you have to bereasonable, of course.
You can't can't wish that yourscan was read yesterday if it
was done today.
That's not going to be uhreality.
(19:08):
But we say if we were if we werea patient, we ask ourselves a
question like if we were to pickup the phone and want to make uh
an appointment, and I'll justpick on mammography because
that's kind of a hot buttontopic now, especially in the
province of Ontario, wherethey've switched to a
self-referral model.
So you don't need a referral toget a mammography.
But if you were a patient andyou were and your aunt was just
(19:28):
diagnosed with breast cancer andyou were in your 40s and you
want to schedule yourmammography, what would be a
reasonable amount of time youwould want to wait for that?
Um, and then we look at and andtry to benchmark that against
other wait times, both locally,provincially, nationally, and
internationally, and come upwith a come up with a number.
So that's one uh thing that wedo.
(19:48):
Then we look at turnaround timesfor things like mammography, of
course, other diagnosticimaging, uh stress tests, echo
path reports, and again,benchmark it against local, but
not just local, also provincial,uh national, international
averages.
And we try to beat all those.
We try to we try to say, okay,that's the average, we're gonna
(20:10):
be better than that.
Is that good enough?
Uh it's a start, and uh, if wecould offer same-day service for
every service we have, we wouldabsolutely do that.
But at least we have a NorthStar, at least we have a metric
that we are or a measure thatwe're trying to get to, and
always asking ourselves, can wedo better?
(20:31):
Is there a better way of servingthe person so so that they have
the least amount of anxietywhile they're waiting for tests
to get done, consults to beseen, results to be reported
back to them?
I want to piggyback on somethingyou said about
profession-centric versuspatient-centric care.
That's been a pillar of theCleveland Clinic since its
(20:53):
inception.
So 104 years ago, uh theCleveland Clinic in Ohio was
started by four physicians whoactually were practicing in
World War I.
And they were in a mash tenttogether, and the patient was in
the center and they broughtservices to that patient.
When they went back in 1921 toNortheast Ohio, they said that
worked really well.
We should get rid of our officesand start the Cleveland Clinic.
(21:15):
And in fact, unlike other healthsystems, there is no department
of medicine, department ofsurgery, department of neurology
at the Cleveland Clinic.
There are only institutes,institutes around patient care.
So there's the Institute ofDigestive Diseases where you
might have colorectal surgeonsand gastroologists and
nutritionists and psychiatristsand immunologists all working
(21:35):
together.
Again, that mash tent, patientin the center, bring the
services to the patient.
That concept has uh pervadedthroughout all the Cleveland
Clinic sites that I mentionedearlier.
And it's uh also the motive weuse in um in Canada as well.
SPEAKER_01 (21:51):
Yeah, thanks for clarifying that.
It sounds like a really uhreally revolutionary model.
I'm curious when you're you'retalking about you know,
measuring metrics that matter,when you're talking about, for
example, mammogram turnaroundtimes.
I'm imagining each step in thatprocess, if you're mapping that
process, each step has areasonable amount of time that
it takes to complete.
(22:12):
And then there's a waitingbetween step A and step B.
And then step B has a certainamount of time to complete, and
then you know you've got awaiting time or some other delay
between B and C.
When you're all looking at theseprocesses and looking to improve
them, are you getting down tothat level of granularity?
Are you and I and I ask thatpartly because I think having
(22:33):
the you talked about beingresource neutral, cost neutral.
One of one of the challenges cansometimes be having this the
staff and the expertise kind ofall in the same room to be able
to map processes down to thatlevel of granularity.
Is that is that part of theconversation?
SPEAKER_00 (22:46):
Yeah.
Um I I you know, I say resourceneutral because I I consider
patient experience and qualitylead as part of that necessary
part of the of the of the caredelivery pathway.
And so the answer to yourquestion is yes, we do look at,
uh we've got patient flow mapsfor almost every type of
(23:08):
encounter that someone wouldinterface with us.
And we've uh, you know, onceyou've established them, they
they don't change much.
And it's just a matter offiguring out where these wait,
these aggregate wait times falland and how long they are.
And then you set set upautomated systems such that when
the wait time uh exceeds, andwe're when we use an electronic
(23:29):
health record like most everyoneelse does now, and we've built
in systems so that theelectronic health record can
flag when those wait timesexceed what we'd like them to
be.
So if I know that uh pulmonaryconsults are now nine weeks, and
I've said no, they must be lessthan four, the EMR will actually
(23:51):
say, hey, red flag, you'rebooking nine weeks out.
You wanted me to tell you whenyou were booking more than four
weeks out.
And so, yeah, the first timedown the hill in the sled uh is
gonna be a little tough andrequire some investment.
But after that, when youautomate these systems, they uh
they serve you well.
SPEAKER_01 (24:09):
And and that's I mean, that's another really
interesting hill that it soundslike you've got you successfully
climbed.
I know some uh institutions willstruggle with, which is, you
know, once we have a a newprocess, a uh you know, new
policy in place, how do wemeasure when the system is in
spec or out of spec?
And it sounds like you've gotsome real metrics that can that
are tied to your EMR that can dothat.
(24:30):
So that's yeah, I can imaginethat's a huge benefit to keeping
on track once you've once you'vegot those uh processes mapped.
This sounds like reallyimportant stuff when it comes to
using metrics that actuallymatter in the outpatient
setting.
And I wanted to to hear a littlemore about another area where
you're, I think, innovating inoutpatient work, and that's your
(24:52):
your role as the chief medicaldirector at uh the Royal Bank of
Canada, RBC.
Um because I understand thatyou're trying to bring a lot of
these kind of whole patientwellness principles, you know,
maybe traditional and and somealso innovative principles to uh
the corporate workplace.
I'm curious what you can tell meabout about that whole uh that
(25:14):
whole model.
SPEAKER_00 (25:15):
Yeah.
So uh that's correct.
I am the chief medical directorfor uh RBC Royal Bank, but it's
through a contract that theyhave with the Cleveland Clinic,
and there's a service line thatwe have called uh Global
Corporate Advisory Services.
And this really grew uh it itstarted before COVID, but it
really grew once COVID um was uhin its you know full flown uh
(25:39):
full-blown stages.
And it it I think it's born fromthe realization that we people
spend a lot of time at work.
They probably spend a third oftheir lives uh in the office.
And while they're there, they'reexposed to a bunch of different
things.
They're exposed to the commuteto the workplace, they're
exposed to their desk space andtheir office space and the
ventilation and the quality ofthe air and that ventilation,
(26:01):
perhaps some of the radiationthat's uh emitted in the in the
in the workplace.
They're exposed to sunlight, orsometimes not if they're working
in a in a building with nowindows.
They're exposed to printer ink,although that's becoming less
and less of an issue.
They're exposed to the buildingitself, what's in the walls and
things like that.
So, and and then they're exposedto the nature of the work with
(26:23):
all its inherent stresses andand and whatnot.
And so companies started torealize that if they were going
to have a resilient anddedicated workforce that showed
up, was present, and thrived atwork, um, they have to be at
least aware of what makes ahealthy workplace and what makes
(26:46):
a healthy workforce.
Um and so we we've been helpingboth the Royal Bank and now uh
dozens of other companiesaddress issues that affect the
health and one well-being oftheir workforce and not just of
individuals.
Um, so that might be things likeletting them know uh about
(27:07):
ergonomics and uh teaching themhow uh you know you should every
20 minutes you should be lookingup from your screen and looking
20 feet away so you don't getyou know changes to your vision
from staring at the screen uhall day.
It might be um looking at theirbuildings that are more than 60
years old and saying, you know,is there asbestos in the walls?
(27:28):
And what what you know, workingwith their uh corporate real
estate groups um and advising onthat.
Um it might be air quality, andunfortunately, as you know, with
with climate change, we'rehaving more and more forest
fires and you know, in Torontoat least, um the the air is not
such great quality every everyfew weeks.
It's sometimes orange when youwalk outside.
(27:49):
Um, and part of that is fromforest fires from the prairies.
And so, what is that, what's theimpact of that when you have a
part of your workforce that havehas chronic lung diseases like
asthma or COPD?
What should you advise uhpeople?
How should they monitor airhealth quality indices?
So that's been a really uhinteresting part of my career.
I've learned a lot ofoccupational medicine.
(28:09):
Uh I've learned about uh a lotof things about uh buildings and
building materials that I neverthought I would ever uh learn
about, certainly didn't learnabout that at medical school.
But these are things that cansignificantly impact the the
health and well-being of peoplethat work in those buildings.
SPEAKER_01 (28:25):
Yeah, I felt myself needing to adjust my uh my
posture in my chair as you weretalking about ergonomics.
I'm sure you noticed.
And uh and and I I yeah, Icertainly hear that.
I mean, it it sounds like thiswas, you know, in the circuitous
pathways that our careerssometimes follow.
It sounds like this has been onearea where, again, you've you've
(28:46):
learned about buildings and airquality, some of these things
which kind of touch torespirogy/slash pulmonology, but
but also um probably a whole lotof other areas.
And so this model, it soundslike is um, you know, advising
companies on a lot of theaspects you talked about.
Is there also like directprovision of medical care?
SPEAKER_00 (29:06):
Yeah, so it's an interesting question.
Uh, in its original concept 10years ago, I've been the medical
director for Royal Bank.
Uh actually, today is my 10-yearanniversary.
Um Happy anniversary.
Thank you.
The the original concepts didnot have any direct patient
care.
It was mostly being the bridgebetween their human resource
(29:26):
department, their benefitsdepartment, and their uh senior
leadership.
Because often there's a littlebit of a disconnect between
those.
You know, if if a new medicationcomes out, they're deciding
whether it should be on theformulary, well, there's a cost
to that, obviously.
And uh the senior leadershipteam may not be able to or want
to incur that cost this year,and uh employee relations has to
(29:48):
deal with the fallout from thatdecision.
And so I would come in and andbridge those two.
So that was the original uhconcept.
However, because we're havingsuch a primary care access
problem, and this is not uniqueto.
Canada.
I've talked to my friends backin the States, and it is a North
American problem, if not aglobal problem.
We've got lots of aging uhpeople with chronic medical
(30:09):
conditions, and we have fewerand fewer family doctors to take
care of them.
Because of that, we've come hadto come up with some unique ways
of offering at least the basicfoundational primary care uh to
groups of patients.
So, for instance, there's a uhuh delivery company, I won't go
into details, that had all oftheir thousand employees in
(30:30):
their main warehouse, and wewent by and we did some health
screening, some basic healthscreening for them.
Um, point of point of care,blood pressure testing, point of
care, cholesterol screening,hemoglobin A1C checking for
diabetes.
You know, we measure we measuredtheir waste circumference.
And at least we gave them ascorecard at the end for those
thousand employees to say, okay,here's the subset of you that
(30:52):
really should go on toconnecting or reconnecting with
your family doctors and takingcare of these things before they
become a problem.
And, you know, we we includedsome mental health stuff in
there as well, and you know,with the PHQ 9.
Um, obviously these were nursesthat were in private booths that
were uh working with thesefolks, but we were able to offer
(31:14):
some, I don't even know if I'dcall it primary care, I'd call
it maybe pre-primary care tothis group of paid uh employees
sponsored by their employer whoall of a sudden, instead of
having to take the half day offto go see their doctor if they
could get in, at the workplacehad this foundational
information about their healthand could start working on that.
(31:35):
We picked up, well, we picked upbrand new diabetics, we picked
up people in stage twohypertension uh that needed to
get uh you know that addressedfairly quickly.
And it was really uh reallyfruitful.
And other companies have lookedat that model and said, okay,
well, maybe that's that's a wayfor us to contribute to our
employees' health andwell-being, and maybe even
(31:56):
decompress the public healthcaresystem a little bit.
SPEAKER_01 (31:58):
And and it sounds like um something that I've
heard kind of more and moreabout, which is how do we, you
know, how do we innovate inthings that are upst care that's
upstream from the hospitalexperience, right?
We spend a whole lot of timefocusing on the hospital and uh
for for good reason.
And and at the same time, wehave a uh, you know, fewer and
(32:19):
fewer family dogs, as you say,trying to care for more and more
people in more and moredistanced communities.
And so, how do you innovate tocreate new models where some of
these people can be met wherethey are uh in a truly
patient-centered way?
And and I understand also thatone of the other initiatives, so
this big initiative has beenthis Tito Care initiative.
(32:41):
Um, tell me about Tito Care.
What's that all about?
SPEAKER_00 (32:43):
So Tito Care is a company um that developed I
would say user-friendlydiagnostic equipment.
And it is can be can be done bya layperson.
It can include many things, butat its very core includes an uh
flexible odoscope to look in theears, uh, a rhinoscope to look
in the nose, a laryngoscope tolook in the mouth, a blood
(33:06):
pressure cuff, a stethoscope.
Uh it can it can include even athree Lib CG and a pulse
oximeter, depending on whatlevel of title care uh you get.
But it's essentially aself-diagnostic,
self-examination tool that canbe placed anywhere and used by
almost anyone.
Um I think we we even had itdown to like the third grade
(33:29):
level, could could learn how touse this.
And we have gone to places whereit's been can either convenient
for people to use this tool,upload that information either
synchronously or asynchronously,and then connect with a
healthcare provider virtually.
Um, and so we've we've placedthese in uh university campuses
(33:51):
where you know students may notmaybe maybe you want to go uh
get a checkup at two in themorning because that's when
you're done studying, right?
And all the pizza places areclosed by then.
Well, you can do that now,right?
We can we've placed these onFirst Nation reserves where
access to care, as you know, isis very challenging.
We've placed this in um inmining company towns where
(34:13):
there'll be this remote areawhere 5,000 employees are
congregated because they're on amining job site and they have no
access to healthcare, and it'sthree hours to the closest.
Can you imagine that?
Imagine wanting to get a checkupto get your blood pressure
checked.
You leave your work, you drivethree hours, you probably wait
in a waiting room for a bit, getyour blood pressure and whatnot
(34:36):
checked, and then go back towork.
Well, that's your whole day isgone.
The productivity loss from thatis immense, multiplied by 5,000
employees.
We can put a title care clinicin that setting, connect with
the nurse practitioners.
And of course, once in a whilewe'll send out sometimes
physicians, sometimes PAs, uhphysician assistants, sometimes
nurse practitioners, uh, to seeany patients that need to be
(34:59):
seen in person.
But the efficiency of that andthe access that that offers
compared to what they have nowis like night and day, right?
The one thing I didn't uhmention, and I I assume you were
going to ask me this question,but I'll just I'll just prompt
you anyways, is is uh who isinterpreting that data.
(35:20):
And so far it's just beenone-to-one.
You know you get your bloodpressure on tight O, and I have
to look at your blood pressureand decide if you have
hypertension.
Well, as you know, you don'tnecessarily need a physician to
decide that anymore.
AI can decide that, right?
So we are looking at, especiallywith uh the dermatoscope, which
I didn't mention, you know, whenyou put a dermatoscope on a
(35:41):
rash, let's say your your localfamily doctor might have seen
that rash 500 times.
I'm just pulling that number outof thin air.
Maybe your dermatologist hasseen that rash 2,000 times.
Well, Google Images has seenthat that rash 5 million times,
right?
And it's I think it's only amatter of time before artificial
intelligence and deep learningis able to not just take that
(36:03):
data that you're uploadingthrough your own self-examined
experience with title care, butalso interpret it correctly and
give you a little bit of a senseof this is urgent.
You must go see someone nowabout this, or try a little
steroid cream and you'll beokay.
SPEAKER_01 (36:20):
So it sounds like between looking, examining the
skin, examining the mouth andthroat, the ears, the blood
pressure, um, there's a wholelot that you can do in the
stethoscope.
Stethoscope as well.
Yeah, and to the three day threelead cg as well.
So there's a lot that you cando.
And it sounds like with very fewresources other than this this
(36:41):
product itself, and maybe somekind of designated you know
area.
Does it does it involve a lot ofcleaning or or maintenance of
this equipment?
SPEAKER_00 (36:50):
Or is that yeah, it it's well we've we've been using
this for about four years now.
The results have been excellent.
We've had very few, in fact,we're gonna be uh writing this
up fairly soon.
Very few user errors, criticalerrors where we're not able to
get the person to get theinformation.
Um the cleaning isself-explanatory and it's done
after after easy use.
(37:12):
And this is like hard plastic,easy, easy stuff to clean.
It's not it's not cloth oranything of that nature.
And the the amount of space thatyou need uh for this is very
little.
You can you can do this in a youknow a six by six foot uh uh
room.
SPEAKER_01 (37:29):
Well, is embedding care in workplaces and you know
residential towers and miningtowns, I mean, is this like the
next frontier of outpatientquality improvement?
I haven't I can I have to sayI've never heard a presentation
on this at any QI conferences,but it sounds uh sounds pretty
revolutionary.
SPEAKER_00 (37:50):
But I think if we take a step back, uh, you know,
I have I have a um a dischargesummary from the 19s, early
1970s, uh, and it was my fatherthat was admitted.
Um, and he was admitted tohospital to manage his
hypertension, and it wasn'tsevere hypertension, it wasn't
life-threatening hypertension,it was just hypertension.
And his cardiologist said, youknow, uh this this the uh it's
(38:14):
comical to read today, you know,50 years later or whatever.
This man's wife is on vacationfor two weeks, so I've admitted
him to hospital so we canaddress his hypertension.
We've come a long way sincethen.
The stuff that we have we admitpeople to the hospital for now
is much, much, much more severe,and rightfully so.
(38:35):
And the consequence of that isthat the stuff that is less
severe than that, we need to nottake care of in a hospital.
We cannot be doing routine.
I you know, I I have ahospital-based clinic and I feel
bad about it because I see somemild asthma there.
I shouldn't be seeing mildasthma in a hospital.
It's way too expensive a placeto see us.
(38:55):
So I think as things that areless acute, subacute and
sub-subacute are being pushedout to the ambulatory space,
it's only a natural extensionthat some of that stuff that was
traditionally in an ambulatoryspace is being pushed into the
community.
Whether that'll be in people'shomes, whether that'll be at
people's workplace, whetherthat'll be people's schools,
whether that'll be people'sneighborhoods, could there could
(39:17):
there be a kiosk in the cornerof your neighborhood, in the
corner of your neighborhoodwhere you could get your
checkup?
I I think that's the way in thefuture, um, especially as blood
diagnostics become more uhefficient and you can just prick
your finger and get a wholebunch of that information.
Obviously, we have to make surethat that's all legitimate and
and meets standards of uh ofcare and and and is
(39:39):
cross-referenced with goldstandards and things like that.
But I I honestly think there'llbe a day very soon where you
will not leave your house to getyour annual physical exam.
SPEAKER_01 (39:50):
Yeah, so that I mean it's as if you anticipated my
next question because I I'mreally interested in in how um
how you're talking about theseinnovative ideas.
And I I wonder if we fastforward five or ten years, what
do you think will surprise usabout routine outpatient visits?
What will outpatient visits looklike?
SPEAKER_00 (40:11):
I think that the foundational information about
yourself, so your sort of yourbiohacking information that
everyone's after will be easilyattainable by yourself and in
your home, right?
Whether it's wearabletechnology, um, whether it's
something like title care whereyou're gathering that
information.
I think that baseline stuff isgonna be there.
I think what's gonna happen isthat the only reason you would
(40:33):
go to see someone in a in anoffice, one is if you need
advanced diagnostic imaging.
So I don't think you're gonnahave an MRI machine in the
corner of your neighborhood.
I think that's something you'regonna have to go to in to see
someone.
Um minor procedures, obviously,you're gonna have to go in for
if you need them all removed andwhatnot.
Vaccinations.
I don't I can't see a day whereyou're self-administering
(40:55):
vaccinations, unless, of course,they're intranasal, and who
knows?
Maybe, maybe we can do that.
Uh, but there'll still be a rolefor for those type of
intervention or procedure-baseduh visits.
But short of that, you know, Iwould say 75% of the stuff that
we have people come to theoffice to get done, prescription
(41:16):
renewals, uh, education ondiabetes, uh, et cetera, et
cetera, et cetera.
I don't think people will becoming to the office to do that
anymore.
If you look at every otherindustry, and as you know,
Jason, unfortunately, medicineuh is usually lagging about 20
years behind every otherindustry.
But if you look at the bankingindustry, you don't you don't go
to the bank anymore.
(41:36):
Everyone does online banking.
It's it's you want to you knowcash a check, you're doing that
in online, deposit a check, youcan transfer money, pay your
mortgage.
None of that is done in a in theactual facility anymore.
And healthcare eventually willwill follow, whether it'll be
five, 10, 15, 20 years from now,who knows?
I think I think we're stillusing faxes, right?
(41:58):
So go find it.
Faxes and pagers.
Faxes and pages, right?
SPEAKER_01 (42:04):
Yeah.
Um, well, I think that's a greatplace to to end our
conversation.
I really appreciate this.
And I think that gives me andhopefully some others a lot of
food for thought on what'scoming down the pipe in
innovative outpatient care andand even in in areas that we
don't even think about as beingoutpatient care, right?
In these whole new kind ofclinic models that you're
(42:26):
describing and you know,advisory, health advisory within
the workplace.
And and so really appreciateKhalil, you taking the time to
uh to have a chat with me today.
And uh yeah, really appreciateyou.
SPEAKER_00 (42:37):
Thank you.
Thank you very much, Jason.
SPEAKER_01 (42:39):
For listeners who'd like to uh follow your work and
or get in contact with you,where should they go?
SPEAKER_00 (42:45):
Uh well, they're if they're on the uh Canadian side
of the border, they could uhlook up Cleveland Clinic Canada
and uh all of our contactinformation is there.
Otherwise, I guess they would uhcontact you to contact me.
SPEAKER_01 (42:59):
Sounds good.
So we'll uh yeah, we'll we'lllink the uh your profile in the
show notes.
And uh thanks so much forsharing your insights on quality
improvement, measuring metricsthat matter, and innovating new
models of outpatient care.
Thanks so much for listening totoday's episode of Leading
Quality.
If you enjoyed the show, pleasetake a moment to like,
(43:20):
subscribe, and share it withsomeone who might find it
useful.
You can find all our episodes atleadingquality.budspout.com or
in your favorite podcast app.
The show was written and hostedby me, Jason Mellowski, edited
by Milan Millson Village, andproduced by Thrive Healthcare
Improvement.
See you next time.
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