#MEQAPI – Tweetchat Nov 30-2017 3:00ET Obesity: Effects on Practice

Just a reminder, MEQAPI stands for Monitoring & Evaluation, Quality Assurance, and Process Improvement, and you can visit us at http://www.meqapi.org.

The steep rise in prevalence of obesity has had an effect on how medical practices operate. Everything from the width of doorways to seating configurations in waiting rooms, OR and inpatient bed reinforcements, gurney and stretcher design, hypodermic needle length, and dosage increments have had to accommodate the increasing size of patients.

Many years ago on an ambulance call to a local restaurant, and before the obesity epidemic, I came face to face with the practical problems related to obesity. The patient was a middle-aged male complaining of radiating chest pain, shortness of breath, and that old specter of “impending sense of doom”. Immediate history was a large meal, several units of wine, brandy and cigars, and a fierce argument with his wife over desert. What may have started with indigestion, anger, and a touch of gastric reflux turned into stress-induced angina. Of course, his 5’8″ 250 lb frame and history of hypertension added to the mix.

The most immediate problem was that he had sagged into a low chair, and our three-person EMT team was unable to lift him onto the collapsible ambulance gurney – which was also too narrow and did not have sufficiently strong struts in the collapsible undercarriage to bear his weight.

This Mobi Ambulance stretcher is a good example of equipment that is designed to be light-weight, and for its ability to load and secure easily in a standard ambulance. Ours was similar, but also many years ago, before fancy titanium alloys.


Plan-B was to use the scoop stretcher.


Author CDang

We quickly realized that we couldn’t get the halves together without manhandling the patient, pinching him, or tearing chunks out of ourselves. Once on the stretcher, we found he was overflowing the sides which were putting pressure on his tissue to an alarming degree. On lifting him, our alarm shifted to an unexpected degree of bowing in the stretcher frame that threatened to pop open the catches at the ends.

Naturally, the elevator was too short to accommodate us, and the two flights of stairs to the ground level was a physical challenge, as was the process of lifting him into the back of the ambulance.

The patient was safely delivered to a ED without being dropped or harmed, but the experience and our painful backs taught us that our equipment was just not suited to heavy patients, and that we had to rethink what we would dispatch to calls that involved high-BMI patients.

In this chat, we will scan the six arms of the QI framework, and discuss what challenges are encountered in medical practices, clinics, and hospitals, and what adaptations are required to provide care  for patients with high BMI.




Participants will bring their own experiences, perspectives, and expectations to the discussion, but the topics might break down something along these lines:

    • Methods
      • Policies: office, organization, or national policies, including, etc
      • Workflow: how things are done including new patient onboarding, care provision, care coordination, ordering/prescribing, billing, patient transfer, etc.
      • Quality Improvement Policies
      • Subsidies and funding
      • Facility Policies
      • Specialty Policies
      • Employment policies
      • National and State Laws
      • Training
      • Navigable processes and policies
      • Patient Centeredness
      • Evidence Based Medicine standards
      • Value-based Care
    • Machines (incl equipment, EHR)
      • Personal Safety Equipment
      • Real Time Locator Systems (RTLS)
      • Med Equipment
      • Test and scanning equipment
      • Equip Ergonomics
      • Interoperability
      • EHR/Software
      • TeleHealth
      • Home Equipment
      • Access Control
      • Office Equipment
      • Product tracking
      • Outcomes tracking
    • People
      • Staffing: sufficient and qualified staff
      • Patients – objectives, attitudes, ability to cope, beliefs, power-distance, health literacy
      • Subject Experts
      • Malpractice suits
      • Role Models, celebrity influence
      • Peer support/conflict
      • Training
      • Vendors
      • Friends/Family
      • Patient participation
      • Attitudes/Bullying
    • Materials
      • Patients: as the “raw material” of the medical process. Patients may come with a range of attitudes, health problems, life situations, and ability to comply with treatment that are challenging and stressful.
      • Supplies: medical or office, inferior fax paper,
      • Data: ability to securely share with correct patient, specialist, lab, etc., and Access to Information
      • Patient self-care materials including checklists and how-to instructions, contact information for questions, and self-care consumables
      • OTC and home remedies and drugs
      • Impurities and variances in product strength and effect
      • Internet sources and access
      • Checklists, SoPs
      • Uniforms, footwear, personal protective equipment
      • Costed consumables
    • Measurement
      • Health outcomes
      • KPIs: operational metrics required by practice, local government, state, federal
      • Quality and safety metrics
      • Adverse effects reporting and metrics
      • Targets: set by practice, insurer, etc. as well as patient goals
      • Gini Index
      • Incentives and rewards
      • Adverse Event reporting
      • Effectiveness of measurement
      • Productivity Metrics
      • Patient Goals
    • Environment
      • Noise: distracting noises, sound levels too high, etc. due to computer systems
      • Space: Cramped, uncomfortable work space etc.
      • Time: Too little time per patient or order, too little time in a day, too many demands
      • Location: things where they should be on the screen, click distance, and location of workstation relative to point of care and patient
      • Control: the degree to which the individual can control their workload and how to accomplish it
      • Fairness: the perception that the burdens and rewards, the effort and outcomes are spread amongst stakeholders in an equitable way
      • Contamination and impurities
      • Temperature: too cold, too hot, too variable
      • Interruptions
      • Political climate
      • Social norms and group identity
      • Electrical Power
      • Climate and weather
      • Income inequality
      • Time
      • Direct marketing to patients

Some of the authors of the works cited above may be responding to the following topics, and participants are invited to describe their experiences of medication errors, and offer their insights and observations.


  1. What METHODS are involved in risks, issues, or practice adaptations to obesity
  2. What MACHINE factors are involved in risks, issues, or practice adaptations to obesity
  3. What PEOPLE factors are involved in risks, issues, or practice adaptations to obesity
  4. What MATERIALS are involved in risks, issues, or practice adaptations to obesity
  5. What MEASUREMENT factors are involved in risks, issues, or practice adaptations to obesity
  6. What ENVIRONMENTAL factors are involved in risks, issues, or practice adaptations to obesity


MEQAPI focuses on healthcare improvement, and in the spirit of shameless borrowing (and efficiency), takes existing perspectives from the IHI, AHRQ, and others.

To quote the IHI on what the Triple Aim encompasses:

The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance. It is IHI’s belief that new designs must be developed to simultaneously pursue three dimensions, which we call the “Triple Aim”:

  • Improving the patient experience of care (including quality and satisfaction);
  • Improving the health of populations; and
  • Reducing the per capita cost of health care.

The six domains of care quality (STEEEP) mapped out by the Agency for Healthcare Research and Quality (AHRQ) are foundational to healthcare improvement. All care, and by inference quality measures, should be focused on being Safe, Timely, Effective, Efficient, Equitable, and Patient Centered. We expand this to include Affordability, STEEEPA.

The MEQAPI tweetchat aims to give voice to a broad range of stakeholders in healthcare improvement, and it embraces everyone from administrators to zoologists, and includes physicians, nurses, researchers, bed czars, cleaners, and yes, patients and care-givers.


The Author and Moderator: Matthew is a principal analyst for healthcare improvement at the Washington D.C. based firm of Whitney, Bradley, and Brown (WBB), and is a strategic adviser to the Blue Faery Liver Cancer Association. Matthew is a peer reviewer for the international journal of Knowledge Management Research and Practice, and writes on topics related to healthcare quality improvement and knowledge management.



Upcoming #MEQAPI Chats

Here is the schedule for forthcoming #MEQAPI chats

  • Nov 16 – No Chat
  • Nov 23 – Obesity and practice. Adapting to the increase in patient obesity rates
  • Nov 30 – No Chat (PEX VA conference)
  • Dec 7 – No Chat (Visiting ZA)
  • Dec 21 – Perfecting Practice – What would a perfect practice look like from QI perspective

Unscheduled but planned:

  • TBI & PTSD
  • Healthcare laws
  • Perfecting Patients
  • Perfecting Physician Education

Note: suggestions welcome! – Please DM @meqapi or use the #MEQAPI hashtag to pass on your ideas/