Opinion, South Africa

Dr Gary Kantor: On Quality Improvement in Healthcare

Anaesthetist Dr Gary Kantor, Co-founder of Best Care Always, talks about the culture and methods of quality improvement and patient safety.

Gary Kantor - EHN

Anaesthetist Dr Gary Kantor, Consultant to Discovery Health and Insight Actuaries, Co-founder of Best Care Always, talks about the culture and methods of quality improvement and patient safety.

Tell us about your healthcare background.

After graduating from the University of Cape Town (UCT) I spent 16 years abroad, working initially in primary care in rural Canada. I then trained as an anaesthetist at the University of Toronto and at the Cleveland Clinic Foundation before taking a faculty position at Case Western Reserve University, also in Cleveland. In 2005 I returned to South Africa on a sabbatical year, with my family, but 11 years later I’m still here!

I currently work as an anaesthetist in private practice and have been an independent part-time clinical consultant to Discovery Health for about eight years, during which time I co-founded Best Care Always, together with a small but dedicated group of “quality activists”. Six months ago I started working with Insight Actuaries, who offer a range of consulting services to hospitals, professional societies, schemes and government. I still work with Discovery on special projects in genomics and Precision Medicine and have also been involved in their eHealth projects. I’ve kept my university position in the US so I’m still exposed to American hospital medicine, returning for a month or so each year to Cleveland to work in theatre.

How did Best Care Always come about?

The Best Care Always! Quality Improvement campaign started in 2009, focused on infection prevention and antibiotic stewardship. The project was a collaborative effort between Discovery, the major hospital groups, professional societies and industry stakeholders. I need to acknowledge several people who worked really hard to develop and lead BCA, as we call it. The short list includes: Dr Dena van den Bergh, Yolanda Walsh, Dr Michele Youngleson, Farzaneh Behroozi, Dr Lloyd Kaseke, Lauren de Kock, and so many others in hospitals, professional groups, provincial health departments and the Hospital Association of South Africa.

Best Care Always was modelled on the 100,000 Lives Campaign run by the US-based Institute for Healthcare Improvement (IHI), which has pioneered and promoted a number of quality and safety improvement concepts and initiatives. For example, IHI introduced, and we adopted, the concept of ‘bundles,’ which are evidence-based tasks — generally three to five — that if performed reliably, for every eligible patient, can significantly improve patient outcomes, as well as IHI’s campaign methodology called the Breakthrough Series Collaborative.

Best Care Always was a deliberate attempt to introduce improvement methods, in public and private sector hospitals, and initially it just happened to be around the use of antibiotics and infection prevention. While it was a practical set of steps to realise measurable improvements, it was also about a methodology that aims to shift a culture; changing the old way of doing things to get to the next level of safety. A big part of that and the basis of the campaign was to encourage collaboration between hospitals, specifically learning from each other which is a powerful concept and is happening  all over the world.

Can you tell us more about the practical steps hospitals carry out under the campaign?

Quality Improvement in healthcare came about by borrowing ideas from other industries like the airline and motor industries, and then adapting those ideas to the context of healthcare. For example, learning how highly reliable industries and organisations like Toyota continuously improve their quality and produce better products at a lower cost.

Under the Best Care Always model, participating hospitals set their own specific improvement goals, such as reducing surgical site infections or catheter-associated urinary infections by specific amounts within a specific time period. It also focused on antibiotic stewardship. To achieve these goals, data has to be collected to identify and measure areas of improvement, and changes have be tested and spread. There’s been evidence of that improvement in both public and private facilities. After an 18-month collaboration in the Western Cape, Groote Schuur Hospital (GSH) reported up to 300 days without any central-line associated blood stream infections in one of their ICU wards. This is an enormous improvement compared to when they started the campaign and were reporting infections every month.

What the campaign highlights is the need to introduce and embed improvements into everyday clinical activities. Especially because nurses and doctors move from one hospital to another, there’s a benefit to having some common systems and benchmarks, for example, around inserting a central line on a patient or putting a patient on a ventilator. Because these interventions are based on international best practices, adapted to the local context, we get to understand what actually works, in our own hospitals, and the data collected supports the reliability of the system.

Unlike collecting data for a research project, you’re not going to control every single variable; you’re not trying to prove an intervention works. You know that if you follow the process for every patient, every time, you are unlikely to get a central line infection. You can collect data and measure your progress using simple tools such as a graph made with paper and pencil. Excel spreadsheets are helpful but not essential, and we also introduced a database accessible via the web, called the BCA intranet. Best Care Always is not about blindly following a recipe; it’s about taking things that have worked elsewhere and using the intelligence of your frontline team to improve care.

From a Best Care Always perspective, what do we know about patient expectation of quality?

In terms of the interventions, we didn’t have a specific patient experience frame on this, but when we started having our annual Quality Intervention summit, we included a patient-centred care track so people working on patient experience measurements and improvements could present their work. All the hospital groups are doing that work. We’ve always had patient satisfaction surveys but I don’t like the term ‘patient satisfaction’ because it suggests more of the “hotel” aspects of a hospital rather than trying to understand all the goals and processes of treatment from a patient’s perspective. For example, patients care about their experience in the hospital in terms of whether the staff, and doctors, were kind to them, listened to them, provided help when they needed it, treated their pain, and whether they got the information that they wanted. All of those factors are not about “satisfaction”; they are about patient experience and how we create value, in the patient’s terms, not only in terms of measured rates of complications and so on.

These are important aspects of quality that I think we have to work on which are just as important as the technical, clinically determined measures. A lot of doctors, particularly in the US, complain that patients can be unreasonable or uninformed and that these measurements or surveys can create ridiculous incentives. The pain survey is an interesting one because treating pain is sometimes a balance between treating it because you don’t want anyone to feel pain, but you also don’t want to overdose on pain medication and create addiction. These can be dangerous drugs; there are people who go to hospital because they are dependent on pain meds and if you don’t give them their medicine they’ll give you a bad rating on the patient experience survey. But we shouldn’t base quality of care measurements on the exceptions to the rule. Most patients are not opioid-addicted and seeking drugs, and they need to have their pain adequately treated, which means we have to measure it.

What role do nurses play as custodians of quality?

When the IHI 100,000 Lives campaign started, the precursor to it was some work, and insights, from some of the best hospitals in America, for example Johns Hopkins Hospital. When Johns Hopkins looked hard at their processes around central line insertions they realised that they were making mistakes like: not prepping the site properly or using full barrier precautions or not taking the line out when it’s no longer necessary. Both nurses and doctors played a huge role in turning this around. Nurses gained the authority to stop doctors from proceeding if they hadn’t gone through the necessary steps. They also organised supplies better for putting in lines, using supply carts which could be brought to the bedside, simple but effective things like that which many, or most, hospitals hadn’t really thought about much before.

Similarly, initiatives like Best Care Always are dependent on nurses and to a large extent, led by nurses. It’s critical that nurses feel empowered as they are the core of the frontline team at the bedside, and in our experience when given support they can come up with solutions. The Red Cross Children’s Hospital identified a young, bright nurse and set aside some time over a period of three months where the hospital reduced her clinical duties so she could work with other nurses at the bedside, observing them and identifying things they could improve on. That’s how you create leaders and instil in them a sense of pride and ultimately co-create a shift in culture and work ethic where a care team is always mindful and striving to improve quality at every patient interaction.

What are your predictions for the next wave of eHealth solutions that will both help drive and measure quality improvements?

I think eHealth has enormous potential but we also need to dispel the myth of “eHealth exceptionalism” or the idea that information technology is some kind of magic solution. If we have systems like Best Care Always where we are deploying and measuring and learning, then technology can be a fantastic enabler and help improve processes that are poorly designed or unreliable.

What technologies do we need? We first need to be clear about our problems. For example, better care coordination is needed, better teamwork and communication, and we have a huge skills shortage. So we need apps that support care coordination and teamwork. I think there is potential in so-called eICU technology so expertise can reach hospitals that are short of skilled professionals. We need electronic health records (EHR) but they should be designed to capture just the right amount of needed clinical documentation and useful data -structured and unstructured – to be able to make use of it for the care of that patient – for example simple care summaries that can be shared – but also for learning and improvement. We need interoperability between systems, which means data standards – our government should be facilitating this or else we will have a Tower of Babel situation, multiple systems but the data stuck inside them, silos. We should create clinical registries around high-value conditions and high-value procedures, like they do in various European countries, particularly Scandinavia. There isn’t any technology in place right now that enables this and is also interoperable with other systems.

Lastly, I think we need to get patients more involved. An example is the Open Notes Project. This study showed that if doctors share their EHR notes with patients, the patients are more likely to adhere to their medication and continue with treatment. And the act of sharing notes is not associated with additional work or risk for the doctors – I think those two elements in conjunction will have a big impact on quality.

Any closing thoughts for providers who are still looking for ways to improve the quality of care in their facilities?

In our experience, frontline providers who have been part of the campaign have had success because they’ve taken ownership of the quality of care they deliver, supported by “head office”, but engaged, interested and in control of the work, determining a starting place and results they wanted to see. Also, patient safety should not really be thought of as a set of projects, or even a campaign, useful as those might be. As Don Berwick has said, patient safety should be like professionalism, a non-negotiable aspect of hospitals and other healthcare settings that we are working on all the time. Or as stated by Jim Reason, “safety is a continually emerging property of a dynamic system”. Putting it in those terms will hopefully make it more interesting to my academic colleagues who should be paying more attention to healthcare systems at this level and possibly a bit less to molecules!

Every hospital in the world has infections and we know from the literature what the rates are likely to be. We know that in low-middle income countries the rates are much higher and, because healthcare is much less accessible, the impact on the population is much greater. In the past, the question has been why bother with these interventions, why is it a priority and is it worth investing in? I think that’s probably no longer an argument, there’s enough experience to understand that there is value in terms of cost savings, patient experience and staff morale. As a provider, if improvement in any of those factors is part of your mandate, as it should be, then the tools exist and are available to you to help you make those improvements and ultimately, deliver the best care always.

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