Publication Date: 2012
Katharine Luther, RN, MPM
Institute for Healthcare Improvement
Q: Describe your career path — how did you get involved in quality improvement?
I’m a nurse by background, in critical care. I’ve always been interested in how things work — not only what you do one-on-one but how the whole system works, how things move. Fifteen or 20 years ago, “performance improvement” was a very new field. I really came into it with Susan Edgman-Levitan and the Picker Institute. They were early in the field of measuring patient satisfaction. (Actually, one of the first quality improvement presentations I did was next door to IHI's Cambridge office, in the Charles Hotel, with Harvey Picker sitting in the back, in his little bow tie!)
While I was at University of Pittsburgh Medical Center, we were just starting to measure our patients’ reactions, using Picker surveys. And I could see the huge disconnect between the nurses feeling they worked really hard and thinking, “Why didn’t I get 100 percent?,” but the patients really feeling that some things are missing.
So I became interested in bridging the gap between what is and what could be, during the mid- to late 1990s. Part of it is data — where’s the gap?, how big is it? — and the second part is how do you help clinicians and front-line staff understand and get over their fears, start thinking differently — and then help them begin to do things differently. That became very intriguing to me. I could see the gap, I could see why the gap existed, so… how do we start to bridge that?
Then when I went to Houston [to Memorial Hermann-Texas Medical Center], I first connected with IHI. Penny Carver [former senior vice president] contacted me and asked me to work on the “Service Collaborative” — one of the first Breakthrough Series Collaboratives, an early program IHI offered.
About the same time we started focusing on medical errors and error prevention, and I led a Memorial Hermann team in an IHI medication safety collaborative. And that was the first time I had ever seen the Model for Improvement, and I thought, “Wow, this is such a different way to think about it. This is something you can do quickly; something people on the front lines can get together on.”
So it was these issues — service, safety, and closing the gap — that really sparked my passion for quality improvement. My career evolved from nursing; by the time I got to Houston in 1996 I was a quality director. It was an exciting time; things were shifting from the “old” QI, where you audited a bunch of charts and then you said, “We’re at 90 percent, thank you very much. We’re good,” to “Oh my gosh, we had a medication error that killed a patient. How did that happen?”
We were also a little bit lucky: Memorial Herman is close to NASA, so we took advantage of that. We spent time there and we learned a lot from them about safety — how to do root cause analysis, how to understand risk. This was around the time people like Don Berwick [IHI founder and former president and CEO] were also learning from other industries — aviation, nuclear power, manufacturing — where quality improvement was built into the work, the standard processes.
And around that time the National Patient Safety Foundation was just forming; we actually hosted one of the first patient safety conferences in Houston. So we worked with Lucian Leape [founder of NPSF]; he was really at the forefront of the patient safety movement. It was just a very formative time and it was fun being part of that.
Then in 1997 things moved up a notch after a crisis: we [Memorial Hermann] were featured in the New York Times after a tragic medical error. It was an article in the Sunday Times magazine on Father’s Day, a cover story about the death of a baby on our pediatric special care unit caused by a medication overdose.
So it was huge, and of course we were very nervous when the reporter came to us … “Oh my gosh, are they going to trash us?” But we as an organization — with some courageous leadership — decided to go public and share our story. It was pretty painful for everybody. Dana-Farber was also included in the article [Dana-Farber Cancer Institute, where Boston Globe health reporter Betsy Lehman died after a chemotherapy overdose in 1995]; it also mentioned a handful of other high-profile medical errors that had come to light in recent years.
What happened was amazing — in the end, it was a great article. The analysis of the tragedy, the whole message of the story, was basically: Who’s to blame is the wrong question. [“How Can We Save the Next Victim?” New York Times, June 15, 1997.]
It really signaled kind of the beginning of a new way of looking at medical errors — the “safety and systems” approach.
After that crisis, our focus really changed to “How can we become very data driven?” and “How can we use data systems that we have to improve care?” One day I was sitting with my chief medical officer, and I was thinking, “We’ve got 13 ICUs in our organization. Let’s work on improvement there. Let’s stay focused on the ICUs and get them in shape.” So that was a starting point.
The industry was changing, too. With all of IHI’s work, with NPSF and a few other organizations, things began to move forward in very different ways.
Q: What was your journey to IHI?
This was right around when IMPACT [IHI’s former membership network, a predecessor of Passport] was starting, so we were one of the first organizations to join. We started working with Roger Resar [IHI Senior Fellow] and implementing bundles. We tested some of the first bundles in our trauma unit, and pretty soon we realized we didn’t have any VAPs [instances of ventilator-associated pneumonias] for a month!
Now, of course, we have ICUs who have gone years without VAP or BSI [bloodstream infection]. But back then, we didn’t know it could be done and we didn’t know how to do it, what the components were.
It was the early days of testing and rapid cycles, and Roger kept coming up with new ideas, so we were down in Houston trying them out, along with other teams in different organizations. We worked with the Central Line Bundle [aimed at preventing bloodstream infections from central lines]; we focused on medication safety.
Through this work, two things happened for us. Most importantly, we learned we could do better — we learned how to learn. Secondly, we learned we could change the direction; the course for patients, for our whole organization. And with all of this, there was culture change. Things really evolved.
We signed on for the first IHI Campaign [100,000 Lives Campaign] — we really embraced it. We had a banner hanging in our main lobby. It was in the shape of a tree, showing how many lives we saved: “200 Lives Saved Last Year.” Then we had smaller banners hung in each medical area, “Medicine: 40,” “Trauma: 6,” and on and on.
And we were one of the first organizations to start working with Brian Jarman [IHI Senior Fellow], understanding HSMR [Hospital Standardized Mortality Ratio]: what it was and how we could implement it. We tested “2x2s” [a matrix tool IHI developed to help chart reviewers analyze patient data as part of the HSMR measurement process].
We did really good ICU work: we cut our inpatient mortality significantly over a period of years — by learning, understanding what we needed to do, and how to do it. And we began to get national recognition for our work; people started paying attention. Gradually, I could see the physicians kind of grumbling: “Who’s this nut woman giving us this data, these reports? She’s all wrong, she doesn’t understand…”
So I realized I had to get physicians on board. Nurses were on board; respiratory therapists were on board; pharmacy was on board. We had quality processes within the hospital for them, but there was nothing in the academic center.
A couple of things came together through the University of Texas; some physicians had been working with the Brent James ATP course [Intermountain Health Institute for Healthcare Delivery Research’s Advanced Training Program in Clinical Practice Improvement]. So there was interest growing within my organization, and we were able to start a small, focused, year-long program for a group of physicians to learn improvement and begin to lead projects in their departments.
The physicians we tapped were assistant and associate professors, three to five years out of their residencies, and we chose them specifically because I thought they’d be the most likely to try new things. And, to everyone’s surprise, they all started to work together — and realize they hadn’t been doing this before! So, someone from the medical ICU said, “Well, I really want to do this, but the patients come from the ED this way…” and the guy from the ED said, “Well I could help you with that. Here’s what we could do ...”
Because of the way academic centers are “siloed” by discipline, there was never a lot of cross-working, so one of the goals of this program was to foster that teamwork. But they really did it themselves, just by sitting together, listening to each other’s problems and learning what each other does.
We did three cycles of this program and then it became operationalized. About 25 physicians came through the program — many of them subsequently appointed vice chairs of quality within their academic departments, which was really great to see.
Q: What work are you doing at IHI?
I joined IHI full time in 2010, and I’ve been leading the Impacting Cost + Quality work, which is really exciting. I think the greatest thing we’re seeing is finance and clinicians working together to solve problems — which doesn’t happen! So it’s really fun to see that begin to happen, to see clinicians understand how finance thinks and finance understand how clinicians think, and both identifying really specific problems they can solve together.
It didn’t happen instantly. We said each team had to have a finance person on it — they usually come wondering what this is all about. But then, usually by the second day, they’re saying, “Wow … we can really help on this!”
So that’s been really rewarding. I think there are a lot of ways we can take the Impacting Cost + Quality work we’re doing with hospitals and move that into Triple Aim communities. There’s a lot of synergy; all of these pieces can work together.
I also help lead IHI’s Quality Improvement for Chairs and Chiefs program, a two-day seminar held twice a year — it’s become a really popular program, for which we can all thank Vin [Vinod Sahney, PhD, founding member and Chairman of IHI’s Board of Directors, and an IHI Senior Fellow].
Vin came to me in 2010 and said, “You know, the academic chairs don’t learn anything about quality improvement.” I said, “I know! We can teach them something about it.” There are usually some factors motivating them to learn: younger staff who know how to do improvement work and want to do it; maybe their [medical school] dean or hospital CEO might be asking them to do it. But they might not quite know how to go about it. So we developed a program together.
Vin knew all the right people; he brought in a lot of great faculty. It’s a really exciting program — it fills up quickly and always sells out. We’re exploring ways to expand it and make it more interactive so we can accept more participants.
Q: What are you most excited about in your work?
When you’re in the middle of this work, it’s long and hard and slogging. But we’ve come so far; we’re doing things that we never dreamed possible. And we still have so far to go.
I think the next phases are: How can we be thinking about a whole community? How can we engage patients in broader, bigger ways? How can we make hospitals smaller but much more efficient and effective? How can we help people see the bridge to the new way? It’s really just like the patient satisfaction scores — “We’re fine,” “No you’re not?” … and then: “What’s the gap? How do we understand it? How do we think differently and move the whole field along?” And: “Here’s the new way; let’s go.”
The exciting thing now is there’s so much momentum in the field, across the industry. You’re working alongside so many other organizations. And the Centers for Medicare & Medicaid Services is at the table now — that’s huge. Before, our work was just in very small pockets. And here at IHI things are really coming together. There’s a lot of synergy — among programs, portfolios, aims. It’s really exciting!