Hi, Dr. Mike Evans, and today’s talk is on
quality improvement, or Q.I., in healthcare. So I guess the first question is why should
you or I care about quality improvement? I mean, to be honest, it sounds
a bit boring. [snoring] Each CEO would have his or her corporate objectives, but actually if you dig a little deeper, it is pretty cool, maybe more a philosophy or attitude about how to make something better. And now that I think about it, it is really the attitude that I am looking for in my patients, the ability and desire to treat their habits, seeing if this change improves their life, and if it does, to try to make it standard practice. You see, for my patients to make these changes requires skills, but it is also an outlook, like humility and self-awareness to say, “Hmmm, I’ve got room for improvement,” the ability to gather better approaches, try them on, see if
they work, and then adapt them until they do. Well, if my patients can do that, then 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 Q.I. 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 Demming, 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. Berwick] 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 will 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 are listening to the noise. They are thinking about what the next
thing to do is, and they are not in the job of solving problems forever. They are in the job of taking the next step. I think those are elements of what
is means to be a systems 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. Evans] Okay. We never dropped a vid
into our vids, and Don is thoughtful, so I kind of thought to improve our messaging. Let me know if you thought it did or
didn’t in your You-Tube comments. [typing] Now, Dr. Berwick went onto found the Institute
for Healthcare Improvement or the I.H.I., and started focusing on the low-hanging
healthcare improvement fruit, which is mostly reducing errors. For example, in Canada, a researcher named Ross Baker lead a study in 2004 that showed out of 2.5 million annual hospital admissions, about 13.5% were having adverse events with one of five of those people dying or
experiencing a permanent disability. In the U.S., the Institute of Medicine estimates 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. As often is the case, knowing the right thing to do and actually doing it are two different things. In 2006, Berwick and his colleagues challenged hundreds of hospitals to bridge this gap. They felt strongly that “some” is not
a number, and “soon” is not a time. They 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 providence, we launched Health Quality Ontario, HQO in order to recognize that it’s tough to balance proactive and reactive care in the field, but if they can help or inventivize
or nudge us toward a reflective practice and improve outcomes, we can actually
create a better user experience for us all. Now, I am 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. The 2010 study calculated inadequate
handwashing caused 247 deaths each day from preventable hospital infections, and that’s just in the U.S., so let’s jump back to simplicity. How to improve seems to boil down
to three questions in a cycle. Improvement starts by saying 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%
of the staff to wash their hands before and after seeing patients by December 1st. Great, we have a name. So let’s start calculating some changes, okay? Mmmm, 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 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 handwashing? Is it self-report? Is it is the amount of soap and disinfectant 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,
something called a PDSA cycle. Plan the test. Do the test. Study the test results, and
then act based on those results. Maybe it is it is new soap
dispensers or little balls of gel. Maybe it is the study that changed the sign
from, “Wash your hands to protect yourself,” to, “Wash your hands to protect your
patient,” which resulted in a third improvement over a two-week period. Maybe it is reward or audit and
feedback or asking patients to check. 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
are learning, saying to yourself, hmmm, here are some ways we can improve. Let’s try them out by dropping them into
your 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. Michael’s in Toronto, elderly
patients with hip fractures were often waiting more than two days for surgery. [clock ticking] This wait was painful with increasing
chance of delirium and depression, longer recovery times, and even death. The care team scratched their chins, mapped
out and redesigned every step in the journey to surgery in order to fast-track these patients. They created a “Code Hip,” called
as soon as the patient arrives. They 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 66 to 90%
having surgery within 48 hours. Now, these changes don’t happen without
engaging the human side of change. One thing you will discover is that it is possible that people you work with might not be as into handwashing or urine infections
or diabetes as you are. I know, crazy! But this leads to a three pieces of advice: First, there is the concept of innovation fatigue. Often your work mates 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, and I might recognize that some of our natural inclinations 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 M.I. and Q.I. 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 Q.I. 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 diabetes may trump your flow sheet, or even focusing on non-diabetes issues, might, in fact, be more helpful for patients’ 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, 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 diagnoses and related problems, generated care plans, but
unfortunately patient use didn’t decrease. The team then flipped their approach
to what is 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 use and admissions. Finally after having done many
interventions, my mantra is: How I can 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 preventative screening. Everyone can help in Q.I. All of these point to the softer side of quality improvement, that when we look at the science of innovation, it is less about big cognitive leaps and more about agility, small incremental steps that build on the ideas of others and engage your
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 is hard to summarize improvement
and not get into bumper sticker territory, but I would advice not to let what you
can’t do stop you from what you can do. It is 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.