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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:

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