Twelve years ago, when Kaveh G. Shojania, M.D. co-authored the best-selling book Internal Bleeding: The Truth Behind America’s Terrifying Epidemic of Medical Mistakes (an explosive look at the rampant errors endemic to modern medical care) the quality improvement (QI) movement had only just begun to take shape in North America.
An integral player in that movement, general internist Dr. Shojania – the opening plenary speaker for the upcoming 2016 International Conference on Residency Education, and the director of the Centre for Quality Improvement and Patient Safety at the University of Toronto – has since established himself as a foremost expert in evaluating and implementing evidence-based strategies for improving healthcare quality and patient safety, and has found himself at the centre of a rapidly growing field of healthcare scholarship.
While the QI movement is still relatively young, Dr. Shojania says he hopes to expand its reach during ICRE 2016, by inspiring an international group of medical educators, program directors/administrators, residents, researchers, policy makers and more to integrate and carry out systemic changes in their own practice related to the science of improvement.
As a sneak peek to his plenary lecture, Dr. Shojania recently took the time to talk to ICRE about what strides have already been made in international healthcare systems around quality improvement; and what more needs to be done.
Q: What are some of the biggest/most critical gaps that currently exist around quality of care and patient safety – and why do you think they still exist in the 21st century?
A: In 1999, the Institute of Medicine in the U.S. published this famous report called To Err is Human: Building a Safer Health System, where they captured everyone’s attention around medical error. Since then, quality improvement has received some sustained attention – and there have been small pockets where we’ve made progress – but there are still tons of patients who don’t receive routine, evidence-based aspects of care. Other problems also exist in the clinical setting such as interruptions, communication barriers, teamwork problems, and so on. But the good news is that I think we now know what we have to do, and the hope is that we’ll make a lot more progress over the next 10 – 15 years.
Q: Why is a focus on quality improvement and patient safety especially important now, in the context of 21st century medical education?
A: There are a few reasons. We’ve currently got unprecedented health care costs that are breaking budgets – now, everyone has shone a light on all the quality and safety issues and huge variations of practice that exist, and in almost every jurisdiction in the country and around the world, governments and other payers of healthcare are starting to notice. I think that now, you really can’t emerge from training and have it be the first time you ever hear about the idea that your performance might be measured.
I did my residency in the mid-1990s – and it was still at the stage where once you were on the wards on your training, it was like being inside a sausage factory: You saw that it wasn’t always pretty, and that it wasn’t what textbook medicine was supposed to be like. You sort of learned that sometimes, things don’t always work out the way they’re supposed to – like, a lab test gets lost, or the wrong patient gets a medication – and for years, no one was really systematically looking at this. I think that now, a shift towards quality improvement is really being welcomed by residents, who see faculty explicitly discussing, studying and teaching these things, and see even amongst themselves, huge variations in the quality of how things like a handoff will occur. To actually recognize that this is as important as how to read an ECG or put in a central line, I think that actually resonates with a lot of residents – and even medical students – as long as they’ve been on the ward for at least two seconds.
Q: In all your research and work around patient safety and quality improvement, what has surprised or inspired you the most?
A: This is such a familiar idea to me now, but I guess that traditionally, in medicine, what was most noble and harmful about how health care worked was that we were really supposed to be the best that we could be – which of course is a noble aspiration – but the flipside was that there was such a focus on knowing everything and being the most skillful technician you could possibly be, that if anything bad ever happened to a patient, it implied that you weren’t good, and that it was a personal failing. What the quality and safety movement has tried to do – borrowing from other high-risk industries like aviation and so on – is recognize that in a complex system like healthcare, you can only get so far by having a bunch of great individuals. Unless you have systems in place to support those individuals, there will be issues related to communication, teamwork, fatigue, etc. So what has inspired me is that there’s an important role in healthcare for having not only good individuals, but good systems as well. It is somewhat liberating to recognize that even if you’re doing the best you can do, if the system doesn’t support you properly, bad things can happen to patients – so the appropriate response should be to fix the system; not to necessarily blame the individual taking care of the patient at the time.
Q: Each healthcare system and institution around the world has some similarities – and some differences. Do you think that truly practical solutions around quality improvement/patient safety be determined on a global scale, or are quality/safety gaps generally country/regionally specific?
A: I would say that a lot of times in healthcare, the individual institutions have done things in a silo, and that has caused problems – especially from a quality perspective. In fact, in the quality world, many have characterized health care as essentially like a bunch of cottage industries – one hospital may do one thing, and has no idea what the hospital down the street is doing. So on the one hand, I recognize that having silos is not a good thing. On the other hand, from an education point of view, I think what’s going on locally just counts so much, and realistically, most residents don’t have that clear of an idea of what’s going on in other schools. I think that within a school, the most important thing is that the teaching about quality and safety not happen in a silo – it has to be connected to the clinical work.
To find out more about Dr. Shojania’s academic contributions and accolades, visit the plenary speakers’ page on the ICRE website.
Dr. Kaveh Shojania will deliver ICRE 2016’s opening plenary on Thursday, September 29, 2016 (16:00 – 17:30) in Niagara Falls, ON.