Quality Improvement in Healthcare

Summary

Dr. Mike Evans discusses the importance of quality improvement (Q.I.) in healthcare, emphasizing the philosophy of continuous enhancement. He highlights the role of systems thinking, inspired by children's curiosity, and the need for change agents. Evans outlines a simple Q.I. cycle involving setting goals, measuring progress, and implementing changes through PDSA cycles. He stresses the human aspect of change, addressing innovation fatigue and prioritizing patient-centered care. The talk concludes with a call to action: start small, focus on simplicity, and make a meaningful impact.

Takeaways

• 😌 **Quality Improvement Mindset**: Quality improvement (QI) is not just a process but a philosophy and attitude aimed at making healthcare better.
• 🏥 **Importance in Healthcare**: QI is crucial in healthcare as it can lead to better patient outcomes and standardize effective practices.
• 👨‍⚕️ **Patient-Centered Approach**: Patients should be encouraged to adopt a QI mindset to improve their health habits, which healthcare providers should mirror.
• 🚀 **Historical Influences**: The science of QI has been developed and refined by leaders from various industries, including automotive and electronics.
• 👶 **Learning from Children**: Children's natural curiosity and systems thinking can inspire QI approaches in healthcare.
• 🔍 **System Thinking**: Systems thinkers are perpetually curious, always looking for the next step to improve without claiming to have all the answers.
• 📉 **Reducing Errors**: A significant focus of QI in healthcare is reducing medical errors, which are often preventable.
• 🌐 **Global Impact**: The impact of QI is global, with studies showing significant reductions in adverse events and errors in healthcare.
• 🔄 **PDSA Cycle**: The Plan-Do-Study-Act (PDSA) cycle is a fundamental tool in QI, allowing for testing and refining changes in practice.
• 🤝 **Engaging Change**: Effective QI requires engaging the human side of change, understanding resistance, and building readiness for improvement.
• 📈 **Measurable Goals**: QI initiatives should have clear, measurable goals to track progress and determine the success of implemented changes.
• 👥 **Patient-Centered Priorities**: QI should prioritize patient-centered care, focusing on what matters most to the patient for effective self-management.
• 💡 **Innovation Fatigue**: It's important to recognize the potential for innovation fatigue and approach change with careful listening and strategic questioning.
• 🔑 **Start Small**: The key to successful QI is to start with small, incremental changes that can be measured and adapted over time.

Q & A

Why is quality improvement important in healthcare?

Quality improvement is crucial in healthcare because it focuses on enhancing patient outcomes, reducing errors, and making care more efficient. It's about adopting a philosophy of continuous improvement to ensure patients receive the best possible care.

What is the role of attitude in quality improvement?

Attitude plays a significant role in quality improvement as it involves a mindset of constant learning, humility, and self-awareness. It's about being open to change, willing to experiment with new approaches, and adapting them until they work effectively.

How did leaders like Walter Shewhart, W. Edwards Deming, and Joseph Juran contribute to the field of quality improvement?

These leaders contributed by developing and simplifying the science of improvement. They introduced systematic approaches and methodologies that are now widely used in various industries, including healthcare, to improve processes and outcomes.

What did Dr. Don Berwick do to apply the principles of quality improvement to healthcare?

Dr. Don Berwick founded the Institute for Healthcare Improvement (IHI) and focused on applying the principles of quality improvement to healthcare. He challenged hospitals to reduce errors and improve patient safety, setting ambitious goals like saving 100,000 lives in 18 months.

What is a PDSA cycle and how does it relate to quality improvement?

A PDSA cycle is a four-step iterative process used for quality improvement: Plan, Do, Study, and Act. It allows for testing changes, studying the results, and then acting on the findings to make further improvements.

How can healthcare professionals measure if a change leads to improvement?

Healthcare professionals can measure improvement by selecting measurable and reliable indicators related to the change. For instance, in handwashing initiatives, they might measure soap usage, self-reports, or audits to see if the change is leading to an increase in handwashing compliance.

What is the 'Code Hip' initiative mentioned in the script?

The 'Code Hip' initiative is a system designed to fast-track elderly patients with hip fractures for surgery. It involves a rapid response protocol that includes urgent listing for surgery, priority consultations, and essential testing to ensure patients receive timely care.

Why is it challenging to get healthcare professionals to adopt new practices?

Adopting new practices can be challenging due to innovation fatigue, where professionals are overwhelmed by too many requests for change. It requires building readiness and confidence for change, often through careful listening and strategic questioning.

How can healthcare systems better engage patients in their care?

Healthcare systems can engage patients by adopting a patient-centered approach, which involves understanding health and lifestyle challenges from the patient's perspective and using motivational interviewing techniques to align care with the patient's priorities and goals.

What is the significance of the phrase 'How can I make it easier to do the right thing?' in the context of quality improvement?

This phrase emphasizes the importance of creating systems and environments that facilitate doing the right thing. It's about making it as easy as possible for healthcare professionals to follow best practices and provide high-quality care.

What advice does Dr. Evans give for starting quality improvement efforts?

Dr. Evans advises starting with something small that can be improved and not letting what you can't do stop you from what you can do. He suggests focusing on simplicity, setting a goal for the near future, and testing changes to move towards that goal.

Outlines

00:00

🧠 Why Quality Improvement Matters in Healthcare

Dr. Mike Evans introduces the concept of Quality Improvement (Q.I.) in healthcare, initially presenting it as potentially boring but later emphasizing its importance. He draws parallels between patient self-improvement and the healthcare system’s need to adapt for better outcomes. By referencing industrial leaders like Toyota and Bell Labs, he highlights how these systems-thinking approaches can be applied to healthcare. Pediatrician Don Berwick’s perspective on systems thinking, using child development as an analogy, is explored. This foundational attitude of curiosity and constant improvement is key to enhancing healthcare.

05:00

🚨 The Impact of Preventable Errors in Healthcare

The paragraph explores the shocking statistics of preventable healthcare errors, such as the 44,000 to 98,000 annual deaths in the U.S., equating this to multiple jumbo jet crashes weekly. Dr. Berwick's I.H.I. initiative aimed to reduce these errors by setting clear goals like saving 100,000 lives in 18 months. The principle of changing systems to alter results is emphasized, underscoring that real improvement requires systemic changes, such as Health Quality Ontario (HQO)'s efforts. Small behaviors, like handwashing, are highlighted as crucial for reducing preventable deaths, showing how even simple actions can have widespread impact.

10:02

🔄 The PDSA Cycle: A Simple Approach to Improvement

This paragraph breaks down the three essential questions for driving improvement in healthcare, starting with identifying the specific goal for improvement. Using the example of increasing handwashing compliance, it explains how to measure improvement and introduces the PDSA cycle (Plan, Do, Study, Act). The text illustrates how even small changes, like altering signage or installing new soap dispensers, can lead to significant improvements. It emphasizes the continuous testing and refining process needed to optimize changes and embed them into daily practice, demonstrating the power of incremental adjustments.

🏥 Hip Fracture Surgery: A Case Study in Systemic Change

Through the example of hip fracture surgery delays at St. Michael’s Hospital in Toronto, the paragraph explains how system redesigns can lead to improved patient outcomes. By implementing a 'Code Hip' process to prioritize elderly patients for surgery, the team was able to reduce wait times significantly, increasing the percentage of surgeries performed within 48 hours. This highlights how systemic improvements, driven by human engagement and collaboration across healthcare teams, can drastically improve the quality of care and reduce patient suffering.

👩‍⚕️ The Human Side of Quality Improvement

This section addresses the challenges in driving behavior change among healthcare professionals. It emphasizes that not everyone shares the same enthusiasm for certain healthcare initiatives, and this resistance can be leveraged as an opportunity for improvement. The concept of 'innovation fatigue' is discussed, recognizing that staff can become overwhelmed by constant demands for change. Using motivational interviewing techniques, the text suggests a more empathetic and patient-centered approach to fostering change, making healthcare more adaptable to individual and system needs.

📊 The Importance of Prioritization in Complex Care

Here, the text delves into how shifting priorities in healthcare, especially in complex care, can affect the focus on specific health outcomes. Using an example from Timmins, Ontario, where a new patient-centered approach was used to address frequent emergency room users, it shows how prioritizing patient discovery and motivational interviewing resulted in an 80% reduction in emergency use. The message is that understanding what matters to patients, alongside traditional clinical care, is key to improving health outcomes and providing more holistic care.

💡 Making It Easier to Do the Right Thing

This section stresses the importance of making quality improvement easier for healthcare workers by sharing the load across all levels of staff. Examples like Kaiser Permanente, where front desk staff can book preventive screenings, show how empowering all members of the healthcare system to contribute to Q.I. can lead to better outcomes. The text emphasizes that innovation in healthcare often comes from small, incremental steps rather than dramatic leaps. It encourages starting with manageable improvements and building momentum through continuous curiosity and adaptation.

🎯 Start Simple, Focus on What You Can Do Now

The final paragraph wraps up the discussion by encouraging a balanced approach to healthcare improvement, urging individuals to focus on simple, actionable changes they can implement immediately. By testing small interventions and building from there, healthcare workers can begin to move the needle toward meaningful goals. The key takeaway is that despite the complexity of healthcare systems, starting with small, focused improvements can lead to significant progress over time.

Keywords

💡Quality Improvement (Q.I.)

Quality Improvement, often abbreviated as Q.I., refers to the ongoing effort to enhance the effectiveness, efficiency, or quality of healthcare services. In the video, Dr. Mike Evans discusses the importance of Q.I. in healthcare, emphasizing it as not just a set of processes but also a philosophy or attitude aimed at making healthcare services better. The video illustrates Q.I. through examples such as reducing hospital errors and improving patient outcomes.

💡Systems Thinker

A systems thinker is someone who understands and analyzes the way different parts of a system work together. In the context of the video, Dr. Berwick describes systems thinkers as perpetually curious individuals who are always looking for the next step to take, similar to how children explore and learn about their environment. This mindset is crucial for quality improvement as it encourages a holistic approach to problem-solving in healthcare.

💡Institute for Healthcare Improvement (IHI)

The Institute for Healthcare Improvement, known as IHI, is a leading organization focused on the science and practice of improving healthcare systems. Dr. Berwick, mentioned in the script, founded IHI to apply principles of improvement from other industries to healthcare, aiming to reduce medical errors and enhance patient safety.

💡PDSA Cycle

The PDSA cycle is a four-step model for actions: Plan, Do, Study, Act. It is a systematic method for testing and refining changes to improve a process. In the video, Dr. Evans explains how the PDSA cycle can be used in healthcare to test small changes, learn from the results, and then make further adjustments to improve practices, such as increasing handwashing compliance among hospital staff.

💡Health Quality Ontario (HQO)

Health Quality Ontario, or HQO, is a provincial advisor in the Canadian province of Ontario, focused on improving the quality of healthcare services. The video script mentions HQO as an example of an organization that helps healthcare providers balance proactive and reactive care, aiming to improve patient outcomes and overall healthcare experiences.

💡Adverse Events

Adverse events in healthcare refer to unintended injuries or complications that result in death, disability, or prolonged hospital stays. The video cites a study by Ross Baker that showed a significant percentage of hospital admissions involved adverse events, underscoring the need for quality improvement initiatives to reduce such occurrences.

💡Motivational Interviewing

Motivational interviewing is a patient-centered counseling method that helps individuals identify their own motivations for change. In the video, Dr. Evans suggests adopting strategies from motivational interviewing to help healthcare providers and patients embrace changes that improve care. This approach is contrasted with the more directive style of problem-solving.

💡Patient-Centered Care

Patient-centered care is an approach to healthcare that prioritizes the patient's values, needs, and preferences in all clinical decisions. The video gives an example from Timmins, Ontario, where a shift to patient-centered care, including motivational interviewing techniques, led to a significant reduction in emergency department use and hospital admissions.

💡Innovation Fatigue

Innovation fatigue refers to the exhaustion or resistance that can occur when individuals are overwhelmed by too many requests for change. Dr. Evans discusses this concept in the context of healthcare providers who may be asked to adopt numerous new practices or protocols, suggesting a more thoughtful approach to implementing change.

💡Complex Care

Complex care in healthcare addresses the needs of patients with multiple chronic conditions or other complicating factors that require a comprehensive, coordinated approach. The video mentions the emerging science of complex care and the importance of understanding and addressing patients' priorities in their care.

💡Code Hip

Code Hip is a protocol mentioned in the video that was implemented at St. Michael's Hospital in Toronto to expedite surgery for elderly patients with hip fractures. This initiative is an example of a targeted quality improvement intervention that significantly reduced wait times and improved patient outcomes.

Highlights

Quality improvement in healthcare is more than just a process; it's a philosophy and attitude towards making things better.

Patients' ability to treat their habits and see if changes improve their life is mirrored in healthcare providers' approach to Q.I.

Skills and outlook, such as humility and self-awareness, are crucial for quality improvement in healthcare.

The science of improvement has been developed by organizations like Toyota and leaders like W. Edwards Demming.

Dr. Don Berwick applied the science of improvement from industries like car manufacturing to healthcare.

Children are natural systems thinkers, always probing and taking the next step, which is a mindset to adopt in Q.I.

Dr. Berwick founded the Institute for Healthcare Improvement (IHI) to focus on reducing healthcare errors.

A study by Ross Baker showed that a significant percentage of hospital admissions resulted in adverse events.

The Institute of Medicine estimates a large number of deaths from preventable errors in the U.S. annually.

Berwick and colleagues challenged hospitals to save 100,000 lives in 18 months by improving systems.

Every system is perfectly designed to get the results it gets; to change results, change the system.

Health Quality Ontario was launched to balance proactive and reactive care and improve outcomes.

Small behaviors like handwashing can have a significant ripple effect on health outcomes.

Improvement starts with three questions: What are you going to improve, how will you know, and what changes will you make?

The PDSA cycle (Plan, Do, Study, Act) is a method for testing and refining changes in healthcare processes.

At St. Michael's Hospital, a 'Code Hip' initiative reduced the wait time for surgery in elderly patients with hip fractures.

Engaging the human side of change is crucial for successful implementation of Q.I. initiatives.

Innovation fatigue is a real concern; it's important to build readiness and confidence for change.

Patient-centered approaches, like 'Patient discovery,' can lead to significant reductions in emergency use and admissions.

The mantra for Q.I. should be making it easier to do the right thing, which involves sharing the load and involving everyone.

Start with something small you can improve and build from there; focus on taking the next step.

Transcripts

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.