Faculty Spotlight: Krishan Soni, MD

Interventional cardiologist Dr. Krishan Soni’s grandfather died of a heart attack at 50, and his father had his first heart attack at 43. Dr. Soni, who recently joined the faculty, now helps many patients with similar conditions. He is also an emerging leader in quality, safety and value, working to improve care for all patients.

Growing up on Long Island, Dr. Soni knew he would become a doctor, but also wanted some broader experiences before plunging into a decade or more of medical training. After earning bachelor’s degrees in biochemistry and economics at Yale University, he worked in management consulting for two years in areas including finance, energy, advertising, mortgages and health care. "It was extremely helpful, giving me skill sets for solving problems, analyzing large data sets, and presenting evidence in a compelling way," said Dr. Soni. "During medical training, I was able to look at how systems issues impact the care we deliver."

After earning his MD and MBA from Yale, he completed his internal medicine residency at UCSF, became the Department of Medicine’s first chief resident for quality improvement and patient safety, then completed fellowships in general cardiology and interventional cardiology.

One big draw to UCSF was the Pathways to Discovery program, which provides longitudinal training in specialized areas. Dr. Soni chose the Health Systems and Leadership track, and in one project, worked with other residents to reduce "door-to-floor" time – the delay that emergency room patients face when waiting to be admitted to the hospital. "We were able to use some of the tools I learned in business school, like queuing theory and operations research methodology, to understand the problem and develop solutions," said Dr. Soni.

During fellowship, he developed and led implementation of a report template for cardiac catheterization patients which includes before-and-after pictures of their arteries and a short description in plain English. "It helped patients better understand their disease and improved how we as doctors communicate with them," said Dr. Soni.

Improving Value

Dr. Soni is excited by the Division of Cardiology’s recent work in improving outpatient care, led by Dr. Rajni Rao, and hopes to bring a similar focus to the inpatient setting. "How do we reduce mortality, readmissions and delays, and improve patient satisfaction?" asked Dr. Soni. "There are a hundred things we could work on. At every single touch point for the patient, we’d like things to be safe, high quality and convenient for the patient."

He was recently appointed as director of value improvement for the Department of Medicine-UCSF Health Subspecialty Services, with a particular focus on improving value across all inpatient specialty practices within UCSF Health. These include cardiology, pulmonology, endocrinology, gastroenterology, rheumatology, nephrology and others.

"Over the past decade, we've come to learn that providing superb care to patients is not just a matter of smart and well trained clinicians – it also requires a system that works," said Dr. Robert M. Wachter, chair of the Department of Medicine, Holly Smith Distinguished Professor in Science and Medicine, and Marc and Lynne Benioff Endowed Chair. "To build such a system, we need individuals who are skilled in both clinical medicine and in leadership and improvement science. Krishan Soni is ideally suited for this role, and I'm excited to work with him in our efforts to make care better and safer for our patients."

"Value is not just about decreasing costs," said Dr. Soni. "It’s about delivering high-quality, safe care to the appropriate patient at the appropriate time that creates good patient satisfaction, divided by the resources that go into that – including cost, time and people. We have to start prioritizing and think about what things are helpful, and what things are not – and may even be harmful. For example, unnecessary radiology studies expose patients to more radiation. We need to ask, ‘Is everything I’m doing going to help me understand the patient’s condition or treat them, and is it worth the side effects, risks and costs?’"

Some of the value improvement projects that he is currently shepherding include:

• Prevent rehospitalizations: Many hospitalized patients with cardiac conditions have complex needs, and need a checkup within a week or two of discharge. Unfortunately, some patients are unable to get a timely appointment to see a cardiologist or internist, and may end up back in the hospital for preventable complications. Dr. Soni, Dr. Rao and their nursing colleagues created a pilot Cardiology Outpatient Recovery (COR) clinic, which assigned a nurse practitioner to meet with patients while they were still hospitalized. She helped develop discharge plans, and scheduled follow-up appointments before they were discharged or within three days of them leaving the hospital. She then saw most patients within two weeks, when problems often start brewing. Dr. Soni and the team are evaluating whether the clinic helps prevent unnecessary rehospitalizations and improves patients’ health outcomes.
• Appropriate testing: One of the most commonly ordered tests in hospitals is troponin, which can indicate whether a patient has suffered a heart attack. Dr. Soni worked with Dr. Leila Yeh Beach, an internal medicine resident, who found that about one in three troponin tests at UCSF were ordered for conditions that were very unlikely to be a heart attack. "A lot of folks say, ‘Just get the test – that way we won’t miss a heart attack,’ said Dr. Soni. Unfortunately, the troponin test has many "false positives," which can lead physicians to order additional tests and procedures that carry additional risks without necessarily benefitting the patient.

For example, a patient came to the Emergency Department complaining of abdominal pain; his history and exam suggested that he had gallstones. However, his troponin test was positive, so he underwent several more tests before cardiologists ruled out a heart attack and finally cleared him to go to the operating room to have his gallstones removed. "In that case, I would define value as finding the gallstones, treating them, and making the patient feel better with a CT scan, an exam and surgery," said Dr. Soni. "Asking the patient to run on a treadmill and delaying treatment of his primary diagnosis by a few days likely added little value to his care."

• Reduce patient wait times: Dr. Soni is guiding team-driven workflow improvements to reduce the number of days a patient must wait to have procedures such as heart catheterization procedures and other cardiac studies. At the actual appointment, Dr. Soni and his colleagues want to reduce time that patients waste waiting to meet with doctors and have their procedures. "Some procedures only last 30 minutes, but the patient may spend six or eight hours here," he said.

Using Lean management techniques – a continuous process improvement model originally developed by Toyota – Dr. Soni brings together faculty and staff to map out every step of a procedure, from scheduling to the appointment to the follow-up call. "We ask everyone, ‘What do you do every day, where do things not work, and what ideas do you have for improving the work?’" he said. "This isn’t something I could do just sitting in my office. To be honest, I don’t know what a nurse does when he or she is preparing a patient for a procedure, so I’m the last person to say how to make it better. I want to encourage the team to come up with great ideas, then empower them to make changes. A lot of this is experimentation – you have an idea, try it, and see if it works. We’re constantly measuring and improving."

• Improving access to stress tests: Using the above approach, Dr. Rao and her colleagues identified bottlenecks in cardiac stress tests for clinic patients. By eliminating inefficient processes and optimizing workflow, they were able to increase the number of stress test appointment slots from three to four per day.

On the inpatient side, UCSF Medical Center and the Division of Cardiology established a Clinical Decision Unit (CDU) a few years ago for patients who come to the Emergency Department with chest pain who are at low likelihood of having severe heart disease. Rather than admit these patients to the cardiology service, these patients stay in an area near the Emergency Department for observation, receive an expedited workup – including a stress test, if needed – and if everything looks fine, are able to go home without being admitted. Patients cannot stay more than 24 hours in the CDU, so if they are unable to get a stress test within that time, they are usually admitted to the hospital.

A team of nurse practitioners in the Heart and Vascular Stress Lab led an interdepartmental collaboration to educate the CDU team on choosing the most appropriate type of stress test for each patient. They also worked with their colleagues to adjust the stress lab’s scheduling to help accommodate CDU patients within the 24-hour window. "Simple things like that can vastly improve access," said Dr. Soni. "It also helps prevent having healthy people in hospital beds while sick people are waiting in the Emergency Department."

Interventional Advances

In addition to thinking about the big picture, Dr. Soni enjoys the hands-on work of interventional cardiology. "We can fix anatomic issues, and because of improved technology, we can do things we weren’t able to offer ten years ago," he said. For example, transcatheter aortic valve replacement (TAVR) allows some patients to receive a replacement valve without undergoing open-heart surgery. Instead, interventional cardiologists insert a replacement valve through a catheter inserted in the groin and thread it up into the heart.

There are also new ways to treat chronic total occlusions (CTOs) – complete blockages of the artery which used to require bypass surgery. "It’s like having a sink drain that is 100 percent blocked – you can’t put anything down the sink to unclog it," said Dr. Soni. However, new techniques allow interventional cardiologists to carefully insert a wire into the artery wall, creating a tunnel in which a balloon can be inflated to open up the blocked area. "The artery wall stretches," said Dr. Soni. "It’s riskier than a standard stent procedure, but this is a potential alternative for patients who are not surgical candidates."

Similarly, heart failure patients were historically not good candidates for stents, because their hearts might be unable to pump enough blood during the procedure. They usually undergo bypass surgery, where a cardiac surgeon can stop the heart and temporarily put them on an external heart pump. Now interventional cardiologists can temporarily insert an Impella – a miniaturized left ventricular device (LVAD) which is inserted through the groin and up into the heart. It helps pump blood during the procedure, then is removed. "Patients go home within a couple of days, rather than spending a week in the hospital," said Dr. Soni.

Dr. Soni appreciates making a difference in patients’ lives. "When I can reassure someone who is worried or provide them with medical or interventional therapy to help them feel better, it’s very rewarding," he said. He also enjoys teaching trainees about cardiology and engaging them in quality improvement projects. "At UCSF, we attract bright, very motivated people at all levels of training," said Dr. Soni. "It’s really fun to see how excited they get about learning, and helping to shape how they think about problems."

Outside of medicine, Dr. Soni is a model railroad fan and a stamp collector. He is married to Ahn Jiwajinda, who works at UCSF on quality improvement in areas such as information technology and human resources. Together they have a young daughter, Olivia.

– Elizabeth Chur