Download The Future of Quality Improvement and Patient Safety in Medicine

The Future of Quality Improvement and Patient Safety in Medicine and Medical
Education: an Interview with Dr. Kaveh Shojania
Shixin Shen1*, Kavita Patel2
1
MPH candidate 2011, Faculty of Medicine, University of Toronto
2
MD candidate 2013, Faculty of Medicine, University of Toronto
*Corresponding Author: [email protected]
Dr. Kaveh Shojania is the inaugural Director of the Center for Patient Safety at the University of
Toronto and the Canada Research Chair in Patient Safety and Quality Improvement. He is also
the Editor-in-Chief of the journal Quality and Safety in Health Care and an Associate Professor
of Medicine at the University of Toronto. Dr. Shojania was interviewed on January 11, 2011.
UTMJ: Could you tell us about the Center for Patient Safety and what it does?
KS: The Center for Patient Safety is a joint collaborative between SickKids Hospital,
Sunnybrook Health Sciences Center and the Faculty of Medicine at the University of Toronto,
officially created in 2008. Besides generating new research, we aim to encourage education
related to patient safety. We hope to develop a cadre of people in different professions and
institutions who are capable of doing work in the area. For instance, in addition to teaching
students, we have a course that specifically targets faculty members. Over the past two and a half
years, about 120 people have taken this course. These people ranged from junior faculty to head
of department at about 15 institutions. This is great because such individuals often play a role in
leading quality improvement and patient safety projects in individual practice settings. Another
goal of ours is to foster connectivity between people in the field in the U of T community. Patient
safety and quality improvement are very heterogeneous fields. There are engineers who perform
human factors work such as designing informatics applications and other equipments that are
easy to use and less error prone. There are others who work in more traditional quality
improvement areas such as infection control, or simulation work such as advanced teamwork
training around crises and use of high fidelity mannequins in training for specific procedures.
Instead of trying to replicate any of these things, at the Center for Patient Safety, we see our job
as coordinating these efforts and putting the right people in touch with each other. We try to
create a clinical interface for individuals working in areas relevant to quality improvement or
patient safety.
UTMJ: Could you discuss your inspiration behind joining the Center for Patient Safety?
KS: I had a successful research career and am a clinician. Through my experiences, I came to
realize that in order to make positive changes locally, we need a critical mass of working
professionals, like the clinicians I have described earlier. When I was in Ottawa, for instance, I
was among a few patient safety researchers who were recognized as successful in the area. As a
result, every time there was a safety problem, they wanted one of us involved. However, I found
it difficult to focus on research while attending every meeting that involved policies or task
forces. Day-to-day operational activities are often counterproductive to research since they are
time consuming and do not translate into academic work products such as papers and grants.
From an operational and academic perspective, it is nearly impossible for one person to be doing
both types of activities. What attracted me to U of T was that there are more of both types of
individuals – researchers who are interested in advancing the science of improving care and
clinicians rolling up their sleeves to take the lead or at least participate in specific local
improvement projects. As a result, individuals are able to concentrate on their tasks at hand and
contribute to healthcare improvement in their own unique ways.
UTMJ: For readers who are new to the topic, could you explain what patient safety entails?
KS: Patient safety is about avoiding harm to patients from their medical care. Some harms, such
as side effects of drugs and post-operative complications, are not preventable. However,
sometimes these complications can be better anticipated and therefore prevented, and sometimes
harms involve outright errors. A classic distinction is that, a patient safety problem does not exist
when someone receives penicillin and has an allergic reaction for the first time, as it simply
represents an unfortunate, unpreventable limitation of current therapy. On the contrary, patients
often receive medications to which they have a previously documented allergy, either because
the information from past medical visits is not readily available or the clinician forgets to ask for
such information. This is a patient safety problem – it is harm from medical care that is
correctable with existing knowledge or technology. Two papers in the New England Journal of
Medicine in recent years have shown major improvements in patient outcomes from the routine
application of a checklist of tasks before, during, and after an operation: Is this the right patient,
has the patient received the appropriate pre-operative antibiotic, have we confirmed we have the
correct surgical site, have we correctly carried out the count of sponges and instruments after the
operation? And so on. These are examples of standard patient safety issues. None of these
questions or the processes they address represents new “science”. The innovation is in the
process redesign, the fact of making care more consistent to avoid oversights such as forgetting
to administer antibiotics, operating on the wrong body part, or leaving behind a surgical sponge.
We are simply recognizing that if existing surgeries are performed in a more uniform way, we
can prevent certain harms to patients and have better outcomes. Other patient safety issues may
involve technological breakdowns, such as technical errors of computer systems or instruments.
There is a whole science of looking at this type of problem now; many ideas come from nonmedical disciplines, such as human factors engineering.
UTMJ: How is the quality of healthcare measured?
KS: According to the Institute of Medicine in the United States, there are six dimensions of
healthcare quality, one of which is patient safety. Other aspects of quality include effectiveness,
patient-centeredness, equity, efficiency, and timeliness. In other word, perfect healthcare is
evidence-based, responsive to individual patient needs, and free of preventable harm,
discrimination, waste, and wait time. Although this is difficult to achieve, people are working to
the best of their abilities to help improve these aspects of quality.
UTMJ: How is quality improvement routinely carried out?
KS: The traditional approach in quality improvement assumes that a knowledge problem exists.
Therefore, knowledge translation or education is often done to improve understanding in the
area. Another approach involves the recognition of existing barriers to doing the right thing at the
right time for the right patient, and subsequent generation of strategies to overcome these
barriers. For instance, in clinical trials, research nurses contact patients to ensure compliance
with interventions and sometimes even assess certain health measures. This can be replicated in
routine practices, where case managers or nurse practitioners can be designated to carry out
certain clinical activities, thereby giving physicians more time to attend to patients and improve
health outcomes. Some approaches for improving healthcare quality have been drawn from other
disciplines. For instance, industrial engineering techniques called Six Sigma and Lean are
increasingly popular strategies for improving the efficiency of processes in healthcare, such as
the flow of patients in clinics and hospitals.
UTMJ: Why is quality improvement important in healthcare?
KS: Medicine has always been very focused on discoveries and innovations. However, as the
discipline evolves, problems such as inequity, wait times and side effects remain and new
problems occur. Our healthcare system is almost like an accelerating car with no seat belts or air
bags. Although we create new treatments to help sicker patients recover more expediently, we
often fail to pay attention to the fact that the system has become very complex and no longer
works the way it did. Thankfully, there are now people who work to fill these gaps and to make
sure care is safe, effective, equal, efficient, timely, and patient-centered.
UTMJ: Why are clinicians needed in quality improvement initiatives?
KS: Quality improvement research differs from other areas of academic research in that
researchers cannot increase their bandwidth by simply taking on graduate students and
supervising them to manage multiple projects. You cannot send a graduate student to ask a group
of surgeons why they are not using a checklist, or a group of clinicians why they are not washing
their hands, or physicians why they are not using some computer decision support tools. They
are unlikely to agree to meet with students. Even if they do, graduate students will not have the
clinical knowledge or experience necessary to engage them or tweak the intervention of interest.
There is no substitute for having clinicians, not just physicians, who can do this type of work.
UTMJ: Many quality improvement organizations emphasize inter-professional collaboration.
Why is this?
KS: Lack of teamwork and communication commonly exist in healthcare because disciplines are
kept in silos, even within medicine itself. These failures often occur because individuals in
different healthcare professions have unique perspectives. Since each patient is under the care of
a team of healthcare professionals, these perspectives must be brought together and open
dialogues must be encouraged in order to improve healthcare. It is also important to note that
inter-professional collaboration is crucial not only in quality improvement, but also in healthcare
in general.
UTMJ: What are some barriers to quality improvement and patient safety initiatives?
KS: We all respond to incentives. For physician, this has normally meant paying attention to
each patient, not necessarily reducing error or waste in the system. For researchers, incentives
have been towards “discovery” – new treatments and technologies, not necessarily making sure
the ones we have are delivered safely and efficiently. Fortunately, over the past ten years, the
area of quality improvement has gained more momentum and physicians began to play a more
active role in effecting systematic changes. This change in attitude came in after the publication
of a 1999 U.S. Institute of Medicine report called To Err is Human. The report revealed
astounding numbers of medical errors and adverse events in the healthcare system and finally put
quality improvement on the map.
UTMJ: In your opinion, is sufficient progress being made in quality improvement and patient
safety in Canada?
KS: Undoubtedly, but it is worth mentioning that changes come slowly. In the first ten years,
most work in patient safety involved documenting the extent of existing problems and
effectiveness studies of candidate patient safety improvements often yielded conflicting
evidence. Since then, more research has focused on understanding the causes of patient safety
problems, so that interventions can be developed, and a few initiatives have shown important
reductions in medical errors and adverse events. In addition, a critical mass of people has been
assembled to work in the area. However, quality problems are not easily fixable. The fight to
improve healthcare is in many ways like the war on cancer - it takes a long time and progress
consists of incremental improvements, not a single “cure”.
UTMJ: Why do you think patient safety and quality improvement is an interesting career path
for medical students?
KS: The appealing thing about working in quality improvement is that the projects are
synergetic with clinical work. When you take care of patients, you often have to deal with system
failures, such as navigation and communication problems. Making a more patient-centered, more
efficient, safer, high-quality system of care speaks to what you do everyday. Increasingly, many
hospitals are beginning to pay more attention to quality issues and recruit individuals to lead
quality improvement activities. In both academic and community settings, it has become an area
of interest for students and residents who are aware of the dysfunctions within the system and
even mid-career clinician faculty members who (I think) recognize that they have come as far as
one can go by delivering good care to individual patients and would now like to improve the
system in which they deliver that care.
UTMJ: What can students do to prepare themselves for quality improvement and patient safety
as future physicians?
KS: A good resource is the Institute for Healthcare Improvement (IHI) Open School, which
offers free online lessons on patient safety, quality improvement, and leadership. Locally,
organizations such as the U of T Chapter of the IHI Open School offer seminars, projects and
observerships in the areas of quality improvement and patient safety. Interested students can also
contact potential supervisors who are knowledgeable in the area and conduct relevant summer or
resident projects.
UTMJ: How do you feel about the future of quality improvement and patient safety education in
Canada?
KS: So far, we have made good progress in education. Quality improvement concepts have
already been incorporated into the undergraduate medical curriculum at schools like U of T.
Some residencies, such as family medicine, are working to make quality improvement projects
mandatory. As a result of these efforts, we are starting to see more students and residents
becoming attracted to this area. I am optimistic about the future and hope that through training,
physicians will acquire the necessary skills to conduct local projects in their own clinics or
develop new knowledge in research.