In my 14 years of experience in health care, one of the most important things I’ve learned is that quality improvement (QI) can happen without the jargon. We need to strip QI of the terminology that often confuses more than it explains, and distill its methods to their core essentials to get the improved health outcomes that we seek.
As I prepared for my keynote address at the recent IHI Africa Forum, I thought about this as I recalled my path into the world of QI. I remember that during my medical training in the Korle Bu Teaching Hospital in Ghana, I started practicing improvement even before I knew it was a science. A particular episode during my time working as a district medical practitioner is particularly striking.
One day, I diagnosed a child with severe malaria, admitted him to the ward, and articulated a very powerful management plan that I had learned during my training. After a few hours, I went to check on the child, and encountered for the first time what I later came to understand later — from my improvement science training — as a series of system failures:
- My pediatric fluid order had been replaced with fluids more suited to adults because the hospital did not stock the pediatric fluid.
- The 250 ml bag I was expecting to see had been replaced by a 500 ml bag because it was what they had.
- Because we had no flow regulation devices, the fluid that was supposed to run over 24 hours had all been delivered in about six hours.
The child’s mother — who had no clue that I was possibly mismanaging the care of her son — smiled with gratitude to see me on the ward.
Solving these issues taught me that to move from a series of PDSA cycles to a scalable change package can entail a lot of heartache, and taking on roles for which I was not originally trained. Overnight, my wife (who is also a doctor) and I became procurement officers, finding places to buy pediatric fluids in the preferred volumes. We also taught the nurses how many drops should run per minute to deliver a certain volume over 24 hours.
Fortunately, the child with malaria recovered, and with the lessons from that episode, we set up a more reliable system to make it easier to follow the prescribed treatment protocol. Doctors and nurses had the will, we all brainstormed to get ideas, and we held each other to account during implementation of a system we co-created; reliable procurement of pediatric fluids, training of clinicians, and some results based monitoring.
Learning from Listening
I have also learned over time that to truly embrace patient- and family-centered care, we must listen to emotions with our hearts, not just to facts with our heads. A patient named Mary (not her real name) first taught me this.
Mary was the most severely ill patient in the hospital one weekend when I was on duty. She was a sickle cell patient in vaso-occlusive crisis. I managed her pain, gave her fluids, and treated an underlying chest infection. After spending a long time with her on the ward, her mother — who was a nurse — came to my home with a question. Were we not giving her too much fluid? I explained to her the rationale for the fluid therapy, the general management plan, etc. I thought we understood each other. She went back to the ward alone.
Mary passed away later that night. Afterward, her mother felt embittered against me because all she had really wanted from me that night was to walk back with her to stay with Mary, even if she was going to pass on. I totally missed that, addressing her emotional needs with scientific facts.
Communities have also taught me to listen because they often have the answers to their problems. If you build will by acknowledging and respecting the leadership of the community, and align with their interests, you can use a team approach that gets results.
My first experience working in a community was early in my medical career. At the time, I had no public health or quality improvement training. My team and I, however, had to learn quickly because months after we started providing health care in the district, we observed the increasing number of patients reporting with motorbike injuries at the emergency room. Within the community, the commercial use of motorbikes to transport people and goods had hugely caught on.
With our very rough research and data analysis skills, we outlined a simple descriptive study that taught us a lot, including types of injuries, days of injuries, correlation with market days and Fridays — when bodies were picked from the hospital mortuary for funerals — and the cost of treatment. We knew we couldn’t solve this problem on our own.
We reached out to motorbike owners and riders and organized a huge community meeting to discuss the problem and our findings. At that meeting, the owners and riders resolved to wear helmets, and stop drinking alcohol before driving. The motorbike owners also asked us to help them resolve the chronic tension between them and the police. By helping them, we earned their trust as partners. We bridged the gap that so often exists between public health and clinical care without realizing that’s what we were doing.
From the beginning of my medical career, I’ve never been satisfied with the health care status quo, but early on I did not know the tools and strategies to use to get better outcomes. But, as Uma Kotagal of Cincinnati Children’s Hospital Medical Center has said to me, sometimes you need to start before you are ready. If you wait to have all the knowledge you need, you might end up doing nothing.
Sodzi Sodzi-Tettey, MD, MPH, is Executive Director and Head of the Africa Region of the Institute for Healthcare Improvement.