What the Quality Improvement Community Brings to the Table During a Pandemic
EXECUTIVE SUMMARY
Healthcare providers around the world are relying on innovation to help their organizations survive the COVID-19 pandemic, a crisis that has brought with it unprecedented challenges and complexity. Some structure is needed to curate the best ideas and ensure they are shared widely.
• Experts note that while command and control functions are vital, it must not overpower or stifle innovation.
• Frameworks like Deming’s System of Profound Knowledge, which is used widely in the quality improvement community, can help leaders think through complex decisions.
• Health systems in many countries are concerned about shortages of personal protective equipment, extreme levels of stress and burnout among workers, and how to most effectively gear up for a surge in COVID-19 patients.
• The pace of innovation must speed up to meet current needs, but it is also important to focus on how to most effectively exchange ideas and new solutions.
The COVID-19 pandemic is challenging the healthcare system in unprecedented ways. Hospitals in outbreak hot spots like New York City and New Orleans have seen COVID-19 cases explode in a matter of days, leading to shortages of personal protective equipment (PPE), intensive care unit beds, ventilators, testing supplies, and other key resources. Leaders and policymakers are scrambling for new solutions.
How can the quality improvement (QI) community make meaningful contributions in these times of crisis? That was the topic of conversation in “Mobilizing to Respond to COVID-19,” the first of several pandemic-related, interactive conversations sponsored by the Institute for Healthcare Improvement (IHI). This virtual exchange of information unearthed a range of options for health systems to consider as they face difficult decisions on how to most effectively negotiate through regulatory constraints and other barriers to effectively address the pandemic in their own communities.
Bring Heart, Progress
“We probably have never experienced circumstances quite as complex and challenging as the ones we are facing right now,” noted Derek Feeley, DBA, president and CEO of IHI and the former chief executive of the National Health Service in Scotland.
Feeley acknowledged there is no magic bullet or no single right answer that could adequately address the multiple issues health systems around the globe are facing. However, he stressed that the QI community can play a strong role in helping healthcare decision-makers find a pathway through the crisis. While the command and control functions that are triggered in times of crisis serve a vital function, Feeley suggested some balance also is essential. “Of course we need some direction, and we need someone to take control of the situation, but not in a way that overpowers or stifles ... innovation,” he offered. “The quality improvement community ... is much more likely to bring an outside-in kind of perspective, and much more likely to bring shared knowledge to solve these kinds of problems rather than a top-down kind of approach.”
Furthermore, Feeley said people who work in QI tend to make decisions that are more connected and integrated rather than set up systems with separate accountabilities. “In the command and control world, people are much more likely to see their job as managing people and budgets. That is likely to still be very important, but unlikely to be sufficient,” he said. “We need to see leaders who are much more willing to act on the system ... this is a great opportunity for the QI community to step up and provide leadership [in this respect].”
One other contribution the QI community can make in times of crisis is a sense of renewal. “What we often see [during crises] is a fear of failure because people’s lives are at stake [and] a loss of heart because [people] get overwhelmed by the sheer deluge of work and the magnitude of what they are facing,” Feeley observed. “We know that quality improvement brings energy, heart, and progress to people. Quite apart from the technical approach that we can bring from the QI community, there is also an emotional and a social duty on us right now.”
Rely on Frameworks
During a pandemic, it can be helpful to use framing devices to help organizations think through decisions and determine what solutions or improvements are needed.
“It is just getting your mind together,” noted Donald Berwick, MD, MPP, FRCP, president emeritus and senior fellow at IHI. “When you are fearful and when there is uncertainty around, frameworks help.”
For example, Berwick noted one of the core frameworks used in the QI community is the System of Profound Knowledge, developed by the noted engineer, W. Edwards Deming. Within this framework, there are four categories of knowledge:
- knowledge of systems;
- knowledge of variation;
- knowledge of psychology;
- knowledge of how to learn.
Regarding “knowledge of systems,” Berwick explained that every organization is responding to the COVID-19 pandemic at a level of interdependency and interaction that no one has ever thought of before. “We have never had to push this hard, but it is about systems and systems design,” observed Berwick, a former administrator at the Centers for Medicare & Medicaid Services.
For example, the issue of supply chain management has come into broad focus as health systems experience shortages of critical supplies and manpower.
“How do we move equipment, supplies, knowledge, and people around in a way that is most responsive to the local need?” Berwick asked. “It is a highly difficult and important way to think in systems terms. “Systems terms also force us into thinking about inter-relationships and interdependencies in ways we never have before.”
The knowledge of variation primarily is about the use of data, Berwick shared. He noted the United States has fallen way behind in this area in its response to the pandemic because health systems were not equipped to perform the kind of diagnostic testing needed to get ahead of the curve. Thus, it has been unclear where the coronavirus is appearing, who is contracting the disease, and what the patterns of acquisition are.
“The use of data and information, and understanding variation, is absolutely crucial in this environment,” Berwick stressed. “We need to get smarter about how we are using and consuming information and sorting wheat from the chaff so we know what bad data look like.”
The knowledge of psychology may be the most important category in the system, Berwick offered. He explained this pertains how people work together, depend on each other, negotiate with one another, and provide support to each other. “That all matters now at a level beyond anything we have experienced before,” he said.
This category covers cognitive psychology, social psychology, group psychology, and learning theory. It also includes the understanding of motivation, Berwick said.
“As I watch this outpouring of generosity and help beyond anything I have ever seen, it restores some sense of human spirit,” he added. But Berwick stressed that respect for the workforce and understanding that people need to be nurtured is crucial.
The final category in the System of Profound Knowledge is all about the learning process. It encompasses plan, do, study, act (PDSA) cycles and other tests of change that can push innovation forward. “We are going to have to be better at that than we have ever been before because we don’t know what the future holds,” Berwick acknowledged.
That means working as a community to try new things and report to each other on what everyone is learning. “[This is] not sloppy science, but disciplined, local tests,” Berwick explained.
Accelerate Innovation
The IHI works with partners in other countries regularly. While the trajectory of the disease in each of these locations is somewhat different, there are at least three issues with which every health system is grappling, Feeley noted.
First, health systems are all reporting that they have “a dire and deeply concerning shortage of PPE,” he explained. “That is international ... something needs to be done to mobilize people’s energies to solve that problem quickly.”
Second, every health system is reporting “extreme levels of stress and burnout,” Feeley noted. “They are tired, they are stressed, they are bloodied, and they are heroic. We see that across the world. Healthcare workers are going the extra mile and doing remarkable things.”
Third, healthcare administrators are preparing to manage a surge in COVID-19 patients. They are thinking deeply about how they are going to meet the needs of hospitals and patients, and what they will do if they cannot secure enough PPE.
The IHI is developing a platform where healthcare providers around the globe can share solutions they have developed with colleagues. “We have been testing the robustness and the utility of that over the last week with our fellows and some of our closest partners,” Feeley said. “It is proving to be an incredible learning platform, a way of exchanging information on a real-time basis about how to solve a particular challenge.”
Nonetheless, the pace of innovation needs to speed up to meet the current needs, Feeley stressed. “We have a pre-existing set of innovation approaches, which largely run in 90-day cycles, [but] at the moment we need closer to 90 innovations than we need 90-day innovations,” he said.
Feeley noted the IHI and its partners are trying to find ways to accelerate the innovation cycle without losing the rigor and the value of the resulting solutions.
Indeed, many healthcare systems are innovating in real time. For instance, Feeley noted Washington state-based Providence has started “The 100 Million Mask Challenge” to create and source protective masks. Other health systems are coming up with new ways to reprocess masks. Certain industries, like the Ford Motor Company, have retooled some of their factories to help manufacture PPE.
Others are innovating to find new ways to work and connect while observing physical distancing recommendations. For IHI, that has meant finding fresh ways to teach, Feeley observed. He added that it also is important to show appreciation for healthcare workers.
“I was really heartened to see the rounds of applause that went around the U.K. for healthcare workers, how many people participated to celebrate the contributions of the healthcare workforce,” Feeley observed.
Such expressions also have been observed in the United States, particularly in large cities such as New York City and Atlanta, where people are going out on their apartment balconies at set times each day to cheer frontline providers. “We need to do more of that, and find new and innovative ways to celebrate the people who are keeping us safe right now,” Feeley stressed.
Curate Ideas
With so much innovation going on, it is important to focus on how to most effectively exchange ideas and new solutions, Berwick stressed. For example, he noted the IHI Leadership Alliance maintains a listserv where hundreds of members post their ideas and experiences.
“How do we curate and harvest from it so it isn’t this overwhelming flood,” he asked. People will pick up on an idea, put it to work quickly, and then report back so others can learn from their experience. “That is the community we need,” Berwick added.
The World Health Organization, the Centers for Disease Control and Prevention, and many other groups maintain these types of curated exchanges. There are many other forums where people are sharing ideas, too, but it is not always easy to sort through the options during a pandemic, Berwick acknowledged.
In fact, Berwick said crisis standards of care is a subject of frequent discussion. When so much demand is hitting healthcare providers, the old regulatory requirements may not work well. In fact, those dated requirements may be counterproductive. Berwick used U.S. state licensing requirements for physicians as an example.
“Telemedicine is cross-state. If we apply the state licensure requirements to telemedicine, we have tied our hands and can’t offer expertise at the pace we want,” Berwick explained.
At individual hospitals, healthcare leaders have to consider whether the rules under which they are operating are impeding effective care. “What can you flex in the rule base you work from that allows your workforce to be much more agile in learning and meeting needs without irresponsibility?” Berwick asked. “There has to be this balance between ‘anything goes’ and some sense of responsibility and discipline in drawing inferences from what is going on. We have to do this at a pace and level we have never before experienced.”
Invest for the Future
Why was the U.S. healthcare system not more prepared for a pandemic? “To be kind to ourselves, nobody knew something of this magnitude would hit this fast and so hard,” Berwick offered. But he also acknowledged there was evidence that the country was not adequately prepared.
Berwick chaired a National Academy of Medicine workshop that, for one year, looked specifically at the issue of U.S. preparedness for 21st century threats. “This was a pretty serious inquiry by dozens, if not hundreds of experts in the U.S. looking at our level of preparedness. Frankly, the conclusion was that we [were] not prepared. We [had not] invested where we need to,” he explained.
The government has established prototype regional structures under the newly renamed National Emerging Special Pathogen Training and Education Center (formerly the National Ebola Training and Education Center). This is a start, but Berwick noted those prototypes have not been spread, habits of cooperation have not been established, and supply chain management is not in place. “Unfortunately, what has happened is what we sort of imagined,” Berwick lamented.
Healthcare providers around the world are relying on innovation to help their organizations survive the COVID-19 pandemic, a crisis that has brought with it unprecedented challenges and complexity. Some structure is needed to curate the best ideas and ensure they are shared widely.
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