Sunday, February 3, 2013

Our journey toward crossing the quality chasm - musings from the Intermountain ATP course

I spent all last week in Salt Lake City, Utah, at one of the worldwide recognized most prestigious academic activities in quality and patient safety - the Intermountain Advanced Training Program in Healthcare Delivery Improvement, which is taught by a veritable pantheon of healthcare quality improvement colossus leaded by Dr. Brent James.

This course is a 20 days course, taught over 4 weeks (one week each month for 4 months), and the attendees are the quality leaders in different institutions - all really smart and engaged individuals with a substantial amount of experience and knowledge in the field - several with 2 or 3 master degrees (MMM or MMA or MBA plus a MS or MPH). However, despite their knowledge and training, still something is missing. It is a fascinating experience to network with such a phenomenal group of professionals with a common goal - provide the best medical care in the world. 

This course helps to fill the gap - Dr. James has taken all the teachings from the gurus in quality, Dr. Deming and Dr. Shewhart and translated into healthcare. Essentially they teach how to understand that healthcare delivery is as well as in manufacturing, a series of processes which receive different inputs in order to have a final output or outcome, and its quality will depend whether it meets or not required specifications. Quality is defined by our own set of values, expectations, cultural beliefs, etc. and good quality is when the output meet specifications (which are defined expectations). The FOCUS-PDSA strategy allows to identify opportunities and implement quality improvement processes in small scales and translate subsequently toward a larger scale. It is very relevant to understand how the industry has improved and how certain industries achieve incredible safety records - e.g. aviation, car manufacturing, etc. - and how the application of Deming's philosophy has been instrumental in this incredible safety record. 

It is important to understand the history of healthcare delivery in America - how its philosophy has changed - after world war 2, there was an emphasis in ensuring access to healthcare to all the population; however after the costs started to rise and the insurance companies started to take control, the shift focused toward cost control and maximizing hospital reimbursement - this was sub-optimal as opportunities to care may have been missed by patients as insurance companies controlled the medical decision making not emphasizing at all in quality of care but just cost of healthcare delivery. However, quality of care was less than optimal and medical errors were the 6th cause of mortality in the US. This was highlighted in an publication by the Institute of Medicine called "To Err is Human" and subsequently by "Crossing the Quality Chasm". This has shifted equation of healthcare delivery toward "value" of care - which meant increasing the quality of healthcare delivery while minimizing unnecessary costs. This is the current philosophy that allows us to design the healthcare processes. 

It is important to stop practicing a highly variable "craft of Medicine" which allows for increase risk of errors and missed opportunities - it allows for an incredibly selfish and individualized practice of "what works for me". This can make a physician practice differently in a same patient/same scenario in different time periods. Patients are increasingly complex; medical knowledge is increasingly complex too - more than 10,000 different journals, it is impossible to know all the current evidence to support a safe medical practice. This is one of the reasons for having quality improvement systems in place - and to have all doctors get on board the ship of quality and safety and adopt the culture of quality as their main philosophy. 

But in order to ensure adequate quality delivery, we need to know whether we are meeting the specifications! Therefore, it is fundamental to have a clear understanding of our current performance - essentially, know well the data to be able to study and appraise it. Be able to graphically show where our performance gaps are is fundamental - using time series, pareto charts, Ishikawa (fish-bone) diagrams or other cause-effect diagrams, histograms, flow charts, etc. (Now a lot of things make more sense!). Metrics should drive performance when understood within an appropriate knowledge and understanding of our own institution philosophy, vision and mission. The graphs allows to identify outliers and areas of opportunity. Errors or mistakes are horrible words - should not be used; the purpose of quality improvement is not to punish or take action toward an individual - the context of all the theory is geared toward improving the system! Rather than using these words, it should be identified as "opportunities for improvement" or "outcomes outside of specification". All individuals within the system should be accountable, but the purpose of QI is to enhance the system in a consistent form. For example - you don't ask when climbing a regional jet whether your pilot is competent - you trust the system! The same should occur in hospitals - create systems that enhance patient safety and consistent quality delivery.

For quality improvement purposes, the most important aspect that Deming taught was to decrease variation - once variation is decreased, the area under the curve decreases - the population bell shape distribution narrows and its peak is more prominent - then it is easier to identify real outliers - the causes for real "signals" and be able to help improve. In a traditional bell shape, when arbitrary cut-offs are met, these outliers can mix with the rest of the population. So it is important to standardize processes to minimize variation. In healthcare, each patient will be different, so if we standardize our processes, the only variation will come from the patient who can receive an individualized care but the overall standards of care will be met. 

The leverage of all resources - technology: electronic health records, computerized-personal-order-entry systems (or CPOE), and non-technology: discharge processes, nurses/physician huddles, etc. - should be targeted toward minimizing variation and use all opportunities to meet top quality standards. 

Once a process is started - a work-flow diagram that illustrates the process and subsequent steps, can be modified with constant feedback from the end-users about its performance to improve it in a continuous way - what is also called continuous improvement.

A beauty if the QI philosophy is that once specifications are being met rather than "sleeping on the fame", a constant pursuit of further enhancement and refinement in the process should be maintained - this desire for continuous improvement is what creates safer and better environments - this philosophy is what helps the world to keep advancing and be a better place for the next generations. 

My responsibility will be to immediately apply all the currently acquired knowledge at my institution, as well as share this philosophy and knowledge with my peers, medical students and both Medicine and Pediatrics residents. This is important as the new generations must harbor the culture of quality and safety as their main philosophy. I'm excited as this will help to deliver a much better medical care and help to shape the Medicine of the future today. 

A safe medicine with highest quality standards allows us to practice our mantra....primum non nocere

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