With the recent election, there has been a new recognition of the various “bubbles” we all seem to be living in. It reminds me of the parable I like to often mention, popularized by the late great writer David Foster Wallace:
Two fish were swimming along when an older fish swam by, nodded his head at them and said, “Mornin’ boys, how’s the water?” The two young fish nod back and swim for a bit, then one turns to the other and says, “What the hell is water?”
Recently, I read a paper that helped me realize I had been swimming in a different lake from most of the “real world” in medicine. I trained and then spent the first 4 years of my post-residency career at UCSF, where quality improvement (QI) was well established and celebrated. Sure, I suppose there were some eye rolls from a few surgeons, or I would hear the off-hand snide remark from a cardiology attending, but by-and-large QI was not controversial at UCSF. It was what we do. As residents, we led QI projects and contributed to QI projects from our colleagues. As a hospitalist faculty member, I led my own QI-related projects and mentored residents and other faculty who led their own QI projects.
Imagine the hard reality that hit me when I read this quote from a resident: “Truly the first thing I think of when I hear [QI] is going to make more work for residents.”
Wait – is QI actually a dirty word for other residents and physicians?
The quote comes from an Academic Medicine study titled “‘It Feels Like a Lot of Extra Work’: Resident Attitudes About Quality Improvement and Implications for an Effective Learning Health Care System.” I read on, and it got worse.
“This hasn’t really made any difference to the patients. Like this checklist we do on rounds, like I don’t know. Maybe it has.”
And, by far, most concerning: “There’s like the central line protocols… If you suspect that anybody has any type of bacteremia, you don’t do a blood culture; you just do a urine culture and pull the lines… we just don’t even test for it because the quality improvement then like marks you off.”
Wow. That is some harsh truth about unintended consequences right there. (Also, apparently us kids of the 90s still say “like” a lot, which is like not very professional and also like kinda grating).
The residents in this study were from the University of Utah – an institution I frequently publicly admire for their incredible progress on systematically introducing value improvement into their practice.
What can we do?
Well, let’s turn to another recent provocative article, “Does Quality Improvement Improve Quality?” by the always brilliantly incisive Mary Dixon-Woods.
Spoiler alert: the answer is, often no.
“…Despite the widespread advocacy for QI, the evidence that it produces positive impacts in healthcare has been very mixed, with many of the better-designed studies producing disappointing results.” The authors propose many reasons for this gap, from the often “time-limited, small-scale projects, led by professionals who may lack the expertise, power or resources to instigate the changes required,” to the lack of attention on how important context is to QI design and results.
When you really get down to it, this actually does jive with many of my experiences with QI. Can I go back and take the blue pill instead of the red one?
Mercifully, they provide advice on “how to improve the quality of quality improvement.” Here is their summary, from Box 1 in the paper. It is a little long, but well worth the read.
Last week, I hosted a group of residents from across different programs at my house for a meeting. The group was the “QI Council,” which was formed by a surgery resident physician who invited friends from each of the residency programs associated with Dell Med. In other words, this group was initiated by the residents and for the residents.
They want to make processes and outcomes better for patients and themselves. I am doing my best to help create our own bubble here where QI is not a dirty word for the residents and where we institute some of the best practices to ensure QI programs will actually result in some improvements. Please don’t pop our bubble yet.
Christopher Moriates, MD is a hospitalist, the assistant Dean for Healthcare Value and an Associate Professor of Internal Medicine at Dell Medical School at University of Texas, Austin. He is also Director of Implementation Initiatives at Costs of Care. He co-authored the book Understanding Value-Based Healthcare (McGraw-Hill, 2015), which Atul Gawande has called “a masterful primer for all clinicians,” and Bob Wachter said is “essential reading for everyone who care about making our system better.”