Quality Improvement and Patient Safetyis More Important thanResearch and Med Ed

Lucas ChartierMD CM, MPH, FRCPC

Director of Quality & Innovation, UHN EDAssistant Professor, UofT

TC-LHIN Lead for EM

Objectives

• Research and Med Ed are necessary but insufficient to improve patient care outcomes

• QIPS is the missing link to improve patient health

• We all have two jobs: doing our job, and improving our job

Pedro: healthy 56yo M with cough, SOB, fever

But…• Can’t afford meds

• Nodule picked up by radiology• No QA process to follow-up• GP info not completed on chart• Phone number not in service• No discharge paper for repeat in 4-6wks

• Comes back with aggressive lung cancer 9 months later

Knowledge creation often failsto improve outcomes for patients

Essential treatments inconsistently received

• NEJM 2003;348(26)– Hypertension: 65%– CHF, COPD, Stroke: 60%– A.fib: 25%

• NEJM 2007;357(15)– Immunizations: 50%– Asthma: 45%– Well-child care: 40%

• Improvement in care from new treatments are marginal compared to the gap from known things

Education is insufficient to achieveanything but knowledge translation

Hierarchy of Intervention Effectiveness

What, then, is quality?

Brook & Lohr. Med Care 1985.

• Difference between efficacy [in RCTs] and effectiveness [in real life] attributable to providers

• The ‘routine’ way of delivering the care studied in the lab that accounts for the difference in outcomes

What, then, is quality?

Institute of Medicine:

STEEEP:• Safe• Timely• Effective• Efficient• Equitable• Patient-centered

So what is quality improvement?

• Improving the system so that all patients receive excellent care despite fallible providers

A Tale of Two Industries

Healthcare

• Patient receives allergenic med– Reprimand, try harder, EHR alert

• Tired & overwhelmed providers– Add alarm, checklist without buy-in

Automobile

• Car accidents on departure– Brake to start, rearview camera

• Tired drivers– Rumble strips, blind spot alarms,

lane change detection, self-driving cars

Targeting the approach: mistakes vs. slips

Total Health Expenditure

Source: Canadian Institute for Health Information (CIHI)

QIPS needs Med Ed

• Let’s embed QIPS into the educational setting

– Establish a norm, that QIPS is ‘part of the job’

• You have two jobs in in healthcare:

– Doing your job, and improving your job!

• CCQI – Co-curriculum in QI

So let’s reframe our teaching then…

Remember Pedro… Some system-oriented solutions

• Extended social work coverage

• Strong QA processes to close the loop

• GP database linked provincially

• Registration clerks have a better system

• Can’t afford meds

• Nodule picked up by radiology• No QA process to follow-up• GP info not completed on chart• Phone number not in service• No discharge paper for repeat in 4-6wks

• Comes back with aggressive lung cancer 9 months later

“The most important thing we have to offer our students is ourselves –everything else they can read in a book”

- Daniel Tosteson (Harvard Medical School Dean), NEJM 1979

So…

• Where is QIPS now?– Growing number of young clinicians involved

• Teaching about patient centredness / EBM– It all needs to be intertwined together

• We don’t all need to do QIPS, but we all have a role– What are YOU doing about this?– Or just get out of the way!

Summary

• Research and Med Ed are necessary but insufficient to improve patient care outcomes

• QIPS is the missing link to improve patient health

• We all have two jobs: doing our job, and improving our job

lucas.chartier@uhn.ca@chartierlucas

Brag & Steal

• Purpose– Improve local care, share nationally

• Numbers– 17% of 401 abstracts from around country– 10 reviewers, great concordance quant/qual– PDSA’ing for next year

• Winners– Great QIPS projects– PDSA cycles with iterative design– Repeated data sampling and evaluation– Not necessarily positive results!

After this session…

• Wine & Cheese for Top-7 moderated QIPS posters in Foyer

• QIPS Committee tomorrow 9:00-10:30am in Glen 201

• QIPS Award to Jennifer Thull-Freedman on Wednesday morning