Kedar Mate, MD, is IHI’s Chief Innovation & Education Officer. In the following interview, he describes his journey and what he sees for the future of the field of quality.
Q: What are some highlights of your journey to IHI?
I’ve been interested in making global health better for a long time. It probably starts from my background – my family is Indian, so when I was a child we often went to Bombay to visit relatives. I saw inequalities and suffering during these trips that I had never imagined in New Jersey, where I grew up.
After I graduated from Brown University, I went to work for Partners in Health (PIH), helping a team in Peru implement a treatment program for patients with drug-resistant tuberculosis (TB) in Carabayllo, an urban slum outside Lima. Patients had to undergo a two-year treatment regimen, using drugs that were very toxic and hard to tolerate. Despite this, it worked — we saw cure rates rise to 70% or higher. So we had an effective therapy and demonstrated that we could successfully treat this deadly disease in the most vulnerable population.
Drug-resistant TB patients were all over Lima, so we had to find a way to spread the therapy beyond the one neighborhood. Jim Kim and Paul Farmer, PIH co-founders, knew of Don Berwick [IHI President Emeritus and Senior Fellow] and IHI’s work. They contacted Don and invited him to come to Peru to help PIH develop a scale-up strategy.
I was assigned to spend time with Don, to help him learn about the project. While he was only there for a brief visit, it was a powerful experience for me — intense exposure to Don’s thinking about health care delivery and quality improvement, which I had never heard of.
Q: What impressed you about Don Berwick’s approach to the Peru PIH project?
It was his optimism, a new perspective. For teams on the ground, there was a level of hopelessness; we knew there was only so much we could do because of the flawed health systems we were working in. The odds were so stacked against these patients that the chances were they’d get the infection again, or, because their living conditions were so poor, they’d get something else — diarrheal disease, perhaps.
We could see the underlying problems, but didn’t have the tools to fix them. For me, that is what Don brought to the PIH project. Suddenly we had a language, a way of thinking about systems as solvable problems, not inevitabilities. You just had to have an aim and the vision to develop changes you could test with a set of measures. This awareness of the power of improvement science, the ability to develop systemic solutions that Don brought my team in Peru, is ultimately what attracted me to IHI.
After PIH, I went to Harvard Medical School and trained in internal medicine. I completed my training at Brigham and Women’s Hospital in Boston and then went to Cornell (Weill Cornell Medical College) to begin work as an assistant professor and a hospitalist at New York Presbyterian Hospital.
The lessons I learned from Don stayed with me, and I kept in touch with him. At the end of my clinical training, I joined IHI as faculty. I also started working with IHI’s team in South Africa focused on HIV/AIDS and maternal and child health. Ultimately, I moved to Durban for two years, serving as IHI’s South Africa country director.
I moved back to the US in 2012, and began working with IHI’s R&D team. Then in 2013, as IHI was beginning to expand its global programs once again, Maureen Bisognano [IHI President Emerita and Senior Fellow] asked me to lead IHI’s work in the Middle East and Asia-Pacific regions.
Q: What is your role as IHI’s Chief Innovation and Education Officer all about?
One part of my job is about creating new knowledge — not just for IHI, but also for the field of improvement. It’s not just about what IHI can do, it’s about what the field of quality and quality improvement can do.
Q: Where would you like to see the field of quality go?
We’ve traditionally been focused on improvement; we’re the Institute for Healthcare Improvement, after all, and the ultimate goal is always to improve outcomes, performance, and our patients’ health and lives, and to do so stably over time.
But to achieve that goal of improvement actually takes more than just traditional quality improvement. It takes knowing and deeply understanding the people with whom you’re trying to make improvements happen. (Some people call them customers, some people call them patients, some people call them moms and dads, cousins, brothers, and so on.)
That’s what Juran called “quality planning.” It’s about planning for quality, creating the operational definitions, the product or service designs and the system specifications to reliably produce these designs for better quality. So that’s part of the puzzle, and I think we’re moving in that direction with the focus on what matters to people, on co-production and co-design. These efforts, at IHI and in the improvement community, fit within that rubric of quality planning.
Q: What would we do differently with more of a focus on quality planning?
System redesign — or quality planning — might require us to dismantle some of the existing designs that are in place to meet specifications we no longer have. Think about fee-for-service reimbursement. Think about the ways we’ve treated chronic disease for generations. Our health care system is one that’s largely been developed over hundreds of years for the primary purpose of providing acute care in highly specialized, centralized facilities, when what we need is a distributed architecture for continuous management of people with chronic disease — very different system specifications, and a very different system design.
When it comes to system design, I think improvers make some mistakes. We start with the notion that the way to best understand a system is to do root cause analysis; to “Ask why 5 times.” But if the objective of system redesign is to fundamentally transform the system, asking what’s wrong with the system as it currently behaves is a recipe for incremental change of the existing system. If you need to design a new system to meet the needs of patients and families, then root cause analysis of the existing process is probably not the right approach.
The right thing to do might be more like what designers do, which is ask a question about what the real need is for the individuals in the system. Not “What’s the root cause of the problem?” But “What’s the real need of the people in the process, in the system? How might we meet that need?” That’s a very different issue …
Q: So if quality improvers don’t always get this right, who can we look to for guidance?
There’s a famous example from a car rental company. It was facing a common problem with long lines of customers at busy airports waiting to go through the car pickup process. They were trying to figure out how to get people through the rental process faster. But they felt if they asked the question “How do we make the line go faster?”, the solutions would end up being focused on the limited number of staff or the slow computer systems, and so on. The change ideas that would surface would be “Let’s add this or that; let’s change the flow in this way ...” That’s not rethinking the notion of the line; it’s finding ways to optimize the system to get people through the line faster.
But the car company didn’t ask that question. It asked, I would argue, a design question: “What are the true needs of the traveler?” The traveler wants to get into their car and drive away as quickly as possible. So, in that scenario, the presence of a line — any line, long or short — is an obstacle to that need. Even if it’s a really short, well-managed line, there’s still a line.
So the company got rid of the line altogether. They created a system that works like this: you sign up for a rental car in advance, online; the night before your reservation, a staff person puts your keys in the ignition and puts your name and a parking space number on a board at the rental desk. They have your credit card information and your license information all stored online. So, you come off the plane, get to the board, see your name and parking space, go find your car in the garage, get in, and drive away. No line! It’s a huge success, but it started with a redesign question: “What is the need of the traveler?” Not a question about “How can we optimize the line?”
I think this is a great model for IHI. In today’s environment, we need to ask the question: “What’s the real need of the patient, the family, the health care consumer right now, and how do we change the design of the system to get us there?” That’s where we need to go with innovation.
So we need quality planning: different designs, based on new user needs. As we go about executing these new designs, we then need quality control to ensure our business processes are reliably producing the care our patients and families need. And when things don’t work, when processes fall outside of control, we need a quality improvement system that returns the process to control.
Q: Quality control sounds like quality assurance. Isn’t that contrary to our approach to improvement?
I think quality control has gotten a bad rap over many years because of this association with quality assurance. To many people, quality assurance is an external body coming in and inspecting and judging — “death by inspection,” it’s sometimes called. That concept of assurance, external validation through a third party, is sometimes equated with quality control.
But it’s not the same thing. The fundamental difference is that quality assurance is performed by third parties, external observers, and it’s meant to assure the public that something is of good quality. A venerable function, we would all argue. When we go to the grocery store, we don’t want to eat tainted meat or poisoned vegetables. We want to eat things that are quality assured. But it does have this element of external inspection.
Quality control is done by operations, by people in the process. It’s not some external observer coming in to judge you periodically. It’s done continually, by the people in the system who do the work of the process every minute of every day. It’s not a third-party intervention that happens once a week or once a year. And it serves an important purpose: it’s a way for the people inside the process to understand whether or not the work they’re doing is meeting the needs of the customer — which all of us want to do, desperately. So fundamentally and operationally, quality assurance and quality control are very, very different.
Q: What keeps you up at night — big challenges you see ahead for IHI & health care improvers?
For health care improvers in general, I think the key challenge is not to stay locked into quality improvement alone. We do need to have a mindset of continuously trying to improve quality, but we need continuous control alongside of continuous improvement.
If health care improvers hew only to the quality improvement piece, then I think we’re in trouble. I think we’ve got to respect quality planning and quality control; put them on the same footing as quality improvement.
Q: What are you most excited about?
The most exciting thing for me is that IHI is in the field doing results-based work much more; our teams are doing work across North America and globally, in a more active way. We’ve got a lot more collaborative programs underway, learning-action networks and the like. And we’re experimenting in new ways; we’re hypothesis-testing and trying to prove the value of quality methodology more and more, in an increasingly wider range of circumstances and issues.
It sounds a bit grandiose, but I think we’re on the precipice of a new generation of scientific knowledge around improvement. It makes me hopeful about our road ahead.
In an organization with such visionary founders and leaders — Don Berwick, and subsequently Maureen Bisognano, and now Derek Feeley, President and CEO — it’s natural to wonder about the long-term path. Can we keep up the momentum? Do we have enough energy in the field? Is there enough new thinking to continue growing and thriving in the spirit of these remarkable founders? With the innovation work IHI’s R&D team is doing to keep pushing the envelope aggressively, I think the answer is Yes.
Kedar Mate, MD, will be presenting at the 2017 IHI National Forum this December 10–13, 2017, in Orlando, FL.