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Fixing healthcare from the inside: embracing improvement science

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Reflecting on the application of quality improvement, Dr Mark Temple, Future Hospital officer, discusses how two presentations have made him think differently about new approaches to enhancing acute medical services.

In the last 2 months, I have been privileged to attend two electrifying presentations that have jolted my thinking about acute medical services, and how to do more with less in a sustainable way.

The first was Professor Don Berwick at his masterful, visionary best at Medicine 2016, the Royal College of Physicians’ annual conference. His presentation weaved a beguiling patient story into the unfolding of three distinct eras of medicine. The bottom line: a heartfelt call to embrace improvement science and listen – really listen – to our patients. At its conclusion I found myself on my feet with the rest of the hall, providing a standing ovation with a tear in my eye.

But it was Dr Brent James, a close colleague of Professor Berwick, who provided a profound illustration of quality improvement in action when he addressed the International Forum on Quality and Safety in Healthcare 2016 in Gothenburg.

‘You have met the greatest enemy of healthcare’

Dr James is a surgeon, statistician and director of quality at Intermountain Healthcare, a 23-hospital group in Utah, United States. Introducing his unflinching review of current healthcare, Dr James said that hospitals were a major public health problem – an opening line which takes some beating. He also objected strongly to the phrase ‘healthcare is broken’ because of its implication that healthcare systems were working in the first place.

His thesis is that even when we are not directly harming patients in hospital, the massive variation in clinical care provided to in-patients is wasteful, potentially harmful, and consumes resources that should be directed to more effective care. Worldwide, clinicians also exhibit a striking inability to do what we know works well.

He points out that we have met the enemy of high-quality, safe, patient care: it is us – all of us.

Steps to quality improvement

Dr James’ approach is to apply rigorous measurement tools to routine care delivery and to do this in close partnership with physicians. To summarise his seven steps to quality improvement:

  • Identify a high-priority clinical process: eg the management of patients with community-acquired pneumonia.
  • Measure baseline variation in practice: eg length of stay. Share this with senior clinicians, avoiding value judgements (what is optimal isn’t known), but a two- or three-fold variation is an opportunity to cut waste and improve care.
  • Build a best practice protocol: working with clinicians, build a protocol recognising that the evidence base is always imperfect.
  • Blend the protocol into clinical workflow: make ‘best care’ the default choice that happens automatically, unless actively modified. Make it easy for clinicians to do the right thing using any effective tools (eg checklists, decision support) to prompt an agreed sequence of interventions.
  • Embed data systems: the systems can track protocol variations and short and long term outcomes (intermediate and final clinical outcomes, costs and patient experience).
  • Use clinical judgement: demand that clinicians use this to deviate from the protocol based on patient need.
  • Feed those data back (variations, outcomes) to clinicians: this will create a lean learning loop where teams can constantly update and improve the protocol.

And my own eighth step: sit back and find that you are doing much more, better, for less.

Reducing waste, driving quality

Headline results? The overall costs of delivery of clinical care by Intermountain have been reduced by 13% in the last 5 years. That is a real reduction in costs impacting on medical insurance premiums, achieved with no reduction in services, no vacancy freezes and no locum caps. Instead, year-on-year, the care of patients in the same high-volume pathways is being delivered more consistently with improved quality and less waste.

In the present parlous state of NHS acute medical services, variation in clinical practice must be the new frontier to explore. It is likely to be uncomfortable, at least initially, and we must ensure that the key drivers for success are applied:

  • collaboration with clinicians
  • transparency
  • timely, accurate, clinical data on care delivered by individual consultant-led teams.

It may take a decade to fully realise the benefits, but we should apply rigorous measurement tools to the delivery of routine clinical care – starting tomorrow.

To contact the Future Hospital Programme please call +44 (0)20 3075 1583 or email futurehospital@rcplondon.ac.uk.