Dr. Mike Evans: Hi, I'm Dr. Mike Evans, and today's talk is on quality improvement or QI in healthcare. I suppose the first question is why should you or I care about quality improvement? I mean, to be honest it sounds a bit boring. Something a CEO would have on her or his corporate objectives, but actually if you dig a little deeper it's pretty cool.
Maybe more of a philosophy or an attitude about how to make something better. And now that I think about it, it's really the attitude I'm looking for in my patients. The ability and desire to tweak their habits, seeing if this change improves their live. And if it does, to try and make it standard practice.
You see, for my patients to make these changes requires skills, but it's also an outlook. The humility and self-awareness to say, "I've got room for improvement." The ability to gather better approaches, try them on and see if they work. And then adapt them until they do.
Well, if my patients can do that, I think they deserve the same from us in the healthcare business. I supposed the next question is, if we have the attitude, how do we actually improve? How do we use QI to make care better?
Well, the improvement business has been around for a while. Organizations like Toyota and Bell Labs, and leaders like Walter Shewhart, W. Edwards Deming and Joseph Juran, polished and simplified the science of improvement.
And then along came a pediatrician named Don Berwick, and he wondered if we could translate the science of building better cars or electronics to healthcare. Dr. Berwick also wondered if there were lessons about systems we could learn from the kids he saw in his clinic.
Dr. Don Berwick: The system's thinker is a perpetually curious person who never thinks they have the whole answer, but is always willing to know what the next step to take is. If you watch a child you'll see this happen. Children in their growth and development are innately system's thinkers. They're always trying the next thing, they're probing the material, they're listening to the noise, they're thinking about what the next thing to do is.
And they're not in the job of solving problems forever. They're in the job of taking the next step. I think those are elements of what it means to be a system thinker. At the core of it is constant curiosity about a world that you will never understand fully, but you might take the next step to understand a little better.
Dr. Mike Evans: Okay, we've never dropped a vid into our vids, and Don is thoughtful, so I thought it might improve our messaging. Let me know if you thought it did or didn't in our YouTube comments. Now, Dr. Berwick went on to co found the Institute for Healthcare Improvement, or the IHI, and started focusing on the low hanging healthcare improvement fruit, which is mostly reducing errors.
For example. In Canada a researcher named Ross Baker, led a study in 2004 that showed out of 2.5 million annual hospital admissions about 13.5% were having adverse events. With one in five of those people dying or experience a permanent disability. In the US the Institute of Medicine estimated that 44 to 98,000 people were dying from preventable errors every year. That's up to four jumbo jet crashes per week. Often these are errors we know how to prevent, but as is often the case knowing what's the right thing to do, and actually doing it are two different things.
In 2006 Berwick and his colleagues challenged hundreds of US hospitals to bridge this gap, and felt strongly that, "Some is not a number and soon is not a time." And so, set the goal of saving 100,000 lives in 18 months. They started with this simple notion. Every system is perfectly designed to get the results it gets, so how do you change the result? Well, you change the system that produces it. Changing the system requires change agents, and in my province we launched Health Quality Ontario. HQO and [inaudible 00:03:40] like it recognize that it's tough to balance proactive and reactive care in the field.
But if they can help, or incentivize, or nudge us towards a more reflective practice and improve outcomes we can actually create a better user experience for us all. Now, I'm making this sound simple like pushing a button, but getting people to change, even a simple behavior like hand washing, can be very complex and exasperating. But these seemingly small behaviors can have a ripple effect on health. A 2010 study calculated inadequate hand washing cause 247 deaths each day from preventable hospital infections, and that's just in the U.S.
Let's jump back to simplicity. How to improve seems to boil down to three questions and a cycle. Improvement starts by setting an aim. Question number one is, what are you going to improve? And by how much? For example. We are going to get 70% of the staff to wash their hands before and after seeing patients by December 1st. Great. We have an aim. Let's start testing some changes, okay? Not so fast. Now you need to ask question two. How will you know if a change is an improvement? We need to choose some things and measure them. What is doable and reliable? And that will tell us if the changes we are making are leading to an improvement.
Is someone documenting doctor or nurse hand washing? Is it self-report? Is it the amount of soap and disinfectant you used? Okay, we have an aim and now we have some measures. Next step is question three. What changes can you make that will lead to the improvement? To start we just want to test one change with something called a PDSA cycle. Plan the test, do the test, study the test results, and then act based on those results. Maybe it's new soap dispensers, or little bottles of gel. Maybe you read about the study that changed the signage from wash your hands to protect yourself, to wash your hands to protect your patients, which resulted in a third improvement over a two week period.
Maybe it's reward or audit and feedback, or asking patients to check. Just pick one and get started. Then you test other changes and the PDSA's just keep rolling. Fine tuning the change based on what you're learning, saying to yourself, "Here are some ways we can improve. Let's try them out by dropping them into our practice in a thoughtful way that fits with our clinic and our patients. And let's measure how we do." Adapt, adopt, or discard. Simple, right? But powerful and it actually works. At my hospital, St. Michael's in Toronto, elderly patients with fractured hips were often waiting more than two days for surgery. This wait was painful with increased chances of conditions like delirium and depression, longer recovery times, and even death.
The care team scratched their chins, mapped out and redesigned every step of the journey to surgery in order to fast track these patients. They created a code hip called as soon as the patient arrives. This streamlined them to the urgent list for surgery, rapid triage, essential testing, priority consults from anesthesia and internal medicine. And so on. All these tweaks led to a jump from 66% to over 90% having surgery within 48 hours. Now, these changes don't happen without engaging the human side of change. One thing you'll discover is that it's possible that the people you work with might not be as into hand washing or urine infections, or diabetes as you are.
I know, crazy. But this leads to three pieces of advice. First is the concept of innovation fatigue. Often your workmates are getting overloaded with requests for practice change, which are well intentioned, but can be overwhelming. My own approach is to take a page from motivational interviewing. MI recognizes some of our natural inclination as problem solvers is to fix things, provide advice and argue for change. But the reality is that not everybody is ready for change.
Both MI and QI recognize that ambivalence about change is normal. That building readiness and confidence for change, a shared agenda, requires careful listening and strategic questioning. The ability to roll with resistance. More of a dance than a directive, I would say. Actually, sometimes resistance to change can actually be an opportunity in QI. Creating diversity or disruption can actually be an opportunity, something to build on. My second point is about priorities. I think we have to acknowledge that patients and your fellow clinicians may have certain priorities on the day.
The talking about depression or headaches may trump your diabetes flow sheet, or even that focusing on their non-diabetes issue might in fact be more helpful for patient self-management. These shifting sands that transition from silo care are the reality of the emerging science of complex care. Sure, asking, What's the matter?" But also asking, "What matters to you?" A great example is in Timmins, a small town in rural Ontario where they wondered if they could do a better job of handling complex patients in the emergency department.
People seen in the emergency more than 14 times or admitted more than three times a year. They started with standard assessment tools. Identify diagnosis and related problems, generated care plans, but unfortunately patient use didn't decrease. The team then flipped their approach to what's called patient discovery, where they identified health and lifestyle challenges from the patient's perspective and combined that discovery with motivational interviewing techniques. This new patient centered approach resulted in more than an 80% reduction in emergency room use and admissions. Finally, after having done many interventions my mantra is, "How can I make it easier to do the right thing?"
Maybe easier is about sharing the load. At Kaiser Permanente front desk staff can actually check and book for preventive screening. Everyone can help in QI. All these point to the softer side of good quality improvement. Though, when we look at the science of innovation it's less about big cognitive leaps, and more about agility, and small incremental steps to build on the ideas of others and engage our own genuine curiosity regarding what motivates and inhibits the individual's and system's path to change.
The main point is, start. Find something you can improve and get going. Look, it's hard to summarize improvement and not get into bumper sticker territory, but I would advise not to let what you can't do stop you from what you can do. It's time to entertain complexity, but focus on simplicity, asking yourself, "What can I do by next Tuesday?" Have a meaningful needle and test some changes to start moving that needle towards an important goal. Hope this helps, and thanks. (Silent).