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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
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
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
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
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!
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