Let's begin with a video from our friends at the Institute for Healthcare Improvement, quality improvement in healthcare. Take notes on the key messages in the video and we'll compare notes at the end. Hi, I'm Dr. Mike Evans. 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? 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, pretty cool, maybe more of a philosophy or an attitude about how to make something better. Another way to think about it, it's through 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, " 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 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 Bell Labs and leaders like Walter Shewhart, W. Edwards Deming, and Joseph Juran polished and simplified the science of improvement. Then along came a pediatrician named Don Berwick. 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. The systems 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 systems 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 systems thinker. At the core of it is constant curiosity about a world that you will never understand fully, which it might take a next step to understand a little better. We've never dropped a vid into our vids. Don's thoughtful, so I thought it might improve our messaging. Let me know if you thought it did or didn't in our YouTube comments. Dr. Berwick went on to co-found the Institute for Healthcare Improvement, or the IHI. Instead of focusing on the low-hanging healthcare improvement fruit, which is mostly reducing errors. For example, in Canada researcher named Ross Baker, led a study in 2004 that showed a 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 US, Institute of Medicine estimated that 44-98,000 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. Set the goal of saving a 100,000 lives in 18 months. They started with this simple notion. Every system is perfectly designed to get the results it gets. How do you change the result? Well, you change the system that produces it. Changing the system requires change agents. In my province relies Health Quality, Ontario, HQO and others like it recognized that it's tough to bounds proactive and reactive care in the field. But if they can help or incentivize or nudges towards more reflective practice and improve outcomes, we can actually create a better user experience for us all. I'm making this sound simple like pushing a button, but getting people to change, even a simple behavior like handwashing can be very complex and exasperating. But these seemingly small behaviors can have a ripple effect on health. A 2010 study calculated inadequate handwashing caused 247 deaths each day from preventable hospital infections. That's just in the US. Let's jump back to simplicity. How to improve seems to boil down to three questions in a cycle. Improvement starts by setting an aim. Question number 1 is, what are you going to improve? By how much? For example, we are going to get 70 percent of the staff to wash their hands before and after seeing patients by December first. Great. We have an aim, so let's start testing some changes. Not so fast. Now you need to ask question 2. 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 used? We have an aim 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 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 balls 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 its reward or audit and feedback or asking patients to check. Just pick one and get started. Then you test other changes, and the PDSAs just keep rolling. Find 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, but powerful and it actually works. In my hospital, St. Michael's 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 scratch 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, they streamline them to the urgent lists 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 percent 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 leaves a three piece of advice. First is the concept of innovation fatigue. Often your work mates are getting overloaded with request for practice change, which are well intention but can be overwhelming. My own approaches to take a page from motivational interviewing and my 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 changes 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 and 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. We're talking about depression or headache may trump your diabetes flow sheet or even that focusing on their non diabetes issue might in fact be more helpful for patients self-management. The shifting sense that transition from siloed care or the reality of the emerging science of complex care. So 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, identified diagnoses and related problems generated care plans, but unfortunately, patient use didn't decrease. The team then flip their approach to what's called patient discovery, where they identified health and lifestyle challenges from the patient's perspective and combine that discovery with motivational interviewing techniques. This new patient-centered approach resulted in more than an 80 percent 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 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 points to the softer side of good quality improvement. That when we look at the scientific innovation, it's less about big cognitive leaps and more about agility and small incremental steps that build on the ideas of others and engage her own genuine curiosity regarding what motivates and inhibits the individual and Systems path to change. The main point is start, find somewhere 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. I hope this helps and thanks. Let's reflect on some of the key messages in the video. What did you know? Did your notes include the importance of starting with something you can improve and get going, making small incremental improvements versus looking for big, giant leaps, making simple changes in complex situations is progress? Change agents in the power of motivating others to change, adopting, adapting, or discarding small changes. Some changes will work as is, others will require modification, and others just need to be discarded. Disruption and change as an opportunity to build. Change can feel chaotic, but the process actually invites new opportunities to strengthen the organization. Focusing on simplicity and asking yourself, what can I do by next Tuesday? Incremental short-term wins contribute to achieving the strategic long view. There are several models for continuous quality improvement, CQI, but all of them focus on the idea of incremental improvement that can be measured and modified quickly. There is a time and place for quality improvement activities that take years to implement and longer still to determine if they are successful. In value-based care, there are many more opportunities to make a series of smaller improvements that over time result in significant changes. In addition to a deep dive into the PDSA model mentioned in the video in this module, you will explore other CQI models including six Sigma, Lean, and Agile techniques.
