Quality Improvement in Healthcare
Mike Evans and today's talk is on quality improvement or qi in healthcare so 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 SEO would have on her or his corporate objectives but actually if you dig a little deeper pretty cool maybe more of a philosophy or an attitude about how to make something better I know that I think about it it's really the attitude I'm looking for my patients the ability and desire to tweak their habits seeing if this change improves their life and if it does to try and make it standard practice you see for my patients to make these changes require skills but it's also an outlook the humility and self-awareness to say hmm 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 so I suppose 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 Bao Labs and leaders like Walter Stewart 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 at his clinic the systems thinker is is a is a perpetually curious person who never thinks they have the whole answer but is always willing to know what the next step take is if you watch a child you'll see this happen children and their growth and development are innately systems thinkers they're always trying the next thing they're 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 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 okay we've never dropped a vid into our vids you know and and Don is thoughtful so I kind of thought it might improve our messaging let me know if you thought it did or didn't in our YouTube comments dr.
Burwick went on to co-found 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 of 2.
5 million annual hospital admissions about 13.
5 percent were having adverse events with one in five of those people dying or experiencing a permanent disability in the u.
Institute of Medicine estimated that 44 to 98 thousand people were dying from preventable errors every year that's up to four jumbo jet crash often these are errors we know how to prevent but 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 said the goal of saving a hundred thousand 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 realize health quality Ontario HQ oh and an order to like it recognise that it's tough to balance proactive and reactive care in the field but if they can help or incentivize or not just towards a more reflective practice and improve outcomes we can actually create a better user experience for us all now making the sounds 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 cost 247 deaths each day from preventable hospital infections and that that's just in the u.
so let's jump back to simplicity how to improve seems to boil down to three questions in a cycle improvement starts by setting a name so question number one is what are you going to improve and by how much so for example we are going to get 70 percent of the staff to wash their hands before and after seeing patients by December 1st great we have a name so let's start testing some changes okay not so fast now you need to ask question – how will you know if it changes 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 used okay we have a name and now we have some measures next up is question 3 what changes can you make that will lead to the improvement to start we just want to test one with something called a PDSA cycle plan the tests do the test study the test results and then act based on those results maybe it's new soap dispensers or little bottles with 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 its reward or audit and feedback or asking patients to check just pick one and get started then you test other changes and the PD essays 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 let's measure how we do adapt adopt or discard simple right but powerful and it actually works at my hospital st.
Michaels in Toronto elderly patients with fractured hips were often waiting more than two days for surgery this way it 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 a patient arrives the streamline 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 a three piece 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 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 the 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 the patience and your fellow clinicians may have certain priorities on the day the talking about depression or headaches may trump your diabetes flowsheet or even that focusing on their non diabetes issue might in fact be more helpful for patient self-management be shifting sands the transition from silo care or 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 Timmons a small town in rural Ontario where they wondered if they could do a better job of handling complex patients in the emergency department so people seen in the emergency more than 14 times or admitted more than three times a year they started with standard assessment tools identified 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 centred approach resulted in more than an 80% reduction in emergency room use in admissions finally after having done many interventions my mantra is how can I make it easier to do the right thing maybe easier it's 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 points of the softer side of good quality improvement then when we look at the science of innovation it's less about big cognitive leaps and and more about agility small incremental they build on the ideas of others and engage their own genuine curiosity regarding what motivates and inhibits the individual and systems 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 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 but focus on simplicity asking yourself what can I do by next Tuesday I have a meaningful Nederland and test some changes to start moving that needle towards an important goal hope this helps and thanks.