BMJ Quality Improvement Forum

What did I as a consultant learn from a conference on healthcare quality improvement?

When I was asked to register for the IHI/BMJ International Forum on Quality & Safety in Healthcare I was a bit concerned.  Being a consultant obstetrician and gynaecologist in a small non-profit hospital in Delhi, I wondered whether the conference would be applicable for our setting because many of the topics seemed related to public health.

But Abhishek Bhartia, our director, thought differently, and soon we were in London to attend what turned out to be a bonanza of sharing, learning and interacting with over 3,000 delegates from about 80 countries!

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A Commitment to Quality

On the day before the start of the three day conference, I attended a full-day course on patient safety.  At my table was a nurse manager from Norway, a pathologist turned manager from Kuwait, and a paediatrician from The Netherlands who headed quality in her neonatology unit.  The paediatrician described how there were regular audits against standard benchmarks for safety and quality.

I found myself thinking how different this was compared to the situation in India, where government teaching hospitals are overwhelmed with patients and struggle to provide minimal care, and private hospitals have very variable quality ranging from good to bad.  I also realised that quality improvement is an unknown science for a majority of doctors in India who mostly think that their responsibility is limited to doing their best for patients on an individual level.

Carol Haraden, a patient safety expert at the Institute for Healthcare Improvement, and one of the leaders of the course, gave a great example of an old patient who was abusive and erratic in the post-operative period following a surgical procedure.  The nursing staff thought he needed psychiatric help and in the middle of the night when a nurse suggested to the doctor that the patient likely needed an antipsychotic, the doctor agreed. When the patient died, an autopsy revealed a pulmonary embolism.

This patient was known to be at high risk of thromboembolism but there had been no risk assessment and no SBAR communication (Situation, Background, Assessment and Recommendation) between the nurse and the doctor.  And it’s not surprising that at 3 am the doctor did not question the nurse’s judgment.  Carol used this example to highlight the importance of building communication and teamwork at par with clinical skills to create a safe environment in healthcare.

The opening keynote address of the conference was by Maureen Bisognano, president and chief executive officer of the IHI.  She gave a beautiful example of an obstetrician dealing with high risk pregnancies who introspected about the reasons behind the high prevalence of preterm births and how they might be prevented – rather than only focusing on the treatment. To think differently has been the highlight of this conference and as a clinician I realised I could have a much greater impact on health by looking beyond the immediate clinical situation.

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I was very impressed by Dr Gary Kaplan’s talk on how the Virginia Mason Medical Center in Seattle has adapted Toyota’s lean manufacturing methods to improve healthcare.  I learnt how tools like value-stream mapping can reveal waste in processes and how events like Rapid Process Improvement Workshops (RPIW) can be used to understand gaps and streamline processes.  I had previously read a book called Transforming Healthcare which told the story of Virginia Mason’s healthcare quality improvement journey but hearing about it from the CEO himself was a treat!

Sharing Hope

Patient engagement was the theme of this year’s Quality Forum.   I heard this lovely keynote address from Martine Wright who was one of the tragic victims of the London Bombings in 2005. She lost both her legs when a bomb went off in the London Underground and was in the hospital for a year.

Martine related how she got the strength to get back to her life and started flying and playing sitting volley ball – things which she had never dreamed of doing before. She even went on to become the captain of the National Sitting Volley Ball team! She called upon healthcare providers to never ever underestimate their potential to change, transform and revolutionise peoples’ lives.  I think this is the greatest gift of the medical community – to have a patient who has no hope left come out of the darkness and pay such a tribute!

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Patient Engagement – A Team Approach

But I couldn’t help thinking that patient engagement seems such a faraway thought in the Indian scenario. Trust between patients and doctors is at a low – and yet if we have to look after our patients well we have to include them in our challenges and dilemmas.

I see this in my work of reducing unnecessary interventions in maternity care and achieving a medically justifiable caesarean rate – work that I had an opportunity to present as a poster at the Forum.  Without joint decision making it would be tempting for me to practice defensive medicine and over-intervene!  Many people appreciated that a small hospital serving private patients was making an effort to tackle the caesarean epidemic in Delhi.

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I did not learn clinical skills or robotic surgery in this conference but what I learnt is perhaps far more important for my patients. I learnt about systems thinking, team building and patient engagement as the building blocks of safety in health care. I came away inspired to continue my journey in making healthcare processes more reliable and fully utilizing the potential of the entire team.

We have experimented with SBAR communication in our labour room; now we need to implement it reliably and further empower our nurses by training them to interpret electronic fetal heart rate tracings.  We are working to reorganize our outpatient care so that other healthcare team members can do some of the routine tasks freeing up consultants to focus on hearing the concerns of patients.  And I am particularly excited by the prospect of involving families in sharing their experience with couples during the antenatal period and using their feedback to improve care.

At the end of the day, we’ve all walked away with insightful and actionable learnings that will help us all become better care providers. In the meantime, I’m looking forward to seeing what will emerge from the International Forum on Quality and Safety in Healthcare being held in Honk Kong this coming September. The Forum promises to “Improve, Innovate, Inspire” – values we could all certainly benefit from.

Consultants, no matter how brilliant they might be individually, will never be able to do their best for patients unless they take leadership for helping build a safer healthcare system.

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  • I felt proud hearing Dr Rinku describe her QI journey of reducing caesarean sections. She was also featured in the film that was shown to all delegates at the end. Was great to have a progressive consultant from our Institute attend such a conference.

  • Jitender Nagpal

    It has been heart warming to be a first hand witness to the amazing evolution of Dr Rinku as she has trudged along the path of quality improvement in her department. The insights that she has acquired and shared along her path have been priceless for me and the institution. Her description of her experience in the London conference highlight her deep understanding of the subject. While there is dearth of such knowledge in the India the vast potential for its application is not difficult to imagine. Her journey and her learning inspire us all at Sitaram Bhartia as we take the first few primordial steps towards making our institute a better and safer place for healthcare…. !

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