Rajni Rao, MDAssistant Professor of Medicine
Cardiology Clinic Practice Chief
What was your career path to UCSF and the field of Cardiology?
I am a Bay Area native, having grown up in Palo Alto. After undergraduate training at Harvard, where I focused on women’s studies and biology, and a year of research in maternal-fetal medicine, I joined UCSF for medical school. Soon thereafter I switched career paths and chose cardiology since the physiology made so much sense; I also found it attractive that even with advances in diagnostic testing, so many cardiac diagnoses can still be obtained from physical examination and understanding of first principles of physics and biology. Finding mentorship and role models in Kanu Chatterjee, Joel Karliner at the SF VA, and Nora Goldschlager at SFGH also had a big impact on me early in medical school. After my internship at the Massachusetts General Hospital, I was fortunate to be able to complete residency and fellowship at UCSF and coordinate my training with my husband, also a cardiologist. I chose to specialize in echocardiography because it was in the echo lab that I had most of my “a-ha” moments – where clinical medicine and physiology came together. As a teenager, my father had introduced me to Berton Roueche’s Medical Detectives– and I still have a penchant for the mystery genre. To me, reading echocardiograms also feels a bit like medical detective work – looking for clues to support a diagnosis. Again, mentoring played a big part –Elyse Foster and Nelson Schiller have such a passion for echocardiography that was really quite infectious.
As the cardiology practice chief, you have successfully led initiatives aimed at improving the quality of care in your practices. What’s motivated you to help lead this work?
I wish I could say that it was part of a planned career path. I started out as a clinician and educator and didn’t know much about quality in a formal sense. Unfortunately, a family member became quite ill early in my career, and after 14 hospitalizations in a 9 month period, I learned quickly what it is like to be a patient and family of a patient. It was really quite enlightening – what can be done well, and where, despite our best intentions, patients can feel alone and confused. I also appreciated the efforts of the entire health care team in a new light – nurses, techs, even the parking attendant – and how interconnected we are from the patient’s vantage. I didn't really know what to do with this other than letting it inform my own experience as a provider. Then, a few years ago, my chief Jeff Olgin asked me if I’d like to help with the rollout of the new EMR, Epic. I seized the opportunity, feeling that as a busy clinician I wanted to be part of making a system work for me and not sit on the sidelines, dissatisfied. What I learned was really eye opening. Though it was easy to be cynical about the health system and EMRs in particular, I found that even one person can make an impact, and that the summation of many small inputs can result in palpable change. From there, I became the clinic practice chief and partnered with an amazing nurse administrative director, Brenda Mar. What I’ve found is that there is so much to do to make our practice run better. Every time we think we have done something well, the field changes, new innovations need to be incorporated, faculty come with unique interests to be supported, our patients change, and our expectations for a good provider experience morph. We are still on the very steep initial phase of a QI curve.
Much of your work and success have centered on improving the patient experience and the experiences of providers and staff. What strategies have you tested and found effective in this work? What have you learned during the process?
Thank you for the acknowledgement, but I feel that we are just scratching the surface. The first thing I’m training myself to do is ask a lot of questions. I started asking my patients questions about how they got their appointment, how they found our clinic, whether we answered the phone, did they know what to expect, etc. Their answers uncovered many easy areas to tackle--sometimes as simple as informing patients if their appointment is during a Giants game so they can plan for traffic/parking. I have also been asking colleagues constantly when I run into them what they think we can do better. While I’d love to take credit, there are a lot of creative ideas out there that just need to be developed. With our staff, they are happy to have an opportunity to voice their ideas to a physician leader. I have learned not to give up on people struggling – development, positive feedback, incentives, and helping them find pride in their work can be transformative (for example, the patient survey results for our front desk staff have improved 6-fold with no change in personnel). Small changes can help generate traction with longtime employees skeptical of new initiatives. I feel that that there is nothing too inconsequential or too small to bother with. Details matter. I am going through Lean training now and the focus on removing wasteful work and improving flow particularly resonates with me. QI seems to be very iterative, incremental, hands-on work, so I am learning to take the long view and to take stock in the small accomplishments along the way.
In addition to your practice chief role, you’ve been involved in teaching and engaging medical students in QI work and supporting your cardiology fellows as well. Based on these experiences, what are some of the most fruitful strategies to teach and engage trainees in QI work?
I am very proud of our fellows who have taken this on with gusto! It started as a conversation with Krishan Soni, who was a DOM QI chief resident and is now an interventional cardiology fellow, about the patient comments from the inpatient surveys showing that there was room to improve peri-procedural communication. We talked about options and really the fellows came up with a plan to show all patients an instructional video about cardiac catheterization prior to informed consent, and then create a patient education document with still images of their cath results for the patient to take home. Gamifying this by showing the results by fellow and by attending helps keep the momentum. It is called “healthy competition” for a reason. The fellows have fine-tuned this in ways to suit their workflow and have collaborated with nursing staff to implement it. There is now interest in other nursing units assisting with this. The residents are interested in it now and look at the patient education handout as a teaching tool on morning rounds. It was particularly gratifying for a clinic patient to show me their document highlighting their coronary lesions. Here I helped a little with project design but mainly served to connect the fellows to various resources and serve as a sounding board. Getting more fellows interested in this sort of work is tough, particularly in cardiology. However, there is a groundswell now and a lot of divisional support in acknowledging trainee QI efforts. At the other end of the education spectrum, having first-year medical students in our clinic was really the brainchild of Ralph Gonzales, and we were willing participants. They really bring a fresh outside perspective. We ask them to do a weekly reflection – in which they must train themselves to take the patient’s perspective - which I find to be a fascinating read and a great source of QI ideas. I try to respond to each of their reflections to make sure they know they are being heard and to show how we may incorporate their suggestions.
The need for engaging specialists in QI work is continuously growing as well. How can we best foster and promote greater specialist involvement moving forward?
I’ve been thinking about this as well. Even the term QI seems foreign to many cardiologists. However cardiology QI is not at all new – in fact cardiology has long been a data-avid field immersed in core measures and guideline-driven. And it is a very clinical field with heavy emphasis on the history and physical examination, carrying on an ancient tradition. Yet the QI that is typically highlighted in cardiology is oft at the 10,000 feet health policy level and less the “in the weeds” details that allow individual institutions to improve their internal processes and excel. However, improvements in metrics such as shortening “door-to-balloon” times for acute MI is an example of a strong local QI effort that many of us think of as good care and the right thing to do but not necessarily QI. I think the key is to train our fellows in the language of QI, to acknowledge how much of what we do already is QI, and to emphasize that if cardiologists want things to be done in a manner that is consistent with our approach and perspective, we need to engage in the process from the beginning.
How do you spend your time away from UCSF?
I live with my husband and 3 kids (ages 7, 5, and 2) in Noe Valley. Life is very full right now and in a way it gives me a balanced outlook. I have found nothing more humbling and heartening than raising children. I can usually be found in the neighborhood with one of my kids or out and about for dinner on Valencia Street, where eating at 6 pm even at the newest hip restaurant is quite family-friendly. Currently, I am in the middle of reading Eric Topol’s The Creative Destruction of Medicine, thoroughly immersed in Downton Abbey, and getting into spinning.
Interviewed Winter 2015