Dr. Vazquez de Anda is the Coordinator of Critical Care Medicine at ISSEMYM Medical Center, Toluca, Mexico – a publicly funded, high-care, specialty, university/teaching hospital with approximately 28,000 patients per year. In this interview with Amanda Heggestad, Dr. Vazquez de Anda shares his experiences and vision for the future of management of critical care.
Can You Briefly Describe Your Professional
I received my certificate as a Medical Doctor, specialist in critical care medicine from the Mexican Board of Critical Care Medicine. My Master’s degree was in Clinical Research. In 2000, I completed my PhD studies at the Department of Anesthesiology, Erasmus University Rotterdam under the supervision of Prof. Dr. B. Lachmann. Back in Mexico, I was promoted to Head of the Respiratory Care Service at the Hospital de Especialidades del Centro Medico Nacional Siglo XXI, Mexico City. In 2003, I was nominated to my current position. Presently, I am a member of the National Research System, of the Mexican Academy of Sciences, and of the National Academy of Medicine. I am also Professor in the Clinical Research Master Program at the medical faculty of the State of Mexico Autonomous University. My continuous research work focuses on Acute Respiratory Distress Syndrome, monitoring of lung function, ARDS, severe sepsis, quality system in critical care, and costs in critical care.
What does Your Typical Day Look Like?
My typical day as Coordinator of the Critical Care Division (Emergency Department, Intensive Care Unit and Respiratory Care Service) starts at 07h30 with a cup of coffee and a review of the nightshift reports followed by a quick round to check the patients who were admitted at the ICU and the critical care area in the ER. At 8h00, I usually attend meetings at the Director’s office to participate in several committees. At 9h00,I complete paperwork and then I have a supervision visit at the ER and ICU to verify all kinds of process errors during the last 24 hours and to discuss clinical cases with attending physicians. At noon, the chief of nurses and I go on a checking round with a particular check list which includes items such as patient’s head position at 30°, prophylaxis for deep venous thrombosis, insulin therapy, sedation, antibiotics, ventilator-associated pneumonia, presence of multiresistant Pseudomonas, vancomycin resistant Staphylococcus aureus, etc. Between 14h00 and16h00 I spend time on research work for discussions and revisions. On Thursdays and Fridays, in the afternoon, I attend meetings with representatives of the pharmaceutical industry. In addition to these activities, the costs of the ICU are monitored during the whole week. Once a month we also have a “Quality” meeting to discuss errors during the processes and to suggest recommendations for improvement. Every six months our hospital is audited by an external, private company in order to meet the ISO 9000-2001 certification requirements.
What Management Issues Take Up Most of
We keep our records on paper and all data are registered by hand (audit books) so most of our time is expended on checking and updating our database for the Quality System and reminding all staff members to keep recording our Quality Processes.
What Sort of Personnel Issues do You Deal
with on a Regular Basis?
Communications skills. Under my supervision I deal with highly educated people (doctors, masters, specialists), professionals (nurses, engineers), technicians (respiratory technicians, paramedics), and also with people with basic education. There have been communication problems in the whole team and for that reason, recently, we (the whole staff of the ER and ICU) had our first meeting on improvement of communication. We have learned that every person plays an important role in the process of patient care and that effective care depends on our teamwork and communications skills.
Describe in More Detail Your Quality Control/
Performance Assessment Procedure
We follow the International Organization for Standardization (ISO) 9000-2001, which focuses on the customer (patients and relatives) satisfaction. The ISO quality management system strives to achieve defined targets with continuous improvement and certified by a third party.
Our hospital follows two macro processes (ER and external consultation) with 16 micro processes (laboratory, ICU, supplies, etc). In our ICU we follow five main processes of Quality Management: admission to the ICU-Mortality Rate, blood transfusion, nosocomial infection, commitment in surviving sepsis campaign, and cost. As improvement, we are working on mechanical ventilation, full equipment function and a hand-washing program, among others.
We measure these processes on a daily basis. Every month we measure the customer satisfaction and every four months we perform an internal audit. We also perform error management and data analysis in order to be able to take corrective measurements and improve the process and to establish preventive policies during patient care.
What are Your Goals for Your ICU/Emergency
In the short term, we aim to establish full control over our quality processes and in the long term, to reach high quality according to the international standards by improving patient safety and reducing professional malpractice, ER and ICU length of stay, mortality rate and costs of attention.
Are there Particular Areas in Which You
Feel Your Department Excels?
In Mexico, our hospital and department have earned a good reputation concerning our standard of treatment mainly in quality care, severe sepsis and mechanical ventilation.
Why? We are one of the few hospitals certified with the ISO 9000-2001 Quality System. To keep such certification we need to keep full records of our processes and to show control and improvement. The track of every patient in the ER and the ICU has been recorded and followed-up on since our opening in January 2003. This database is our main tool for comparison with other Mexican ICUs. Our results have been presented at national and international meetings.
Please give Examples of Two Extremes that
You Face During Your Work?
The first example would be trying to introduce the change from the traditional way of working in the ICU to a better organized, teamwork care and secondly, keeping the balance between administrative and clinical work while lowering mortality rates and keeping cost efficiency in mind. For example, in the last six months we have decreased our mortality rate from 27% to 20% with less expenditure than in the first semester of 2005.
What is the Hardest Decision You have had
to Make as an ICU/Emergency Department Manager?
To accept when I am doing something wrong, to slow down when I am going too fast, and to correct things on time.
What has Been Your most Satisfying Experience
as Head of Your Department?
The most satisfying experience has been seeing the results of the three and a half years work in a team of young and enthusiastic people – from designing and planning a brand new ER/ICU with the latest equipment and medications for critically ill patients, to developing a working quality culture that has decreased our mortality rate at lower costs.
What Skills do You Feel are Most Essential
to Being an ICU Manager?
Knowledge, vision and leadership.
What are the Most Important Issues that
You Feel the ICU Community Currently Needs to Address?
Management skills. Two years ago, I was invited to attend a meeting on Excellency in Critical Care given by Dr. Tom Steward and his team. This meeting inspired me to work on improvement of our performance in ICU. Critical care is 100% teamwork with a multidisciplinary r e l a t i o n s h i p between ICU members and other specialties. Any failure in the chain of attention may affect the patient’s clinical evolution. We have to work as a team, managing communication skills, negotiation, motivation, and improvement of patient safety. For us, working towards this goal has been a very satisfying experience.