Quality Improvement in Healthcare

Quality Improvement in Healthcare

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.


76 thoughts on “Quality Improvement in Healthcare”

  • I think it would be good to include videos into your videos. Just make sure there are not too many and they're kept short. I still want to see your drawings!

  • Christopher Herdman says:

    I love these videos so, so much.
    I agree video in video is fine but so long as short and not detracting from Liisa's amazing work.


  • Vids in Vids work when kept short and relevant. Sometimes the best way to say something comes from the person who said it. I say keep it. 
    Of note, I've been involved in QI in US Navy hospitals for years. Your talk describes Franklin Covey's 4 Disciplines of Execution approach (similar to your PDSA) and the end of your video describes Appreciative Inquiry (building on the ideas of others). 
    I've seen many ways to slice it, but in the end, you nailed it with staff attitude. 20% of your staff are the go-getters trying to influence 60% of the staff to think like they do. (The last 20% are averse to change and generally can't be helped). 
    Great videos – keep them coming!

  • Courtney Francis says:

    @DocMikeEvans i am Dyslexic and enjoy your videos very much.  For me personally i rather not to see a person as this extra stimuli is a little distracting. 

    let me explain
    When i see characters  I rather them to be neutral if possible (without gender, features) kind of like a cartoon or shaded character. I did find that i was paying more attention to what Dr Don was wearing and his hair trying even trying to figure out his cultural identity.

    a quick suggestion alternative to a visual video maybe using audio only instead would be meeting you part way.  

    just a thought but i wonder if others also felt or did the same. 


  • Great video and videos overall. Topics that make one think and superbly presented. Embedded videos are fine as long as they contextual snippets kept at a reasonable length. 

  • The "vid in a vid" was most definitely helpful, Dr. Evans.  Thanks for your fantastic educational videos.  Please keep them coming!

  • What would motivate a for-profit hospital to reduce ER visits and admissions? It seems that fixing perverse profit incentives must be a key part of QI, making universal healthcare a notable objective. 

  • OMG!!!- your introduction to QI ia faaaaantastic. Its just what I was looking for. A breif intervention for QI ludites. EVERYONE should watch it.

  • Gwendolyn Howard says:

    Enjoyed your Video!!! I'm a visual learner. The concepts and images you used created a mental picture of what continuous quality improvement means.Good Job!

  • Tracey Warrener says:

    Dr Mike Evans,  I am so happy to have found you! Thank you for a great and simple presentation.  This is really helpful in the UK also.

  • Thank you I really enjoyed this. It was fast paced (I had to press pause a few times to make notes !!) but that wasn't a problem and the cartoons provided energy. I thought a video within this video worked well.

  • Excellent simple video, thank you!…wish this could be the intro to the QI concept in medical school and residency as this is so much more engaging than that with which we're usually presented!

  • I find it of the upmost importance to ensure that healthcare improves. Many people are killed or injured from simple error of healthcare professionals. I understand some mistakes can simply not be avoided and we are indeed human, but many mistakes are just careless error and I find this unacceptable. I believe healthcare workers should always make quality healthcare their first priority, and do their best to leave their personal lives 'at the door' as they walk into work. I found it astonishing that one study showed that 247 deaths happen each day from hospital infections in the US from inadequate hand washing. This is an area that can easily be fixed by paying close attention to basic standards of healthcare. I agree with the videos three standards of change. Simple practices such as documenting hand washing can make a huge difference in the future. I also agree with how difficult it may be to get people to change. With collaboration and time, I believe it can get done. One study showed the importance of patient centered care, and how it increased quality improvement in healthcare. As a future OT, client centered practice is one area that we always focus on. My professors always stress the importance of making the treatment meaningful to the individual for maximal benefit. I am glad to see that other practices are adopting this mindset as well.

  • Kaitlyn Lipinski says:

    There are a lot of improvements that can be made to our healthcare system, starting with the amount of patients killed due to doctors mistakes. When it comes to being a doctor it is about treating people and even saving lives, some are the careless mistakes made as the video mentions cost so many individuals their life. Something like hand washing causing 247 each day should not be happening. It is sad to think that there are so many infections caused simply because doctors are not properly washing their hands. By changing the system we can lower the amount of negative outcomes in the healthcare field. By making changes and measuring the improvement, there can be a positive impact on patient care. The number of deaths caused by easily avoidable mistakes  should be much lower and can be reduced to improve the quality of healthcare people receive.

  • Is hanging a different handwashing sign really something that gives a sustained effect, or is that a short-term "Hawthorne Effect" at work? Dr. Deming would have taught to look at data over time, not just a two data point comparison of before and after.

  • Elizabeth Guglielmi says:

    It is absolutely startling that 44,000-98,000 people in the U.S. are dying from preventable errors every year. Health Care Management companies, such as Blue Cross & Blue Shield, have made dramatic improvements in cost due to enforced policies with their members. By creating financial incentives (or financial penalties) to encourage people to exercise or quit smoking, wellness incentives have become the norm in health care management. What previously was considered intrusive by employees, has become the norm in corporate America.  It seems the time is right to use these same types of incentives with providers to reduce errors and improve outcomes. This could include financial surcharges on providers or health systems if certain metrics are not met, or financial bonuses if the metrics are exceeded.

  • The American health care system has serious problems with quality and safety. Ethical issues arise in QI because attempts to improve the quality of care for some patients may sometimes inadvertently cause harm, or may benefit some patients at the expense of others, or may waste limited health-care resources. Ethical issues also arise because some activities aimed at improvement have been interpreted as a form of medical research in which patients are used as subjects. Is this the most effective and reasonable way to regulate QI to ensure that it is carried out in an ethical fashion?

  • Everyday we try to improve something about ourselves or the way we go about things. Some improvements are so minuscule that we do not even notice them. However, something we can all appreciate is the quality improvement of healthcare. Some errors are over looked and do not even come into discussion where we can improve. Take the washing hand statistic. 44,000-98,000 people in the U.S. die from preventable errors every year. We do not need to flip the entire system, but the objective is to become more efficient in what we do in the healthcare field. With improvement comes change and not everyone is okay with change. As Dr. Evans stated "people can become overwhelmed with change." As humans we like to be set in routines that go smoothly. Any bump in the road can steer us in the wrong direction and become lost. Small changes can be good and overtime can accumulate into something greater. Take the study of fractured hip patients in St. Micheal's Hospital. The tweak in the system of getting to the patients in the ER bumped the percentage of patients receiving surgery in a 48 hour period from 66% to 90%. Even though not every change will make that big of an impact it is still a goal to improve.

  • Many of us look for our doctors to take care of our every dying need, for them to make sure we healthy. When in all actuality it starts with us. We have to make sure we improve ourselves, in our daily lives. Making sure we eat right, don’t smoke, and just making sure we are taking the right steps in order to make less visits to our doctors. When they say it’s in our attitude that is very much true, because having a negative attitude about things will not make anything better for the situation. It is a good thing for you to keep trying if one thing doesn't work. It’s a process of trial and error, just as long as you make it to whatever works for you. And once you find that one thing stick to it until you need to switch to another strategy. Don Berwick was one to realize that he could learn from the kids he saw in his clinic, which is a god thing because even the young ones can teach you some new things. The system thinker is one who is always curious, who doesn't know the whole answer but take the proper steps to get to the next step. Children are by nature System thinkers by Berwick. By changing the way we live our lives could decrease the negative outcomes of health care.

  • PDSA cycle "developed by Associates in Process Improvement? Gosh, and there I was believing it was developed by Dr Deming from Dr Shewhart – which Deming had the grace to call the Shewhart cycle. But clearly API got there before Deming in 1950 and Shewhart in the 1930's. So API must be at least 80 years old, must it not?

  • Loved the video! As a Public Health student studying for an upcoming exam on quality of care, hearing about quality improvement in an easily understandable way is quite helpful. 🙂

  • A wonderful video with a great message.  Thank you, Dr. Mike!  I will be sharing this and your other videos with my healthcare students in the future.

  • Dr Mike;
    An excellent and "good news" presentation. Some of the improvements obtained were really amazing. The dropped-in video was a very good idea. It lets us see the human face of improvement.

    One comment about quality improvement and control. In industry, the word quality means making sure that the standards and procedures are followed exactly.But when this word gets it out of its cage and into the hands of non technical and or non business types like medical practitioners, its meaning changes. This is no surprise, the general population thinks of quality as well designed, effective, reliable and even beautiful.

    What you are really talking about with these improvements, as Deming would say, is "continuous improvement" of a delivery system, or "kaizen" in Japanese. As examples, quality control of handwashing is making sure that doctors and nurses do this exactly as instructed. Quality improvement and continuous improvement gets more interesting. Now you ask are they all using enough soap and washing long enough? Do all the dispensers contain the same soap? Are the ingredients really anti-bacterial?
    Are there better, more expensive ingredients that are much more effective? Some harmful ingredients were removed from the dispensers in hospitals last year. There are no signs or recordings warning people with colds to wear masks as they enter the hospital !!

    Now when we come to continuous improvement, you touched on this in your video, when you said we must be sure that the handwashing really works. A systems approach would look at all factors that cause illness in the hospital setting. This gets back to what you did in your 23-1/2 hour video. Viruses are very common causes of diseases in emergency rooms. Why don't doctors and nurses wear masks when they themselves are breathing the air around patients and carrying the viruses from room to room? Why are old bandages, pads and syringes often seen on the floor of emergency rooms? Are the rooms really cleaned thoroughly? What are the most effective ways to really scrub C. Diffficile and other nasty viruses from rooms? Hydrogen peroxide? Irradiation of rooms? What about the air filtration systems in hospitals?

    Yes, it gets very complicated and expensive quickly. But some of the low hanging fruit is not being plucked. Doctors and nurses do not wear masks all the time, probably because they don't wearing them. When they tried to force nurses who didn't get the flu shot to wear masks, this was more about forcing everyone to comply and support the drug industry than help patients.The chemicals used to wash floors and walls do not appear to be especially effective. Like you say, it's actually very fascinating, not boring.

  • A very insightful video and applicable to more than just the healthcare system. The methods discussed can be used in people's day to day lives to achieve personal goals, as well as to improve business productivity, and processes involved in specific industries. It seems a huge problem we have is to focus on the problems but we forget that we have the power to change them. It may not be possibly to implement a quick fix to rectify an issue, however, with small steps that lead to a planned goal, change can be implemented.

  • Great video as always! Do you happen to have a link to the study you mentioned (at 5:35) regarding a handwashing poster creating a 1/3 improvement in handwashing over a 2 week period?

  • JehovahTsidkenu says:

    Thank you for the information. I am looking for information on the Donebedian model and found this. You make the process a little easier to understand. Just need more input at this time. P.S. The vid-in-vid is a nice touch.

  • JehovahTsidkenu says:

    Is there a way to review the study you reference about the hospital in Timmins? I am working toward my MPH and writing a piece on using the Donebedian Model to improve patient outcomes. Thank you for your help.

  • I agree with this video. If doctors and physicians expect their patients to adjust their daily life, patients should be able to expect health care professionals to do the same. There is a difference between recognizing something is wrong in healthcare, compared to knowing how to prevent it. Seemingly small behaviors such as improving hand washing technique can have a positive ripple effect throughout the healthcare system. Healthcare needs to be able to measure if changes actually lead to improvement. In the video they discussed the PDSA cycle and I highly agree with it. However, I feel that most hospitals either disregard or slack when it comes to this cycle. If hospitals are motivated enough to see improved they will do this cycle of planning a change, doing the change, study the change results, then act on those results. Health care professionals need to adapt, adopt, or discard the results of these changes. I believe hospitals and their employees need to view this video and learn more about quality improvement.

  • While it may seem that both the pros and cons of screening seem almost hand in hand, the choice to do annual screening tests. Even though sometimes these test can be a little misleading and not as black and white as we hope. But some knowledge is better than no knowledge. Also even though some of the test that are run are not very beneficial for those who are not at risk, it does help those who are. By getting screened for certain diseases the general knowledge of the overall health of people can be better looked upon. With some of the test creating false advertising of a patient's health, I believe that it is worth the time and effort. If I am misdiagnosed with something that I do not have, is definitely better than not taking the chance to even knowing where my health is even at. As far as being misdiagnosed with nothing when actually there is something wrong, that is just the something that comes with life. No one is ever perfect, and most diseases are hard to catch to begin with. It is just the chance that you are willing to take if you are willing to benefit and further your knowledge of your own personal health.

  • Congrats! This video was very instructional and fun at the same time. I find the way you included the video was great: short, right to the point and it felt like it belonged with the drawings.

  • I enjoyed watching and learning from your video. The drawings along with the words and narration made it very easy to understand and apply the knowledge. Thanks!

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  • Bob Emerson
    I am currently working on my degree in Healthcare management. There are many articles and publications available for research.
    This information is direct and to the point. As a healthcare provider and manager we put too much emphasis on the big picture. I enjoyed this article because the Patient Discovery and Motivational Interviewing is it is what is all about.

    Thank You

  • Appreciate the video. A lot covered with use of the drawings.  Starting simple is best. Making small incremental steps is what many of us overlook. Thanks for reminding me of what is necessary to be a change agent.  keep them coming.

  • Joselyn Hernandez Galvan says:

    i really liked the video within the video to help clarify!!! plus your voice is so soothing thank you so much for that clarification

  • This was a very helpful video to me by teaching me, by thinking about how every step no matter how small is, is a step towards future end goal.

  • Great video and good examples. I actually discovered I actually discovered IHI during my MBA and used QI techniques partly learned from the organisation.

  • I know this is a little late…but I liked the video in a video. Helps put pieces together as I've used some IHI stuff before. Thanks!

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