Aileen Adriano, MD

Clinical Associate Professor

Department of Anesthesiology, Perioperative and Pain Medicine

Provide patient-centered, high quality, safe, and financially responsible care

Interdisciplinary coordination of care and determination of best practices is paramount. Within the perioperative services, we are in the beginning stages of establishing the surgical home. As one of our goals will be to enhance recovery after surgery, I will be spearheading the peri-operative anesthetic management of gyn-oncology patients as they move through the Stanford healthcare system.  More  Through collaboration with my colleagues and surgeons, I will review our current practice in this patient population, establish and implement perioperative anesthetic protocols.

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Neera Ahuja, MD

Clinical Associate Professor

Department of Internal Medicine 

Multidisciplinary team approach to inpatient care

Stanford Hospital is currently facing a challenge meeting the demand for inpatient admissions due to the limited number of beds available, i.e. a 'throughput' challenge. Additionally, patients often do not feel informed about their medical care plan. My goal is to work with the efforts underway at Stanford Hospital to improve throughput and patient communication for all patients admitted to the General Medicine Wards.  More 

To accomplish this, I believe several tactics can be effective. First, given the great deal of variation in the communication practice amongst physicians and the numerous care providers (nurses, pharmacists, case managers, social workers, physical and occupational therapists, etc.), I intend to work with hospital and department leadership to standardize this process (specifically, to have a dedicated time for each of these providers to meet and discuss the care of the patient, so that each is up to date with the plan and able to keep the patient informed).

Second, I believe the physician representative for this conversation should be the attending physician, rather than the resident, given that residents turn over each month and may not be driven by the same throughput measures as the attendings.

Third, I would like to transition my group to be compromised of faculty who can commit to this practice consistently; which means attrition of faculty who cannot.

Fourth, I believe the optimal time for this multidisciplinary team rounds discussion is in the morning and during the housestaff's educational conference. This will allow for care plans to be formulated earlier in the day, allow for discharges to occur earlier, and protect the housestaff's educational time.

I envision many challenges to this initiative but I believe it will ultimately optimize patient care and satisfaction, maximize housestaff education, and be a sustainable practice for our faculty.

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Mark Buyyounouski, MD, MS

Associate Professor and Director of Clinical Operations, Genitourinary Cancers and Billing

Department of Radiation Oncology

Develop a shared decision-making (SDM) process for prostate cancer radiation therapy

The Institute of Medicine recently evaluated the cancer care delivery system in the United States and concluded in in a state of crisis. There is no better example of this than the treatment of prostate cancer. Time and time again, studies in prominent journal such as the New England Journal of Medicine have reported patterns of care that are centered on physician-centric and exploit reimbursement incentives.  More  A refocusing of cancer care is greatly needed. For example, unfavorable incentives for prostate brachytherapy has led to poor utilization nationally and locally, despite evidence that results may be superior with fewer side effects.

In professional and layperson communities, there is increasingly priority placed on quality verses quantity of life. The management of prostate cancer is a disease where survival can be measured in decades and patients are more likely to suffer a side effect of their treatment than metastasis or death from disease. Prostate cancer is the ideal testing ground for programs that develop and refine a shared decision-making (SDM) process because patients often have treatment choices.

Last, with increasing access to health care due to the Affordable Care Act and demand on health care due to aging Boomers, and possibly the internationalization of health care, the current practice and reimbursement patterns in the US are unsustainable. The prospective collection of important outcomes measures; such as effectiveness of SDM, patient quality of life (QOL), and prostate cancer outcome measures are needed to guide national and international health care policy toward cost-effective and efficient health care.

Specific Aims: 

1. To develop a SDM process for prostate cancer radiation therapy.
2. To standardize the treatment options discussed with patients independent ofradiation oncologist with the help of decision aids (e.g. video and written materials).
3. To pilot a revised incentive structure for physician reimbursement that includes programmatic incentives such as treatment utilization, SDM, and patient satisfaction metrics.
4. To explore measures that evaluate efficiency beyond traditional measures of cost-effectiveness.

This will be a challenging initiative because: 1) it will require a collective effort to develop decision aids for patients, 2) it will require creating a process to aid and evaluate SDM, 3) it may be unpopular with stakeholders because it requires new workflow, skills, and risks, 4) it will require collecting various metrics to demonstrate value, 5) it will require faith that in the long term, shared decision making will result in treatments that reduce the burden of disease measured by greater patient satisfaction and QOL, which in turn will result in greater patient volume for clinical and non-clinical investigations, and greater presence in prostate cancer care regional, nationally, and perhaps internationally.

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Daniel Chang, MD

Associate Professor

Department of Radiation Oncology

Improve housing options for patients to receive radiation therapy at Stanford Cancer Institute

The purpose of this project to address housing needs for patients seen at Stanford Cancer Institute who need radiation therapy. Many patients travel from long distances to be seen by Stanford physicians for their cancer treatment, given that Stanford is a tertiary care center with specialists and advanced radiation technology. However, many patients find the prospect of daily radiation for 4-8 weeks prohibitive financially, and they often choose to receive their treatment at facility closer to home as a result.  More Social services is able to provide some amount of help which is based on income, but does little to offset the high cost of housing for that period of time. 

For this project, I propose to do a financial analysis of the patients that our department is not able to treat due to housing constraints and quantify the lost revenue that results. With this information, I will engage Stanford Hospital leadership as well as local area lodging facilities to develop a business plan to help subsidize or offset these costs for patients so that they will be able to receive high quality cancer care while improving the revenue stream for Stanford Hospital. By the end of this project, I hope to have a plan in place and implemented so that patients will have an affordable housing option.

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Odette Harris, MD, MPH

Associate Professor and Director of Brain Injury; Department of Neurosurgery 

Associate Chief of Staff, Rehabilition; Palo Alto Veterans Affairs Health Care System

Measure early cognitive decline caused by traumatic brain injuries

The signature injury of the OEF/OIF/OND conflicts is traumatic brain injury (TBI), designated Polytrauma. The VA created an extensive infrastructure focused on comprehensive management of these patients. The Palo Alto VA is one of 5 such programs.

Data support a concern for those aging with a historical diagnosis of TBI, and a higher likelihood of future early decline in cognitive functioning. It is expected that this cohort is vulnerable.  More 

The current staff expertise in TBI care coupled with the Polytrauma programmatic infrastructure including the Assistive Technology Center, presents a unique opportunity to pivot focus to meet those challenges expected among an aging cohort. We propose a broader integration of technologies in the management of an older cohort.

Our hypothesis: The effect of early cognitive decline may be mitigated by comprehensive rehabilitation with integrated technologies, such that functional status is preserved for longer durations.

Part #1: Focus on an elderly cohort with identified cognitive decline. This cohort will serve to further develop, refine, and improve future programs.

Part #2: Cohort #2 -- Polytrauma post TBI patients without evidence of cognitive decline beyond their post TBI baseline. The cohort will be stratified; those exposed to additional technology training, others- treatment only. This cohort will be followed to assess long-term impact with outcomes focused on delayed or preserved functioning.

Part #3: Aging population post TBI is not specific to the military. The highest volume of TBI patients by decade at Stanford is 80s. We propose incorporating into the Neurosurgery/Neurology Clinics. 

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Charles C. Hill, MD

Clinical Associate Professor, Department of Anesthesiology, Perioperative and Pain Medicine

Medical Director, Cardiovascular ICU

Develop an integrated and comprehenisve team-based approach to the care of cardiac surgical patients

Traditionally, the perioperative care of cardiac surgical patients has been dependent upon the cardiac surgeon as the primary provider and decision maker. These responsibilities included the preoperative preparation for surgery, successfully performing the operation and guiding the postoperative intensive care unit (ICU) and hospital care plans. While this system successfully treated many patients, the ongoing evolution of healthcare has illuminated the need for a systems-based approach.  More 

Two factors have combined to propel the impetus for a change in the healthcare delivery paradigm. First and foremost, the patient population is older, often with multiple serious co-morbidities. Second, successfully treating the patient is now only part of the assessment of an institution’s performance. New metrics related to quality scores and resource utilization are now used to determine how effective an organization is with regard to certain diagnoses and procedures.

At Stanford Healthcare, we have slowly begun the process of developing an integrated healthcare team dedicated to the care of the cardiac surgical patient. We have a preoperative clinic, a dedicated cardiac anesthesia and ICU service and a core group of care providers who are responsible for the patients after the ICU until discharge. My strategic initiative is to more formally align cardiac surgery and cardiac anesthesia by developing an integrated team-based approach to the perioperative care of the cardiac surgical patient, with a particular emphasis on optimizing quality metrics and resource utilization. 

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Chris Holsinger, MD, FACS

Professor and Chief, Division of Head and Neck Surgery, Department of Otolaryngology 

Dr. Holsinger received his medical degree from Vanderbilt School of Medicine, completed his internship and residency at Baylor College of Medicine, and his Fellowship in head and neck surgical oncology at the University of Texas M. D. Anderson Cancer Center. In 2003, he was awarded a Fulbright Scholarship to study surgery at the University of Paris with Professor Ollivier Laccourreye and with Professor Wolfgang Steiner at the Georg-August University in Göttingen. Dr. Holsinger leads the multidisciplinary Head and Neck Oncology Program at the Stanford Cancer Center. From 2003-2013, he worked at the Department of Head and Neck Surgery at the University of Texas M.D. Anderson Cancer Center, where he founded and led the Program in Minimally Invasive and Endoscopic Head and Neck Surgery and co-directed the program in Minimally Invasive Technology in Oncologic Surgery. His research and clinical expertise focus on clinical trials research, robotic surgery, and improving the quality of cancer care both within head and neck oncology and beyond. At Stanford, he founded the Program in Robotic Surgery, which coordinates clinical operations, as well as provides education to residents, fellows, and staff. This multidisciplinary program is also studying the value and cost of robotic surgery across several organ sites, measuring the impact of reduced length of stay and post-operative dose reduction of adjuvant therapies. At the Cancer Center, Dr. Holsinger has led several efforts to transform cancer care delivery. He currently leads the initiative to improve the quality of multidisciplinary tumor boards across the Cancer Center. He also serves as the surgical principal investigator for RTOG 0920, “Radiation Therapy With or Without Cetuximab in Treating Patients Who Have Undergone Surgery for Locally Advanced Head and Neck Cancer.” Dr. Holsinger coordinates credentialing for ECOG3311, a prospective randomized clinical trial evaluating the role of transoral robotic surgery for patients with HPV-associated oropharyngeal cancer. Dr. Holsinger has authored or co-authored numerous articles and abstracts, which have appeared in publications such as the New England Journal of Medicine, Journal of the American College of Surgeons, Journal of Clinical Oncology, Clinical Cancer Research, Head & Neck, Laryngoscope, and Archives of Otolaryngology – Head and Neck Surgery. Boardcertified by the American Board of Otolaryngology, Dr. Holsinger is a member of numerous societies including the American College of Surgeons, the American Society of Clinical Oncology, and the American Head and Neck Society.

Aya Kamaya, MD

Associate Professor

Department of Radiology

Lead a team of ultrasound and liver imaging experts across the country

The team aims to create guidelines for ultrasound evaluation of the liver in patients at risk for developing hepatocellular carcinoma as part of the Liver Imaging and Reporting Data System (LI-RADS). Currently, no defined standard screening or surveillance guideline is universally accepted. Some groups such as the American Association for the Study of Liver Disease have vague guidelines, while others such as the Organ Procurement and Transplantation Network have no screening recommendations. Our group will define screening and surveillance imaging recommendations, create a standard lexicon for sonographic imaging, and follow-up recommendations.  More  This will require a significant amount of coordination of numerous radiologists, many of whom are senior authorities in the field. After we put together our recommendations, I plan to implement our recommendations at Stanford to help improve our screening and surveillance program in hepatology.

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Joseph Kim, MD 

Clinical Associate Professor, Division of Pediatric Hospital Medicine

Department of Pediatrics

Staff a team of hospitalists to improve NICU patient satisfaction

LPCH has recently staffed the John Muir Hospitalist Program. Their roles include covering the level 3 NICU at night, attending deliveries, attend on the Wards and Well Baby Nursery, and perform ED consults. Satisfaction from these areas has been high except from the NICU. They have immediate expectations that these hospitalists will be able to manage Level 3 NICU patients at night. The relationship between the team of NICU physicians and nurses and the team of hospitalists has been tenuous and not very collegial or supportive. More  The NICU culture is quite different from other areas in the hospital and this has been a challenge for the hospitalists to embrace and adopt.

I have been tasked to staff a team of hospitalists that will be equipped to cover all these areas of the hospital. This will entail building a training program that will equip the hospitalists to be able to manage Level 3 NICU patients in emergency situations as well competency in managing routine overnight clinical issues such as vent management. The big challenge is getting the buy in from both teams, the NICU and the Hospitalist teams, as the relationship between them need healing and a “do over”. There doesn’t appear to be a very supportive and collegial atmosphere in the NICU with the hospitalist team. Consequently, mending this relationship will be difficult. I have the verbal support of the NICU medical director, but there are personalities and a culture change that will need to be addressed.

My proposed strategy is to:

1. Meet regularly with the NICU leaders and staff to address the cultural issues.

        a. Take steps to improve communication between the two teams on the front line level.

        b. Address the personality issues

        c. Create standard work and processes for “forced” communications.

2. Develop a training program for the Hospitalist group at John Muir and at other sites (LPCH).

3. Develop a short term and long term staffing model that will adequately and safely address the safety needs in the NICU.

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Ruth Lathi, MD

Associate Professor

Department of Obstetrics and Gynecology

Create a task force to address the growing needs for preconception genetic counseling and testing

Due to rapidly evolving genetic testing options for couples wishing to build their families, we are seeing an increasing demand for genetic testing and counseling services in the Stanford Center for Reproductive Medicine Clinic. In order to offer the most up to date knowledge and technologies to our patients, we need a close collaboration between reproductive endocrinology and genetics departments. Creating a dedicated program, which brings these 2 fields together would benefit our patients and increase access to exciting new breakthroughs, such as carrier screening, preimplantation genetic diagnosis and non-invasive prenatal testing in the first trimester.  More  Specifically, we would want to provide guidelines for testing that incorporate the changing landscape of genetic testing and services.

As a start, I would like to create a task force to address the growing needs for preconception genetic counseling and testing. Secondly, create a business plan that involves hiring 1 additional genetic counselor to work in the REI clinic. This program is in line with the strategic priorities of the Children’s Hospital’s “Start Strong” initiative, because it give couples a preconception opportunity to understand their risks of having a child with a genetic disorder and options for reducing their risk of having an affected. Although the first goal of the program will be to provide counseling and access to couples with a history of infertility or an affected family member, ultimately any couple who desires preconception screening could benefit from a this comprehensive approach to reproductive genetics. Additionally, this collaboration would expand the educational and research opportunities for trainees in both genetics and obstetrics and gynecology.

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James Lock, MD, PhD

Professor and Associate Chair

Department of Psychiatry and Behavioral Sciences

Evaluate the opportunities of greater integration of the Humanities and Medicine and Mecidicne and the Humanities

There is a need to promote the human side of medicine to improve clinical care and outcomes; there is a need to promote an academic understanding of the problems inherent in medical research and practice. 

Medicine is the most human of the sciences. The physician-patient relationship is at the heart of medicine. Developments in science, technology, and the economics of health care pose significant challenges to the nature, quality, and maintenance of this relationship.  More Evidence suggests that clinical outcomes, satisfaction (for both patients and physicians), and costs are negatively affected when the human side of medicine is neglected, marginalized, or disregarded. In the busy world of medicine, it is tempting to avoid self-reflection in the service of expediency, but the potential costs are high. Stanford Medicine sets itself apart from most medical schools by being located in an active university campus with world class scholars in humanities at our doorstep giving rise to a opportunity to promote interdisciplinary work at a world class level. Indeed, there are already a number of medical humanities/humanities in medicine initiatives active within Stanford Medicine, but these initiatives lack an integrated vision, strategy, or plan to maximize the potential of these and other not yet identified activities. In short they need leadership.

The project entails the following: identification of key stake holders; meet with key stake holders to learn about their interest and priorities related to humanities and medicine; develop a working group of thought leaders committed to the importance of developing an academic/clinical interface in medicine and the humanities and providing leadership for these endeavors; identify key opportunities for enhancing the relationship between medicine and the humanities; develop a 3-5 year plan for enhancing/developing academic and clinical interface between the medicine and the humanities at Stanford. 

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Deirdre J. Lyell, MD 

Professor

Department of Obstetrics and Gynecology (Maternal Fetal Medicine)

Develop a universal umbilical cord blood collection program

After umbilical cord blood is collected at newborn delivery for routine medical purposes, the remainder is currently discarded. Umbilical cord blood has increasingly become central to research involving pregnancy, the fetus/newborn, and stem cells, yet several issues arise from collecting umbilical cord blood for research.  More 

The timing of approaching patients for research is problematic. Researchers ideally approach patients in advance but this makes the actual collection difficult due to lack of predictability of newborn delivery timing. When a patient is enrolled in a study, the delivering team may be unaware of the patient’s study participation or may overlook this extra step if they are busy, and the sample may not be collected. For more reliable collection, patients are approached on Labor and Delivery while in labor or preparing to undergo scheduled cesarean delivery, but the timing of this approach is unacceptable to some patients. 

Patient research fatigue is also an issue. The Department of Obstetrics and Gynecology has contractual research obligations to the NICHD and the March of Dimes Prematurity Research Center, and qualified patients are approached for enrollment into these studies, as well as other ongoing internal studies. Multiple research groups at Stanford have expressed interest in umbilical cord blood for various research projects. The department must balance patient satisfaction with our mission to support research both within the department and throughout Stanford University.

This initiative will lead to implementation of universal umbilical cord blood collection on Labor and Delivery. Cord blood will be stored on Labor and Delivery for 24 hours and will then be discarded. Researchers with patients already enrolled in studies will be alerted to the patient’s delivery through the EPIC computer system, and will be able to pick up the routinely collected cord blood, eliminating the chance that the additional collection step was missed. Researchers who wish to enroll patients into research will approach patients postpartum, asking them for consent to utilize de-identified cord blood samples that have already been collected. In addition, there will be an option for de-identified cord blood collection without consent.

The success of this project will require input from and coordination with Labor and Delivery and postpartum nursing, residents and attendings from the faculty and private practices, the division of Maternal-Fetal Medicine research team, input from the IRB and University Counsel, as well as financial support and a location for storage. 

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Ravi Majeti, MD, PhD 

Associate Professor, Division of Hematology

Department of Medicine

Development of an Acute Myeloid Leukemia translational research program

The goal of this project is to establish an integrated translational research program for AML. Currently, a separate AML Database and AML Tissue Bank are independent efforts. The AML Database was established by Dr. Bruno Medeiros and includes approximately 800 patients. This database collects patient characteristics, such as demographics, genetic and molecular abnormalities, treatment protocols, response to therapy, and long-term outcomes. New subject data entry is performed multiple times per week, and follow up data entry is performed ad hoc.  More 

In parallel, Dr. Ravi Majeti has established the AML Tissue Bank consisting of approximately 600 cryopreserved patient samples. Laboratory research has focused on genomic and functional characterization, including genotyping, gene expression, immunophenotyping, and xenografting of these patient samples. New samples are obtained daily from inpatient and outpatient clinics. Notably, there is significant overlap in the patients enrolled in the database and tissue bank. This project will integrate these efforts into a new AML Translational Research Program that will link clinical informatics to research parameters and stored biospecimens in a unified database. This objective will be accomplished using multiple resources including: hiring of a data manager for data capture and entry, engaging the Stanford Cancer Center database managers to construct the new database, engaging the Stanford Human Immune Monitoring Core to migrate tissue bank data to the Biobank platform, and developing the bioinformatics necessary for managing, storing, and sharing the integrated data. Ultimately, the success of the project will be measured by new collaborative publications and recruitment of external funding. 

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Iris Schrijver, MD

Professor, Pathology and Pediatrics

Director, Molecular Pathology Laboratory

Physician-Wellness: An assessment of key issues and potential solutions that impact physician wellbeing and professional satisfaction at Stanford

The inaugural physician wellness survey from the Stanford Committee for Professional Satisfaction and Support (SCPSS) identified that drivers of professional fulfillment include perceived appreciation, peer support, alignment of institutional goals with personal values, and schedule control. It also illuminated that 26% of participating physicians had symptoms of burnout, particularly among Clinician Educator and Medical Center Line faculty.  More I propose a Physician-Wellness project to build on this survey – in collaboration with the SCPSS and in coordination with the Dean’s Office – to identify concrete physician wellness opportunities in all areas of work-life integration.

The project’s success will be measured by physician participation and by refined definition of physician work-life wellness optimization needs. The project begins with confidential peer-to-peer interviews with select faculty and small groups of physicians from individual departments. Issues raised in these initial discussions will shape an anonymous survey for all members of the medical staff (SHC and LPCH). The survey’s findings will subsequently be used to formulate actions that can effectively improve alignment of physician health promotion needs and organizational goals in consultation with the SCPSS and with Stanford Medicine leadership. This project is likely to bring to light particular concerns that can be addressed in the short or medium-term to make a substantial and positive difference. The more general findings from this project will support the long-term Stanford Medicine commitment to improving professional satisfaction for our physicians. 

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Karl G. Sylvester, MD 

Associate Professor, Surgery (Pediatric Surgery) and Pediatrics

Executive Director, Center for Fetal and Maternal Health

Program in translational research within the Center for Fetal Maternal Health, Johnson Center

The Center for Fetal Maternal Health (CFMH) at Lucile Packard Children’s Hospital Stanford (LPCHS) is a multidisciplinary program for the diagnosis and management of complex fetal problems and placental disorders. Launched in 2009, the CFMH provides a single point of entry for referring physicians and patients to access the diagnostic, medical and surgical expertise for expectant mothers and babies at LPCHS.  More The mission of the CFMH is to provide comprehensive and outstanding care to expectant mothers, complex fetal patients and high-risk newborns through a multidisciplinary medical and surgical approach, coupled with innovative diagnostic and treatment modalities, and informed by pioneering clinical and basic interdisciplinary research. Accordingly, one of the primary objectives for the CFMH to achieve this mission is: 

Foster innovation through ground breaking basic, clinical and translational research in a collaborative framework that combines disciplines at LPCH and Stanford University. (Part V. C)

The CFMH began a significant programmatic expansion in 2012. Initial clinical programmatic needs that are all well underway included: establish leadership team, establish a key strategic relationship with a nation leading fetal center for collaboration, initiate and obtain fetal intervention capabilities. One of the key pieces to the expansion of the CFMH is a strategic relationship with the Texas Children’s Hospital. The principle advantages of this relationship include clinical expertise and education to expand LPCHS’s clinical expertise. There is now an unprecedented opportunity for this program at LPCHs to lead the collaboration in innovative efforts based upon translational research and technologies developed within Stanford Medicine and the University.

In keeping with the vision for Stanford Medicine to lead the Biomedical Revolution in the coming decades, the Center for Fetal Maternal Health (CFMH) would like to move forward with a research and innovation initiative that leverages existing strengths at LPCHS with the School of Medicine and the remainder of Stanford University. The existing and expanding strengths of Stanford Medicine with the potential for significant impact on clinical care include molecular diagnostics and therapeutic, candidate target identification using cell free DNA, RNA, next generation sequencing (NGS), proteomics, metabolomics, and immunologic discovery platforms including Cytomics (CyTOF).

Accordingly, the CFMH is seeking to expand the research and innovation arm to meet many of our transdisciplinary objectives through the creation of a perinatal tissue bank. There are two principle components to this program, create the tissue bank and recruit an individual with the skill set to establish, utilize and maintain this resource. The recruit would be responsible for:

1. Consolidating research and innovation efforts within the CMFHS that utilize human tissue
2. Initiate focused studies leveraging the existing strengths and platforms in use at the School of Medicine and the rest of Stanford University, especially in related areas such as the March of Dimes Program on causes and prevention of preterm birth, placental biology, expanded prematurity research and premature newborn biology.
3. Create and maintain a perinatal tissue bank that would include prenatal, placental, cord blood and neonatal specimens all linked to numerous longitudinal databases including CPQCC, CMQCC, OSHPD, and the CA Department of Public Health. 

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