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How QI Can Turn Skeptics into Believers

By Paulo Borem | Thursday, September 29, 2016
How Quality Improvement Can Turn Skeptics into Believers

Many hospitals in Brazil are participating in two large-scale IHI collaboratives in hopes of eliminating device-related infections and improving maternal and newborn safety. In a new interview, IHI Director, Paulo Borem, MD, describes what he’s learned about engaging clinicians in quality improvement work and how teams went from skeptics to believers.

What have been the highlights of directing IHI’s collaboratives in Brazil for the past year?

The Parto Adequado work to reduce unnecessary C-sections has been one highlight. Over the last 10 years, the C-section rate in Brazil reached 85 percent in the private sector. Everybody has been trying to solve this big problem, but nobody could. So, when the Brazilian government’s regulatory agency invited IHI to help, we immediately saw this as a big opportunity.

Health care-acquired infections are another big issue in Brazil. Last year, we started a collaborative with the Associação Santa Catarina called Salus Vitae. We’ve had 13 ICUs working to reduce infections, especially infection related to devices, including catheters, ventilators, and central lines. The results have been amazing. In most of the hospitals, the rate of device-related infection cases dropped by half after 15 months. The teams are doing a great job of adopting the CA-UTI, ventilator, and central line bundles. The early results have been so good that their goal is now zero.

What have been the keys to these dramatic improvements?

The Model for Improvement — it brings hope to people. When you put together the will to improve and this method, things happen. 

How does the Model for Improvement give people hope?

Before the Salus Vitae collaborative, I think people sometimes assumed these infections were a natural consequence of using these interventions. When we first proposed a 50 percent reduction in device-related infections, many of the teams were skeptical and resistant. They said things like, “Nobody can reduce infections by 50 percent in 18 months. We’ve tried before.” But we said, “It’s possible. Let’s keep trying.”

Using tools such as the Model for Improvement, we provided a lot of structured support to the teams. We helped them create a measurement strategy and plans to implement change packages. We helped them organize the work in face-to-face meetings and coached them on WebEx calls. During the action periods, they used the Model for Improvement to test changes.

Eventually, people saw the number of infections starting to go down. Now they say, “Wow! We’ve had five months without any infections.” We saw a big change in the mindset of both the front line and in the leadership. 

As a doctor, what do you think are the keys to engaging clinicians in improvement?

Data is one of the most powerful things you can use to convert people. There was a doctor who was very against setting such a bold infection reduction aim when we first met him. But during the most recent learning session, he started seeing the results — many hospitals with zero infections for many months — and we converted him to the idea that it’s possible. He offered to help train more doctors and nurses. He went from resistant to engaged.  

Most doctors don’t think about systems, so they sometimes get defensive when we talk about patient safety. They think we’re talking about blame and shame. But I see reason for hope because more doctors are understanding this systems mindset.

For example, a physician at one of the hospitals I visited completely changed the way that he thinks about taking care of babies and mothers while taking part in the Parto Adequado collaborative. He went from 80 percent of his patients having C-sections to 50 percent. That kind of change is becoming common in all of the Parto Adequado hospitals.

Every system is perfectly designed to get the results it gets, and more doctors are seeing they have a role in changing that system with their behavior.

You may also be interested in:

IHI's 2nd Latin American Forum on Quality and Safety in Healthcare​​ (October 26-28, 2016 in Mexico City)

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