Wednesday, November 30, 2011

Will lightning strike twice? My QI journey takes me back to IHI

My QI journey started 5 years ago at the IHI National Forum.  It was literally a life-changing experience for me.   This weekend, I'm going to the IHI National Forum again.  Will lightning strike twice?

That first visit opened my eyes to different ways of delivering and thinking about health care.  It sparked my interest in Clinical Practice Redesign (CPR), and through that work, gave rise to this blog. (Before you follow the link to my very first blog post - about my IHI visit - I want to say that I'd like to believe that my writing has... evolved since then.  Here it is.)  

CPR and QI work led to a relationship with Saskatchewan's Health Quality Council (HQC), which eventually resulted in the incredible opportunity to take a half-time, year-long consulting position with them.  

I've been privileged to be invited to share the results of our CPR work in Saskatchewan and across Canada.  Through these engagements, I've developed relationships with many other people who are likewise committed to improving Canadian health care.

My first IHI visit started me on this journey by showing me that there is a better way, and that there are robust methods by which to plot a new course and then make haste.  My career path has been radically altered by that experience.

What will next week bring?

Perhaps the last 5 years were "low-hanging fruit".  I was likely an easy convert.  I was already primed for the IHI experience and what followed.  Saskatoon Health Region wouldn't have sponsored my attendance if I hadn't expressed some interest in learning about QI.  I doubt that every attendee experiences the same epiphany that I did.  Unless they're putting something in the food. (That egg salad sandwich did taste a little funny.)

Last time, I learned to see a whole new world.  After having been immersed in QI for 5 years, can there possibly be another surprising experience waiting for me?

I hope so.

Wednesday, November 23, 2011

Major professorial cringe moment!

This morning, I had the opportunity to address the first year medical student class about Clinical Practice Redesign and our urology office project.  (I told you about last year's visit with the first year students in this post.  By the way, one of last year's students did contact me and we've been working on a practice redesign project since the summer.)   The best part of the presentation (for me, anyway) is the students' participation.  I've presented our practice work to many different audiences over the last 4 years, and first year medical students reliably ask the most probing questions.  Perhaps it's because we haven't yet brainwashed them into thinking about things "our way".

I try to encourage their participation with regular pauses and prompts.  And with a little bribery (Tim Hortons gift cards for randomly selected hand-raisers).  This group of students were enthusiastic with their questions and comments.

About 30 minutes into the session, I realized that we had spent so much time with questions that I was not going to finish my presentation on time.  Two students had their hands up, and I indicated we had time for one question, and then I would move on.

At the end of the session, the course instructor - who had been distributing the gift cards on my behalf - had reserved one of the cards and announced that it was for the student who I had passed over when she raised her hand.

I mentally kicked myself.  I realized that I had "got through the material" and finished showing the slide show I had created, but it was at the cost of stepping on the contribution of the students - the contribution that I had explicitly encouraged at the beginning of my presentation.  These students wouldn't have been worse off if they missed hearing just one of the half-dozen practice redesign examples I brought along.  The questions they asked were insightful enough to spark a discussion that was more enlightening than the slides I had to show.

And, after telling them that it was essential to focus on the patient's needs when redesigning their work, I had been totally "provider-centric" by satisfying my own compulsion to slog through my slide deck.  This is the product I have, and I'm going to give it to you, no matter what you want!

That wasn't the worst part.

After the lecture, I went over to the student to apologize for cutting her off and to hear her question.  She asked how we could tell if our practice's improvement efforts could make us "too efficient".

She illustrated her point with a personal story.  She had waited many months for a consultation with a specialist.  At the visit, the doctor made a diagnosis and gave her a sheet of paper containing information about the condition.  The doctor told her that this would give her the information she needed to manage her problem, and sent her on her way.

The student's comment was that although this was a very efficient way to use the specialist's time, she felt somewhat short-changed by not having adequate opportunity to interact and ask questions.

Her insight is known as "balancing measures".  Whenever we make a change in a system with the intent of improving one aspect of it, there may be unanticipated and unwanted consequences in another area.  For example, if I want to reduce the wait time for cystoscopic bladder examinations, I may decide to increase our daily capacity by 50%.  We'll reduce our wait time, but the nursing staff who assist me in the exam room will be run ragged.  They may take more sick time, or even ask for a transfer.  We could check this balancing measure by doing a staff satisfaction survey before and after the system change.

I reminded the student that her unsatisfactory consultant visit was a reminder that, when implementing system changes, we should always consider our primary goal: Putting the patient first.

That's when the cringe hit me.

In my quest to zip efficiently through my presentation, I lost sight of the real reason I was there: Putting the students first and encouraging a sense of curiosity around different ways of delivering care.

Maybe I'll get it right next year.