Why It Matters
"Once they get a taste of using QI to make incremental improvement on something they thought was impossible to change, there is no going back. They can’t unsee what they’ve seen. They can now imagine a world where these inequities do not exist."
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Lessons for Health Equity: Making the Impossible Possible

By Kedar Mate | Friday, October 14, 2022
Lessons for Health Equity Making the Impossible Possible Photo by Muzammil Soorma | Unsplash

When the challenges we face today seem utterly intractable, it is worth remembering that it was once considered lunacy to try eliminating what used to be one of the most common healthcare-acquired infections.

About 20 years ago, most of us assumed that a certain proportion of patients who had an endotracheal tube while on a ventilator would inevitably develop pneumonia. The conventional thinking was that it was an unavoidable tradeoff — or a necessary price to pay — for an intervention that had the capacity to save patients’ lives.

IHI, in collaboration with our faculty and partners, questioned the validity of this assumption. Why, this group asked, do we have to accept this tradeoff? Why not change our operating assumptions? Instead of assuming that VAPs were “the cost of doing business,” we started working as if this was not an inevitability and developed the elements that eventually became known as the IHI ventilator bundle.

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Once we began to promote the idea that reliable implementation of this bundle could reduce these infections — and maybe avoid them entirely — some practitioners responded with skepticism or disbelief. But clinicians in ICUs all over the US (indeed, all over the world) gave it a try. And, when they did, many saw the days between a ventilator-associated pneumonia for a 20-bed ICU go from five to 15 to 25 to 100 days between infections. Some went for a whole year without an infection. Indeed, there were ICUs pre-COVID that had gone thousands of days without a ventilator-associated pneumonia.

We made the impossible possible by thinking differently about the problem. We imagined a world without it. There are lessons here for health equity.

When you give a clinical team data that makes clear that there is an inequity occurring in their environment that is compromising the health outcomes of their patients, our sworn oaths as clinical providers call on us to eliminate those inequities. To abide by a system that produces disparate outcomes for disempowered or under-resourced patient populations becomes unconscionable. Righting those wrongs can become a rallying cry for clinicians.

I’ve seen this time and again, in health system after health system, from urban environments to rural environments. Whether the disparities are by race, geography, gender, or sexual orientation, I’ve seen organizations and individuals choose to see inequities as the avoidable, unnecessary, undesirable variation they are and act accordingly. And it lights a fire inside them. Once they get a taste of using quality improvement methods to make incremental improvement on something they thought was impossible to change, there is no going back. They can’t unsee what they’ve seen. They can now imagine a world where these inequities do not exist.

For example, one multihospital health system stratified their stroke care data, and found a massive difference between the care received by Black patients when compared to White patients. The time to care for Black patients was longer at every step of the stroke care pathway despite coming in with similar presentations. By the end of the care pathway, there was a 20-minute difference to get the appropriate clot-busting therapy. This means it took more than 70 percent longer for Black patients to get lifesaving and disability-preventing treatment.

The ED team were shown the data, and they were horrified. It mobilized them to take action. They raised this into the consciousness of everyone in the emergency room and made the requisite system changes, including standardizing assessment, reducing time to seeing a clinician, and reducing time to implementing orders for any patient in the stroke pathway. These changes eliminated that gap in performance in a very short period of time. Within 11 weeks, their data indicated they had completely eliminated that disparity.

Massive change is possible because once a single team starts to make progress on equity, other clinicians start asking themselves important questions about where their disparities might lie. And this kicks off a virtuous cycle of inequity elimination, where all or most clinical departments in health systems we work with start looking at their data to find their disparities (because inequities are there if you have the courage to look).

Not every equity project will take less than three months to get results. Some of the inequities we need to address are more complex than others. Undoing the legacy effects of hundreds of years of trauma and systemic oppression is not going to happen overnight. But it is possible to take what we might have assumed was impervious to improvement and make it better, if we’re willing to admit that inequities exist, and apply ourselves with discipline to the challenges before us.

Editor’s note: Look for more each month from IHI President and CEO Kedar Mate, MD, (@KedarMate) on improvement science, social justice, leadership, and improving health and health care worldwide.

You may also be interested in:

Using Quality Improvement to Address Racism

Payers Investing in Health Equity: Collaborating to Take on Big Challenges

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