Leading Quality
Welcome to Leading Quality, the show that dives into the real-world stories and strategies of healthcare quality improvement leaders at all levels, from Frontline Champions to C-Suite Executives. Each episode uncovers how these dedicated professionals tackle complex topics in real healthcare environments. Discussion range from QI fundamentals, to leadership, technology, AI, and beyond. If you’re passionate about elevating patient care and want practical insights that go beyond the buzzwords, this podcast is for you. Tune in for inspirational conversations, innovative frameworks, and the behind-the-scenes details you won’t hear anywhere else, and discover how you, too, can lead quality improvement from wherever you stand in healthcare.
Leading Quality
Small Changes That Move Mountains: Metrics That Matter and the Outpatient Revolution
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
Data-driven care is the only way to deliver care. If you're going to deliver quality care, you have to continue to measure what you're doing, how you're doing it, and how effective it is. Otherwise, not only could you stagnate at a certain level of quality, but I think you could actually get worse at it.
SPEAKER_01:Welcome to Leading Quality, the podcast spotlighting the people moving healthcare forward from the front lines to the C suite. I'm your host, Jason Meadows. My guest today is Dr. Khalil Sivji, medical director at Cleveland Clinic Canada and a pulmonary critical care physician who's turned bedside frustrations into system level fixes. Trained at Brown, University of Connecticut, Yale, where he served as chief medical resident, and Weill Cornell, Khalil learned early how smart data can shorten suffering. First at Kaiser Permanente and later in Toronto, where he led respirology at Sunnybrook Health Sciences Center, taught at the University of Toronto, and built programs that move patients faster from worry to treatment. Today, he's pairing that ethos with new care models, metrics that matter dashboards, EMR flags that catch weights before they snowball, and embedded near work, near-home clinics that make prevention practical for busy people. He also serves as chief medical director for the Royal Bank of Canada, advising on healthier workplaces and upstream screening that spots hypertension, diabetes, and mental health needs before they become emergencies. He's a fellow of the Royal College of Physicians and Surgeons of Canada and the American College of Chest Physicians. Active with the Ontario Medical Association and American Thoracic Society. And when he's not rewiring care pathways, you'll find him on the tennis court, a golf green, or cheering on his beloved Yukon Huskies. Dr. Sivji, Khalil, welcome to the show. Thank you, Jason. So we've known each other for a little while, but um even just before hitting record, having a bit of a dialogue about some of our respective backgrounds. And I wanted to dive a little more into yours. You've had an interesting career path, as I alluded to, uh, both from in the US and Canada. When did quality and patient experience first click for you? Was that earlier in your training? Did that come later after you were in attending?
SPEAKER_00:Yeah, you know, it probably wasn't a single event that uh where where something clicked and I became interested in quality, was through a series of observations throughout my career where I just looked at the way something was done. And when I asked why it was being done that way or why we couldn't do it a more efficient or safer way, uh, I never got a clear response to that. It was always kind of this is the way we do it. I think my absolute first episode of that was when I was working as a staff attending uh in California in the ICU, and we would have patients that were intubated, and some of our patients uh were covered by intensivists who were there all day, every day, all night, every night. And then we had a few patients who were rounded on by community-based docs. And those docs would come in after their busy clinic, three o'clock, four o'clock, five o'clock in the evening, make a slight adjustment to the ventilator, and then leave. And nothing would happen until 24 hours later when they came back. And sometimes on the weekends, it would be longer than 24 hours before they came back. So these patients were obviously on these ventilators for longer periods of times than the patients that were covered by the intensivists on site. And so I asked, why is that? Well, why aren't these changes made either by myself or by other critical care docs that happened to be there? And the answer I got was that's the way it is. And so we developed a liberation protocol from the ventilator, a ventilation liberation protocol. And I proposed it to the docs that were based in the community who surprisingly uh had no problem 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 uh healthcare organization in Southern California at the time, and got it through the appropriate committees uh and we and we launched this thing. And all of a sudden, we measured uh a difference in how fast people were liberated from the ventilator. And that was sort of the first uh light bulb that went off that said, wow, someone who is a junior staff can make an impact like that. I wonder what else is out there. And so every other step through my career, I just kept looking for these opportunities where small changes could have huge impact. And you they were essentially resource neutral. It's just taking what you have, rearranging it, and getting better outcomes.
SPEAKER_01:Yeah, I I think uh so many of us in the quality improvement space who have found our way here, one way or another, have had those kind of light bulb moments as you describe. One thing that's exciting about this and these types of conversations uh for me is to to kind of show others who haven't maybe haven't yet had that light bulb moment or or at different stages in their QI path to realize that, as you said, a junior staff member can be really impactful, that that people can can often be brought around to good ideas if they're presented well and if we've navigated the the change management landscape effectively. But that's um that's really powerful. So you you mentioned you know working in Southern California, and I think you were working for for Kaiser at the time, if I recall correctly.
SPEAKER_00:That's that's correct.
SPEAKER_01:What did you learn about integrated data-driven care um when you were practicing there? Or or how has that become a prominent theme for you since working there?
SPEAKER_00:Yeah, I I've come to appreciate that uh data-driven care is the only way to deliver care. Uh, if you're gonna deliver quality care, you have to continue to measure what you're doing, how you're doing it, and how effective it is. Otherwise, not only could you stagnate at a certain level of quality, but I think you could actually get worse at it. Uh, one example that I uh had when I first joined uh the current uh hospital system that I'm in now in Toronto was our lung cancer data. And so we would look at patients who came in with a suspicious lung nodule, and they would come to see us, so they'd wait to see the to the see the pulmonologist or respirologist, as as we call it in Canada. And that wait might be days to weeks, at which point we then see them, of course, do a complete history of physical, look at the x-ray order of CT, weight number two. Uh, once the CT was done and interpreted, they'd come back and see us. We decide do we do a bronchoscopy, do we do a CT guided needle biopsy, do we do a PET scan? What's the next step? Weight number three. Uh, and eventually we would have histology, we'd prove they have lung cancer, and we'd send them to the thoracic surgeon or the radiation oncologist or the next appropriate specialist. And when you added up these sequential weights, uh, it became months of waiting. And and uh we know now that in fact lung cancer can upstage in as little as two to three weeks. And so as we got busier and busier, these weights just got higher and higher. And um, there was no way I could just sit and and watch that happen. And uh that was one of the times where I said, okay, we've we've got to change this entire system again, completely resource neutral. It was just about realigning what you ordered and when you ordered it. So the the second that that referral came in for a suspicious nodule, I had already ordered the CAT scan, I had ordered the CT guided needle biopsy, I had ordered the referral to the oncologists. I could always cancel those if I didn't need them, but we showed that that changed our uh time to treat lung cancer from about six months, which was really hard for me to believe, uh, down to less than 90 days, which still is a long time and it still could be an upstage, but it was a step in the right direction. And from then I was convinced that 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 was going to practice going forward.
SPEAKER_01:Yeah, I do wonder actually. I first of all, I'm fully bought into that approach. Um, you really can't affect what you can't measure. And this is something that I feel like I spend a lot of time preaching. And I I'm curious if you've noticed differences in different places you've practiced, whether it be different parts of the US or the change over to Canada, if there was different approaches or different willingness to really take a data-first approach.
SPEAKER_00:Yeah. I I think that in the end, at least in North America, we all got into this profession for the right reason, which is to help people and uh to make sure that uh the care that we deliver is the best care that can be delivered. And I I think that transcends border borders, I think it transcends cultures, I think it transcends economic uh systems as well. And maybe I've just been lucky, but I found that anytime that I come across a system of uh operations that I think could be more efficient or working well, uh, and and then introduced a concept of how to change it to make it more efficient and more patient-centered and more effective, that I have been met with uh actu actually very little resistance. The only exception to that I would say is in and it was not in in my current job, it was in a prior uh job, and it wasn't with Kaiser, so I'm gonna take them off the off the table here for a second. But it was in a it was in a place I was moonlighting, actually, and I was seeing pulmonary consults uh to try to decompress their wait list. And I would walk in and there would be a couple of consults in a in a fax folder for me to look through and decide who I was gonna schedule to see. But then there would be two other fax folders uh with other physicians' uh names on them. And I said, Well, what's what's in those? I wonder if there's any urgent consults in those. And the answer I got back was, well, Dr., and I'll use a fake name here, Dr. Jones is on vacation for two weeks. He that's his pile. And I said, but what if there's a just lung nodule in that pile? What if there's a I've you know coughed up some bloodstreak sputum in that pile? And the answer I got was, well, Dr. Jones will get to it when he gets back. And that sort of profession-centered organization of medicine in the community setting 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 such that there is a Dr. Jones pile and there is a Dr. Sy pile, but there's also an urgent pile where someone with uh very few rules to follow could identify urgent, what sounds like urgent consults, put them in an urgent pile, and the next person that got to that pile sketch saw those patients, not the person waiting to come back from vacation in two weeks. A little bit of resistance, obviously, that's fee for service. You know, you you you eat what you kill kind of thing, and you have to make sure that the number of referrals you get is sufficient to sustain your your practice. But I think with enough time and with enough discussion, open discussion, we were able to get through that. In fact, we did have an urgent console pile in the end.
SPEAKER_01:Yeah, that's great. And I'm sure that was impactful. Were you able to measure any uh any metrics in terms of the turnaround there?
SPEAKER_00:Yeah, that so I was I was a pulmonary fellow at the time. I didn't want to rattle the cage too much. And uh so I uh yeah, I just I I I 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:Fair enough. And then, you know, your career saw you in 2005 relocating to Toronto. And so I think the cross-border moves, although they're becoming, I think, a lot more frequent, are are still uh you're still in a pretty small group of people. I'm curious what inspired that transition, how that went, um, and uh where you find yourself now.
SPEAKER_00:You know, I had a knack for leadership even as a young uh kid, and it wasn't actually because I sought it out, or nor was it because I was appointed such. And I I came to this realization actually in Little League, where I was never captain of my Little League team, but I showed up on time, I went through the all the drills the way I was supposed to, and every day I gave it my all. And at the end of my last season, the coach came up to me and his son was on the team and was actually the captain every year I was there. But he came up to me privately and he said, You know, you know, you although my son, and I'll say his name, although my son Sean has been the captain, wore the C on his jersey, you've been the captain of this team. You've led this team. And I said, What do you mean by that? He says, You led by example, you led because you worked hard, you showed up every day, and you gave it your all. And so that uh struck a chord with me. And I and I realized that you know, leadership sometimes chooses you. And so when I went through fellowship and I and I graduated, I knew that I was going to um eventually climb the leadership ladder. When I was with Kaiser Permanente, I was I was being groomed to go through their leadership process. But sometimes if you have the opportunity to skip a couple rungs on ladders, you do that. And in 2005, I was given that opportunity. The University of Toronto has four teaching hospitals. Uh, Sunnybrook Health Science Center is one of them. And the uh opportunity came up for me to be the division head there in respiratory, which was a couple of rungs of the ladder up from where I was with Kaiser. I'm also from uh the northeast uh of this of the United States, and Toronto was a great uh place to be and much closer to quote unquote home. So that that factored in as well. But that's what what that's why I made the decision, and uh uh it was it was a great one to make.
SPEAKER_01:Yeah, and I I think there's probably a lot that we could dive into there in in your time at Sunnybrook and beyond. But taking a another step or two ahead, you actually gave a uh facilitated a great lecture with one of your colleagues, Heather, at our CQO community, a community of quality leaders that uh has been convening uh every month for a few years now. And um it was talking a lot about how you so your your practice now is uh based out of Cleveland Clinic Canada, and you're a unique organization, as I understand it, in that you are solely outpatient focused, in contrast to the way the the model works in the US with the Cleveland Clinic, I think being both inpatient and outpatient. Yeah. Your presentation recently was about your efforts towards using metrics that matter and uh how you measure quality in the outpatient setting. So I'm wondering if you can tell me a little bit about that work specifically.
SPEAKER_00:Yeah, sure. So you're absolutely correct. Uh Cleveland Clinic Canada, which has been around for 20 years, is based in two ambulatory clinics in uh downtown Toronto and Midtown Toronto, although we have a virtual presence and we have uh affiliate clinics throughout Canada, as opposed to the Cleveland Clinic in Northeast Ohio, which has you know dozens of buildings and inpatient beds, and they're also in Florida and Las Vegas and Abu Dhabi and London. But we're unique in the fact that we don't have hospital beds, and that is simply uh a function 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 uh focus on the patient and being uh driven by patients' needs and delivering patient-centered care. So the emphasis on the patient experience, I would argue, is equal in our Toronto slash Canada offices as it is on main campus. And just because you are being treated for a urinary track infection in Toronto and maybe not on IV antibiotics in a hospital bed for euros sepsis doesn't mean that we can ignore uh your experience. And the patient experience is is is really important. So how we handle you when you come in, when we see you, so access to our care, how we make sure that you don't have an uh a drug allergy to the antibiotic we're gonna use, how we follow you up, how we answer your questions, how we let you know that your urine culture showed a certain uh E. coli that is sensitive to the antibiotic that we gave you, how we handle the adverse reaction to the antibiotic. Um, all of that is, I think, important, not just in terms of patient experience, but also in uh in terms of quality and safety. And so we have an emphasis on that. And and the the colleague you were referencing earlier in your question, Heather, is our uh senior director of the patient experience. And so her and I meet on a regular basis. She uh reports to me the Pruscani responses from all of our service lines, and I won't go through them all, but we have seven total service lines. We also go through our uh safety event reporting data. We look at our root cause analysis we're done, we look at process improvement that's occurred in the clinic, and we look at those metrics that matter that you referenced. So things like uh how long did it take for our diagnostic imaging to turnaround? Because that matters. When you you have a mammogram, um not that I've had a mammogram, but you can imagine if you've had a mammogram and you're waiting for those results, you're staring at the ceiling for those nights. And the difference between seven days and three days in terms of a turnaround time is massive. It may not impact the uh overall outcome, especially if it's a negative mammogram. But you know, a week staring at the ceiling, wondering if you have breast cancer because your aunt just had uh was diagnosed with breast cancer is is super impactful and I believe uh matters.
SPEAKER_01:Yeah, and I'm seeing an interesting contrast there between what you just described, which sounds like a very patient-centered viewpoint to the kind of the more physician or staff-centered models that that we sometimes see and that you were kind of uh mentioning before, that absolutely makes a difference. And we hear that on the front lines. We hear people saying, why hasn't this test or that test resulted yet when it's been you know seven days and could reasonably be done faster than that? So, how do you approach measurement, making sure that these metrics matter, how you choose kind of which metrics you you use, and you know, how is it different between the outpatient world and the inpatient world? Because I think a lot of of us in healthcare QI are um are inpatient people.
SPEAKER_00:So that that term about uh wait waiting for your scan to turn around, I've heard it called scansiety. But, anyways, we so so we try to limit scansiety and other other anxieties really by asking ourselves if we were the patient, and you have to be reasonable, of course. You can't can't wish that your scan was read yesterday if it was done today. That's not going to be uh reality. But we say if we were if we were a patient, we ask ourselves a question like if we were to pick up the phone and want to make uh an appointment, and I'll just pick on mammography because that's kind of a hot button topic now, especially in the province of Ontario, where they've switched to a self-referral model. So you don't need a referral to get a mammography. But if you were a patient and you were and your aunt was just diagnosed with breast cancer and you were in your 40s and you want to schedule your mammography, what would be a reasonable amount of time you would want to wait for that? Um, and then we look at and and try to benchmark that against other wait times, both locally, provincially, nationally, and internationally, and come up with a come up with a number. So that's one uh thing that we do. Then we look at turnaround times for things like mammography, of course, other diagnostic imaging, 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 be better than that. Is that good enough? Uh it's a start, and uh, if we could offer same-day service for every service we have, we would absolutely do that. But at least we have a North Star, at least we have a metric that we are or a measure that we're trying to get to, and always asking ourselves, can we do better? Is there a better way of serving the person so so that they have the least amount of anxiety while they're waiting for tests to get done, consults to be seen, results to be reported back to them? I want to piggyback on something you said about profession-centric versus patient-centric care. That's been a pillar of the Cleveland Clinic since its inception. So 104 years ago, uh the Cleveland Clinic in Ohio was started by four physicians who actually were practicing in World War I. And they were in a mash tent together, and the patient was in the center and they brought services to that patient. When they went back in 1921 to Northeast Ohio, they said that worked really well. We should get rid of our offices and start the Cleveland Clinic. And in fact, unlike other health systems, there is no department of medicine, department of surgery, department of neurology at the Cleveland Clinic. There are only institutes, institutes around patient care. So there's the Institute of Digestive Diseases where you might have colorectal surgeons and gastroologists and nutritionists and psychiatrists and immunologists all working together. Again, that mash tent, patient in the center, bring the services to the patient. That concept has uh pervaded throughout all the Cleveland Clinic sites that I mentioned earlier. And it's uh also the motive we use in um in Canada as well.
SPEAKER_01:Yeah, thanks for clarifying that. It sounds like a really uh really revolutionary model. I'm curious when you're you're talking about you know, measuring metrics that matter, when you're talking about, for example, mammogram turnaround times. I'm imagining each step in that process, if you're mapping that process, each step has a reasonable amount of time that it takes to complete. And then there's a waiting between step A and step B. And then step B has a certain amount of time to complete, and then you know you've got a waiting time or some other delay between B and C. When you're all looking at these processes and looking to improve them, are you getting down to that level of granularity? Are you and I and I ask that partly because I think having the you talked about being resource neutral, cost neutral. One of one of the challenges can sometimes be having this the staff and the expertise kind of all in the same room to be able to map processes down to that level of granularity. Is that is that part of the conversation?
SPEAKER_00:Yeah. Um I I you know, I say resource neutral because I I consider patient experience and quality lead as part of that necessary part of the of the of the care delivery pathway. And so the answer to your question is yes, we do look at, uh we've got patient flow maps for almost every type of encounter that someone would interface with us. And we've uh, you know, once you've established them, they they don't change much. And it's just a matter of figuring out where these wait, these aggregate wait times fall and and how long they are. And then you set set up automated systems such that when the wait time uh exceeds, and we're when we use an electronic health record like most everyone else does now, and we've built in systems so that the electronic health record can flag when those wait times exceed what we'd like them to be. So if I know that uh pulmonary consults are now nine weeks, and I've said no, they must be less than four, the EMR will actually say, hey, red flag, you're booking nine weeks out. You wanted me to tell you when you were booking more than four weeks out. And so, yeah, the first time down the hill in the sled uh is gonna be a little tough and require some investment. But after that, when you automate these systems, they uh they serve you well.
SPEAKER_01:And and that's I mean, that's another really interesting hill that it sounds like you've got you successfully climbed. I know some uh institutions will struggle with, which is, you know, once we have a a new process, a uh you know, new policy in place, how do we measure when the system is in spec or out of spec? And it sounds like you've got some real metrics that can that are tied to your EMR that can do that. So that's yeah, I can imagine that's a huge benefit to keeping on track once you've once you've got those uh processes mapped. This sounds like really important stuff when it comes to using metrics that actually matter in the outpatient setting. And I wanted to to hear a little more about another area where you're, I think, innovating in outpatient work, and that's your your role as the chief medical director at uh the Royal Bank of Canada, RBC. Um because I understand that you're trying to bring a lot of these kind of whole patient wellness principles, you know, maybe traditional and and some also innovative principles to uh the corporate workplace. I'm curious what you can tell me about about that whole uh that whole model.
SPEAKER_00:Yeah. So uh that's correct. I am the chief medical director for uh RBC Royal Bank, but it's through a contract that they have with the Cleveland Clinic, and there's a service line that we have called uh Global Corporate Advisory Services. And this really grew uh it it started before COVID, but it really grew once COVID um was uh in its you know full flown uh full-blown stages. And it it I think it's born from the realization that we people spend a lot of time at work. They probably spend a third of their lives uh in the office. And while they're there, they're exposed to a bunch of different things. They're exposed to the commute to the workplace, they're exposed to their desk space and their office space and the ventilation and the quality of the air and that ventilation, perhaps some of the radiation that's uh emitted in the in the in the workplace. They're exposed to sunlight, or sometimes not if they're working in a in a building with no windows. They're exposed to printer ink, although that's becoming less and less of an issue. They're exposed to the building itself, what's in the walls and things like that. So, and and then they're exposed to the nature of the work with all its inherent stresses and and and whatnot. And so companies started to realize that if they were going to have a resilient and dedicated workforce that showed up, was present, and thrived at work, um, they have to be at least aware of what makes a healthy workplace and what makes a healthy workforce. Um and so we we've been helping both the Royal Bank and now uh dozens of other companies address issues that affect the health and one well-being of their workforce and not just of individuals. Um, so that might be things like letting them know uh about ergonomics and uh teaching them how uh you know you should every 20 minutes you should be looking up from your screen and looking 20 feet away so you don't get you know changes to your vision from staring at the screen uh all day. It might be um looking at their buildings that are more than 60 years old and saying, you know, is there asbestos in the walls? And what what you know, working with their uh corporate real estate groups um and advising on that. Um it might be air quality, and unfortunately, as you know, with with climate change, we're having more and more forest fires and you know, in Toronto at least, um the the air is not such great quality every every few weeks. It's sometimes orange when you walk outside. Um, and part of that is from forest fires from the prairies. And so, what is that, what's the impact of that when you have a part of your workforce that have has chronic lung diseases like asthma or COPD? What should you advise uh people? How should they monitor air health quality indices? So that's been a really uh interesting part of my career. I've learned a lot of occupational medicine. Uh I've learned about uh a lot of things about uh buildings and building materials that I never thought I would ever uh learn about, certainly didn't learn about that at medical school. But these are things that can significantly impact the the health and well-being of people that work in those buildings.
SPEAKER_01:Yeah, I felt myself needing to adjust my uh my posture in my chair as you were talking about ergonomics. I'm sure you noticed. And uh and and I I yeah, I certainly hear that. I mean, it it sounds like this was, you know, in the circuitous pathways that our careers sometimes follow. It sounds like this has been one area where, again, you've you've learned about buildings and air quality, some of these things which kind of touch to respirogy/slash pulmonology, but but also um probably a whole lot of other areas. And so this model, it sounds like is um, you know, advising companies on a lot of the aspects you talked about. Is there also like direct provision of medical care?
SPEAKER_00:Yeah, so it's an interesting question. Uh, in its original concept 10 years ago, I've been the medical director for Royal Bank. Uh actually, today is my 10-year anniversary. Um Happy anniversary. Thank you. The the original concepts did not have any direct patient care. It was mostly being the bridge between their human resource department, their benefits department, and their uh senior leadership. Because often there's a little bit of a disconnect between those. You know, if if a new medication comes out, they're deciding whether it should be on the formulary, well, there's a cost to that, obviously. And uh the senior leadership team may not be able to or want to incur that cost this year, and uh employee relations has to deal with the fallout from that decision. And so I would come in and and bridge those two. So that was the original uh concept. However, because we're having such a primary care access problem, and this is not unique to. Canada. I've talked to my friends back in the States, and it is a North American problem, if not a global problem. We've got lots of aging uh people with chronic medical conditions, and we have fewer and fewer family doctors to take care of them. Because of that, we've come had to come up with some unique ways of offering at least the basic foundational primary care uh to groups of patients. So, for instance, there's a uh uh delivery company, I won't go into details, that had all of their thousand employees in their main warehouse, and we went by and we did some health screening, some basic health screening 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 measured their waste circumference. And at least we gave them a scorecard at the end for those thousand employees to say, okay, here's the subset of you that really should go on to connecting or reconnecting with your family doctors and taking care of these things before they become a problem. And, you know, we we included some mental health stuff in there as well, and you know, with the PHQ 9. Um, obviously these were nurses that were in private booths that were uh working with these folks, but we were able to offer some, I don't even know if I'd call it primary care, I'd call it maybe pre-primary care to this group of paid uh employees sponsored by their employer who all of a sudden, instead of having to take the half day off to go see their doctor if they could get in, at the workplace had this foundational information about their health and could start working on that. We picked up, well, we picked up brand new diabetics, we picked up people in stage two hypertension uh that needed to get uh you know that addressed fairly quickly. And it was really uh really fruitful. And other companies have looked at that model and said, okay, well, maybe that's that's a way for us to contribute to our employees' health and well-being, and maybe even decompress the public healthcare system a little bit.
SPEAKER_01:And and it sounds like um something that I've heard kind of more and more about, which is how do we, you know, how do we innovate in things that are upst care that's upstream from the hospital experience, right? We spend a whole lot of time focusing on the hospital and uh for for good reason. And and at the same time, we have a uh, you know, fewer and fewer family dogs, as you say, trying to care for more and more people in more and more distanced communities. And so, how do you innovate to create new models where some of these people can be met where they are uh in a truly patient-centered way? And and I understand also that one of the other initiatives, so this big initiative has been this Tito Care initiative. Um, tell me about Tito Care. What's that all about?
SPEAKER_00:So Tito Care is a company um that developed I would say user-friendly diagnostic equipment. And it is can be can be done by a layperson. It can include many things, but at its very core includes an uh flexible odoscope to look in the ears, uh, a rhinoscope to look in the nose, a laryngoscope to look in the mouth, a blood pressure cuff, a stethoscope. Uh it can it can include even a three Lib CG and a pulse oximeter, depending on what level of title care uh you get. But it's essentially a self-diagnostic, self-examination tool that can be placed anywhere and used by almost anyone. Um I think we we even had it down to like the third grade level, could could learn how to use this. And we have gone to places where it'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 placed these in uh university campuses where you know students may not maybe maybe you want to go uh get a checkup at two in the morning because that's when you're done studying, right? And all the pizza places are closed by then. Well, you can do that now, right? We can we've placed these on First Nation reserves where access to care, as you know, is is very challenging. We've placed this in um in mining company towns where there'll be this remote area where 5,000 employees are congregated because they're on a mining job site and they have no access to healthcare, and it's three hours to the closest. Can you imagine that? Imagine wanting to get a checkup to get your blood pressure checked. You leave your work, you drive three hours, you probably wait in a waiting room for a bit, get your blood pressure and whatnot checked, and then go back to work. Well, that's your whole day is gone. The productivity loss from that is immense, multiplied by 5,000 employees. We can put a title care clinic in that setting, connect with the nurse practitioners. And of course, once in a while we'll send out sometimes physicians, sometimes PAs, uh physician assistants, sometimes nurse practitioners, uh, to see any patients that need to be seen in person. But the efficiency of that and the access that that offers compared to what they have now is like night and day, right? The one thing I didn't uh mention, 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 is interpreting that data. And so far it's just been one-to-one. You know you get your blood pressure on tight O, and I have to look at your blood pressure and decide if you have hypertension. Well, as you know, you don't necessarily need a physician to decide that anymore. AI can decide that, right? So we are looking at, especially with uh the dermatoscope, which I didn't mention, you know, when you put a dermatoscope on a rash, let's say your your local family doctor might have seen that rash 500 times. I'm just pulling that number out of thin air. Maybe your dermatologist has seen that rash 2,000 times. Well, Google Images has seen that that rash 5 million times, right? And it's I think it's only a matter of time before artificial intelligence and deep learning is able to not just take that data that you're uploading through your own self-examined experience with title care, but also interpret it correctly and give you a little bit of a sense of this is urgent. You must go see someone now about this, or try a little steroid cream and you'll be okay.
SPEAKER_01:So it sounds like between looking, examining the skin, examining the mouth and throat, the ears, the blood pressure, um, there's a whole lot that you can do in the stethoscope. Stethoscope as well. Yeah, and to the three day three lead cg as well. So there's a lot that you can do. And it sounds like with very few resources other than this this product itself, and maybe some kind of designated you know area. Does it does it involve a lot of cleaning or or maintenance of this equipment?
SPEAKER_00: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, critical errors where we're not able to get the person to get the information. Um the cleaning is self-explanatory and it's done after after easy use. And this is like hard plastic, easy, easy stuff to clean. It's not it's not cloth or anything of that nature. And the the amount of space that you need uh for this is very little. You can you can do this in a you know a six by six foot uh uh room.
SPEAKER_01:Well, is embedding care in workplaces and you know residential towers and mining towns, I mean, is this like the next frontier of outpatient quality improvement? I haven't I can I have to say I've never heard a presentation on this at any QI conferences, but it sounds uh sounds pretty revolutionary.
SPEAKER_00:But I think if we take a step back, uh, you know, I have I have a um a discharge summary from the 19s, early 1970s, uh, and it was my father that was admitted. Um, and he was admitted to hospital to manage his hypertension, and it wasn't severe hypertension, it wasn't life-threatening hypertension, it was just hypertension. And his cardiologist said, you know, uh this this the uh it's comical to read today, you know, 50 years later or whatever. This man's wife is on vacation for two weeks, so I've admitted him to hospital so we can address his hypertension. We've come a long way since then. The stuff that we have we admit people to the hospital for now is much, much, much more severe, and rightfully so. And the consequence of that is that the stuff that is less severe than that, we need to not take care of in a hospital. We cannot be doing routine. I you know, I I have a hospital-based clinic and I feel bad about it because I see some mild asthma there. I shouldn't be seeing mild asthma in a hospital. It's way too expensive a place to see us. So I think as things that are less acute, subacute and sub-subacute are being pushed out to the ambulatory space, it's only a natural extension that some of that stuff that was traditionally in an ambulatory space is being pushed into the community. Whether that'll be in people's homes, whether that'll be at people's workplace, whether that'll be people's schools, whether that'll be people's neighborhoods, could there could there be a kiosk in the corner of your neighborhood, in the corner of your neighborhood where you could get your checkup? I I think that's the way in the future, um, especially as blood diagnostics become more uh efficient and you can just prick your finger and get a whole bunch of that information. Obviously, we have to make sure that that's all legitimate and and meets standards of uh of care and and and is cross-referenced with gold standards and things like that. But I I honestly think there'll be a day very soon where you will not leave your house to get your annual physical exam.
SPEAKER_01:Yeah, so that I mean it's as if you anticipated my next question because I I'm really interested in in how um how you're talking about these innovative ideas. And I I wonder if we fast forward five or ten years, what do you think will surprise us about routine outpatient visits? What will outpatient visits look like?
SPEAKER_00:I think that the foundational information about yourself, so your sort of your biohacking information that everyone's after will be easily attainable by yourself and in your home, right? Whether it's wearable technology, um, whether it's something like title care where you're gathering that information. I think that baseline stuff is gonna be there. I think what's gonna happen is that the only reason you would go to see someone in a in an office, one is if you need advanced diagnostic imaging. So I don't think you're gonna have an MRI machine in the corner of your neighborhood. I think that's something you're gonna 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 and whatnot. Vaccinations. I don't I can't see a day where you're self-administering vaccinations, unless, of course, they're intranasal, and who knows? Maybe, maybe we can do that. Uh, but there'll still be a role for for those type of intervention or procedure-based uh visits. But short of that, you know, I would say 75% of the stuff that we have people come to the office to get done, prescription renewals, uh, education on diabetes, uh, et cetera, et cetera, et cetera. I don't think people will be coming to the office to do that anymore. If you look at every other industry, and as you know, Jason, unfortunately, medicine uh is usually lagging about 20 years behind every other industry. But if you look at the banking industry, you don't you don't go to the bank anymore. Everyone does online banking. It's it's you want to you know cash a check, you're doing that in online, deposit a check, you can transfer money, pay your mortgage. None of that is done in a in the actual facility anymore. And healthcare eventually will will follow, whether it'll be five, 10, 15, 20 years from now, who knows? I think I think we're still using faxes, right? So go find it. Faxes and pagers. Faxes and pages, right?
SPEAKER_01:Yeah. Um, well, I think that's a great place to to end our conversation. I really appreciate this. And I think that gives me and hopefully some others a lot of food for thought on what's coming down the pipe in innovative outpatient care and and even in in areas that we don't even think about as being outpatient care, right? In these whole new kind of clinic models that you're describing and you know, advisory, health advisory within the workplace. And and so really appreciate Khalil, you taking the time to uh to have a chat with me today. And uh yeah, really appreciate you.
SPEAKER_00:Thank you. Thank you very much, Jason.
SPEAKER_01:For listeners who'd like to uh follow your work and or get in contact with you, where should they go?
SPEAKER_00:Uh well, they're if they're on the uh Canadian side of the border, they could uh look up Cleveland Clinic Canada and uh all of our contact information is there. Otherwise, I guess they would uh contact you to contact me.
SPEAKER_01:Sounds good. So we'll uh yeah, we'll we'll link the uh your profile in the show notes. And uh thanks so much for sharing your insights on quality improvement, measuring metrics that matter, and innovating new models of outpatient care. Thanks so much for listening to today's episode of Leading Quality. If you enjoyed the show, please take a moment to like, subscribe, and share it with someone who might find it useful. You can find all our episodes at leadingquality.budspout.com or in your favorite podcast app. The show was written and hosted by me, Jason Mellowski, edited by Milan Millson Village, and produced by Thrive Healthcare Improvement. See you next time.
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