Alison Starr is a QI superfan. As a participant in IHI’s Improvement Advisor Professional Development Program, Starr took on a project to improve morbidity and mortality reviews at Australia’s Western Sydney Local Health District, which serves a population of near a million and is growing fast. We asked her a few questions about what she learned in her project — and in her side job as a football umpire.

How did you first become interested in QI? 

Wow — that’s like asking me how I found my purpose in life! Looking back, I think I’ve always been interested in QI, but I didn’t know that’s what it was in the beginning. As a speech pathologist, I loved looking at data about our care and whether it translated into meaningful outcomes for patients. I was always asking, “What can we do better?”

What was your first QI project, and what did you learn from it?

My first project was working on the long waiting lists within a community speech pathology service. We had to redesign the intake, scheduling, and treatment processes.

I learned a lot about making hard decisions, such as not offering therapy in a limited service to clients whose chances of improvement were relatively low. This was a really hard lesson, and I still see it as a huge challenge for public health care today. What should we stop doing in order to do other things better? We are the custodians of taxpayers’ money and we must be accountable for spending it wisely.

Tell us about your Improvement Advisor (IA) project. Why did it matter to you?

My IA project was about mortality review. We have four acute hospitals in our system, and all of them had different ways of reviewing the deaths of patients — it was very patchy and there was no standardization. We owe it to our patients to learn from the outcomes of health care, especially from unexpected and potentially preventable deaths.

End-of-life care is my passion, and I wanted to collect data on how well we were planning for patients’ care. Do we understand our patients’ and families’ wishes? Do we plan early and consult them in planning their care? Mortality review was the first step to learning more about how well we do this.

There were two parts to my project. First, we tested a tool to screen all deaths across the system to identify areas for improvement. Second, we worked with clinical teams to strengthen the morbidity and mortality meetings that each service conducts. Some services documented these very well, and had systems for closing the loop on actions for improvement. Others held them in isolation and weren’t always capturing the potential for broader system improvement.

What were your results?

For the mortality screening piece, we collected some really useful data that showed how many patients required a rapid response for deterioration in their condition — and that for some of these patients, the conversation about end-of-life care didn’t really begin until they’d had one of these calls.

We are just about to appoint someone to a screening role (finally heading to implementation after 18 months!), and the metrics from my project will become a permanent dashboard for measuring our success. We’re also using some of the case studies as examples in our education. The morbidity and mortality meetings are in the implementation phase now, with standardized templates and processes in place. Almost half of our departments have now completed a full quarterly reporting cycle and the rest are on the way.

One of the most pleasing things that happened was during a presentation to a safety and quality committee. The consumer on the group contacted me to ask about how consumers could contribute to making this happen. I believe consumers are an underutilized lever for improving our system, so it was exciting to get their interest.

How did the IHI Improvement Advisor program change your perspective on QI?

The biggest eye-opener for me was rapid-cycle PDSAs and the value of making predictions. I was used to measuring at the end of a project, but not every step of the way.

I did my first PDSA, just to gather information, from my hotel room in Boston in half an hour. I had electronic access to the first screening tests, and I’d been told that we had poor compliance in completion of resuscitation plans for patients. So I was expecting to see results confirming this — but 100 percent of patients had a plan! This was a huge revelation. What I later learned was that the biggest issue was with timeliness of completion, not the completion itself.

Of course, this completely changed my approach to improvement. It really cemented the idea of rapid cycles and changing hypotheses. I’ve never forgotten it.

What was the biggest surprise in doing the project?

I thought I would experience resistance in my project — and I was right. But the resistance came from different teams than I expected — the departments I thought would be my greatest naysayers were actually my biggest supporters, and vice versa. For the teams that were resistant, I stayed in the background, worked through team members they trusted, and tried to hold true to the perspective that we all want to do the best for patients. And I invoked the good old spirit of competition. With plenty of patience, it worked!

You’re an avid sports fan and also worked as a football umpire (Australian Rules Football, for the Americans). Are there any lessons from sports that you use in QI?

Australian Rules Football is the greatest game in the world! As they say here in Australia, I’m a one-eyed footy tragic — I only have eyes for my team, the Sydney Swans.

I moved from watching to participating relatively late in life — I didn’t start running until I was 40. Becoming fit was really like a QI project in itself. I knew I was going to need metrics to keep me motivated. There was no way I could compete with the 17-year-old male bodies that mostly fill the umpiring ranks. So I got myself a GPS watch and tracked my progress and personal bests.

The other big learnings were about discipline, teamwork, and leadership. Turning up at training twice a week and working hard got you the best games on the weekend. Team support meant a lot when I came in last in a 5-kilometer time trial. I learned that leadership doesn’t have to be about status and position — I watched those 17-year-old umpires take on players and coaches more than twice their age, standing up for what was right with maturity and calm authority.

What advice would you give other QI learners, especially those who are just getting started?

Think of the project itself as a vehicle for learning the methodology. When I was struggling, I didn’t worry about how many mistakes I made, or even whether the project itself delivered as intended. It was building skills and capability that I could use on other projects and spread across the system.

I also learned that feeling lost is a normal symptom of struggling — especially when learning the harder concepts of QI and measurement! This is where the energy and collegiality of the IA program saved me — use the listserv and the expertise of faculty as your support network — you’ll find many people feel the same, and someone will have been there before you and have helpful advice.

The IA program changed my QI world — I’m now known as the “chart nerd” at work. Which means more opportunities for nerdiness keep coming to me, and fellow nerds are coming out of the woodwork, too!

Share your QI challenges and triumphs in the comments below, and learn more about Alison’s work on her health system’s quality web site: http://www.qualitymatters.co.