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Board-certified nurse practitioner Shabeena Hirani discusses her article “From nurse practitioner to quality improvement leader in sleep medicine,” sharing her journey from clinical care to driving systemic change. Shabeena explains how her experiences in internal medicine, pulmonology, and sleep medicine revealed gaps in follow-up care, underdiagnosed conditions, and barriers to treatment. She describes initiatives she led to improve outcomes for patients with obstructive sleep apnea and asthma, enhance patient education for labor epidurals, and strengthen care coordination. She also highlights the importance of mentorship, equity, and advancing the role of nurse practitioners as leaders within health care teams. Listeners will gain actionable insights on how providers can lead quality improvement, redesign systems for better outcomes, and inspire future clinicians.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Shabeena Hirani, she is a nurse practitioner, and today’s KevinMD article is “From nurse practitioner to quality improvement leader in sleep medicine.” Shabeena, welcome to the show.

Shabeena Hirani: Thank you, Kevin.

Kevin Pho: All right, so tell us a little about your story and then the KevinMD article that you shared with us today.

Shabeena Hirani: I am Shabeena Hirani. I am a doctor of nursing practice and board-certified nurse practitioner with over a decade of experience in internal medicine, pulmonology, and sleep medicine. Most of my work has been with diverse outpatient care settings in New York where I have the privilege of taking care of patients who come from diverse backgrounds. They face chronic illnesses, be it asthma, sleep apnea, or diabetes. My passion is not only providing direct patient care but also driving quality improvement initiatives to make the health care delivery system more consistent, equitable, and patient-centered.

Kevin Pho: All right, now for those who did not read your KevinMD article, what is it about?

Shabeena Hirani: So, it is basically, as you mentioned the headline, “From nurse practitioner to quality improvement leader in sleep medicine.” It really grew out of my own journey from focusing on individual patient encounters to looking at the system with patients around it. Early in my career, I noticed recurring patterns of missed appointments, underdiagnosed sleep apnea, and uncontrolled asthma. Writing the article is just a way of reflecting on how I began designing solutions and structuring a tracking system for decision-making.

Kevin Pho: And when you notice these patterns, like you mentioned, these underdiagnoses of sleep apnea patients and patients missing appointments, what were some of the core reasons why those things were happening?

Shabeena Hirani: I wish I would have known this earlier in my practice. I think it is a lack of awareness; patients just do not know how dangerous and life-threatening these conditions are. I think just spending that quality time with the patients in that encounter and making them realize what it is and what can be done about it makes the most out of the visit.

Kevin Pho: So you mentioned that you created or designed a structured tracking system for sleep apnea and asthma patients. What is that? What does that look like?

Shabeena Hirani: So, we basically designed, you know, we started at a very grassroots level of having Google Sheets, trying to track patients. OK, this patient, has the patient come to pick up the device? Did the patient return the device? Did we review the study? Did we send the patient for titration? Simple things like that. But with the new EHR that we have now adopted, we will basically have these pop-ups in each patient’s chart so that things are not missed. You and I both know how busy it can get with internal medicine, how demanding it is, and how easy it is to miss out on things. So these small things are something that we are looking into to redesign patient education and look for a system where sleep apnea and asthma are taken care of.

Kevin Pho: Now, can you tell me a case study or a story of this tracking system in action and how that improved care for that particular patient?

Shabeena Hirani: We have quite a few, but if we look at a case study, I have a patient, morbidly obese, who comes to me wanting to get a bariatric surgery procedure. OK. We need to do the pulmonary and the sleep apnea clearance. We sent him for sleep studies. The patient gets a sleep study; the patient gets the machine. We talk about some lifestyle changes. We talk about sleep apnea and the treatment and the impact that it can have on the quality of his life. He is compliant with his sleep apnea machine and all of the lifestyle factors.

What we see over a period of four months, as he was waiting for his other clearances (cardiology, psychological, and psychiatric clearances), is he lost so much weight that he canceled his bariatric surgery procedure. This is something that is so impressive, that lifestyle changes are the key and core to making patients’ lives easier.

Kevin Pho: So tell us a little bit about your practice where you implemented this tracking system. What is it like? Do you work for yourself, with a group, academic, or owned by a hospital? What is your practice like?

Shabeena Hirani: We are a multi-specialty clinic. I have Dr. Aslam Jivani; he is the primary pulmonologist. I have been with him since 2014 when I was a registered nurse, and I worked with him under his mentorship and guidance. I was so impressed that patient care is so important and being in the front of things and having a direct interaction is important. I went back to nurse practitioner school while simultaneously working, and then I thought I could do better and attained a terminal degree, and I went back to a doctorate in nursing program. So this is the journey so far. We are into a team partnership soon wherein we see almost sixty to eighty patients per day, depending on how the volume is. We have cardiology and orthopedics that we have associated with, and we take patients as a whole.

Kevin Pho: So in terms of this system-level improvement of care that you implement in your practice, for other practices who may be listening to you, how can they themselves start to implement these system-wide improvements? Because you are right, sometimes there are only so many things that we can do one-on-one in the exam room. We do need these tracking systems to do these more population-based approaches. So for those who are interested in starting out and doing something like you did, what kind of advice would you have for them?

Shabeena Hirani: The lesson that I would like to share is never underestimate the power of noticing patterns. Often the small things are underdiagnosed. Small things like missed appointments, delayed testing, and lack of education are signals of system-wide opportunities for improvement. As clinicians, we have a responsibility not just to treat but to step back, ask why these gaps exist, and design solutions around them.

Also, leadership matters. Investing in future clinicians ensures sustainable change. That is what we do with students coming in: PA students, NP students. We have medical assistant students who come in and so much that they love our practice that they want to get hired. I think this is something that speaks volumes about how things are done here.

Kevin Pho: And how do you notice these patterns? Is it through the electronic medical record? Does it track, of course, if patients miss a certain number of appointments and raise a flag? Give us a story of some of these patterns that you would notice and how you would act on them.

Shabeena Hirani: What we basically do is we have a consistent pattern in terms of documentation. We have chart alerts that come up with every patient’s chart as to what we can do to make things better. We can be so busy seeing so many patients, and we have so much additional support staff that helps us tag things and helps highlight stuff, put things on patients’ charts that we do not miss. We set reminders. OK. Offer a pneumonia vaccine next visit. The patient already received an RSV today. Things like that, that we are able to track and make a meaningful impact on patient care.

Kevin Pho: Now talk to us about the role of advanced practice providers like yourself in terms of leading system-level improvements in care. How often are these initiatives led by nurse practitioners like yourself?

Shabeena Hirani: I think we can do better. There is a lot of scope for improvement for how nurse practitioners are still being taught to be mid-level providers, wherein they are still considered to be somewhere in between registered nurses and MD physicians. I think when we are working in collaboration, we need to widen our horizons and give them a chance, and nurse practitioners need to step up. We need to make sure our voices are heard and our patients are advocated for.

Kevin Pho: Tell us about the time that you spend doing these system approaches versus one-on-one in the exam room seeing patients. How is your time divided?

Shabeena Hirani: More than fifty percent of my time is in the room with the patient. What I try to do with my visits is have more than seventy-five percent of the time go into counseling, education, and reinforcing positive behaviors like compliance with medications, compliance with their apnea machines, inhalers, and stuff like that.

Kevin Pho: And in terms of the biggest challenges most clinicians face when it comes to this patient education piece, of course, is time. I know how busy you are, like all clinicians. How do you fit in that time for that all-important patient education piece?

Shabeena Hirani: I try to start with education. That way, it is not left out and not taken care of because other things that come into perspective, as to the patient telling why they are here, what their problem is, we definitely address that. But with diabetes, what are your lifestyle changes? What have you done so far? How are you with your diet? Smoking cessation, abstinence from alcohol, stuff like that. I try to give that a priority because primary care and prevention are the key.

Kevin Pho: We are talking to Shabeena Hirani, she is a nurse practitioner. Today’s KevinMD article is “From nurse practitioner to quality improvement leader in sleep medicine.” So Shabeena, what do you have to look forward to? Talk to us about what initiatives you may be undertaking when it comes to that quality improvement piece and how that intersects with what you are doing.

Shabeena Hirani: I want to look at something wherein we are able, just like you might know, we have a citywide immunization vaccine registry, I want a level of integration of the electronic health record so that if all of these are integrated to begin with in New York City, I can open my chart and have information on when the patient went to the emergency room, when the patient went to the urgent care. If a patient was seen by the cardiologist, I should be able to have access to all of that in an integrated health care system. That way there is no duplication and replication of medications and continuity of care is maintained.

Kevin Pho: And how about those clinicians who are interested in integrating themselves more or participating more in quality improvement? Do they need to get advanced degrees or public health degrees? Tell us what kind of qualifications they may need, or is it just simply if they have the interest?

Shabeena Hirani: I think it is if they have the interest, and I think there is enough support staff that is out there for us to be implementing these things. If we are looking into, frankly speaking, making less money, talking to the patient, and looking at what is the prevention part of it, and trying to integrate all of this, I think a little bit more of it helps with our health care backgrounds and can make this much easier.

Kevin Pho: And of course, let us end with some take-home messages that you want to leave with the KevinMD audience.

Shabeena Hirani: What I think is it happens when we transform the system around patients to ensure consistency, accessibility, and improvement. So whether you are a nurse practitioner, a physician, or even an allied health professional, you should have the ability to lead from where you stand and keep the patient at the center. There are challenges, and there are so many things that we are looking at, but do not underestimate the ability to drive meaningful change.

Kevin Pho: Shabeena, thank you so much for sharing your perspective and insight. Thanks again for coming on the show.

Shabeena Hirani: Thank you, Kevin, for having me.