Why standards or training do not fix all problems: How to identify and improve system problems

1. Why standards or training do not fix all problems: How to identify and improve system problems Nigel Livesley MD, MPH Regional Director, South Asia USAID ASSIST Project URC Email: nlivesley@urc-chs.com Twitter: @NigelLivesley

2. % of women attending ANC clinic whose BP and Hb is measured

3. Improving health service delivery organisational performance in health systems.Pallas et al. International Health 4 (2012) 20–29 • Standards and guidelines • (accreditation, quality inspection) • Knowledge and skills enhancement • Leadership and management • (supervision) • Organisational structure • Incentives • Process improvement • Organisational culture

4. The highest attainable standard of health Interaction between provider and patient

5. The highest attainable standard of health Interaction between provider and patient Culture Skills enhancement Healthcare process improvement Skills + process improvement Organizational design Leadership and management Standards and guidelines Incentives $$

6. % of women attending ANC clinic whose BP and Hb is measured

7. This could be due to poor individual performance or poor systems Primarily system problem There are barriers preventing nurses from doing their job Solutions Process improvement Management

8. This could be due to poor individual performance or poor systems Primarily individual problem Nurses aren’t doing their job Lack of knowledge Lack of skills Lack of motivation Solutions Standards Training Incentives Supervision Primarily system problem There are barriers preventing nurses from doing their job Solutions Process improvement Management

9. This could be due to poor individual performance or poor systems Primarily individual problem Nurses aren’t doing their job Lack of knowledge Lack of skills Lack of motivation Solutions Standards Training Incentives Supervision Primarily system problem There are barriers preventing nurses from doing their job Solutions Process improvement Management

10. % of women attending ANC clinic whose BP and Hb is measured

11. Huge variation from patient to patient and week to week

12. Improving processes of care…

13. …led to a nine fold increase in the number of women identified with risk factors 18 high-risk pregnancies identified (1.4%) 39 high-risk pregnancies identified (12.3%)

14. The highest attainable standard of health Interaction between provider and patient Culture Skills enhancement Healthcare process improvement Skills + process improvement Organizational design Leadership and management Standards and guidelines Incentives $$

15. To Err is Human: “the majority of medical errors do not result from individual recklessness … More commonly, errors are caused by faulty systems, processes, and conditions that lead people to make mistakes” “Health care organizations must develop a “culture of safety”... This will mean incorporating a variety of well-understood safety principles, such as designing jobs and working conditions for safety; standardizing and simplifying equipment, supplies, and processes; and enabling care providers to avoid reliance on memory.”

16. How well does the QI community do at making system changes?

17. System vs individual changes

18. Examples

19. Examples

20. Examples

21. Interventions to change systems remain underused Kellogg et al. BMJ Qal Saf 2017

22. Most changes focus on individuals 73% 27%

23. Skepticism about the ability of health care workers to identify and implement system changes

24. Skepticism about the ability of health care workers to identify and implement system changes Skepticism should not stop us from trying to get better

25. Number of kidney transplants per year 1933-1954

26. Number of SUCCESSFUL kidney transplants per year 1933-1954

27. Review meeting in 1963 • 216 transplants reported, most had died early: • Cadaveric - 81% • “Kidney transplantation is still highly experimental and not yet a therapeutic procedure

28. Increased use of new approaches • 1 year cadaveric survival - 50%

29. Continued refinement • 1 year cadaveric survival - 85%

30. This happened because of incremental improvements in: Surgical technique Immunosuppression Anti-infective therapy Reducing time to transplant Organ preservation Histocompatability typing

31. New things rarely work perfectly • Making new things better takes testing and adaptation and science

32. New things rarely work perfectly • Making new things better takes testing and adaptation and science • The QI community tends to not practice what we preach when it comes to our own approaches

33. What are the barriers to making system changes?

34. Why do QI teams not make many system changes? Humans are predisposed to assign responsibility to people Identifying system problems and making system changes require a new set of skills

35. Fundamental attribution error • “the tendency for people to place an undue emphasis on internal characteristics (personality) to explain someone else's behavior in a given situation rather than considering the situation's external factors” • Wikipedia

36. Quiz show experimentRoss, Amabile and Steinmetz 1977 • Eighteen pairs of students were randomly assigned to be: • questioner • told to come up with 10 questions they knew the answer to • contestant • 24 observers watched • They new the questioner and participant roles were randomly assigned • They new the questioners were coming up with their own questions • Observers rated the questioners and contestants on their ‘general knowledge’ • Observers rated the questioners knowledge as superior

37. Quiz show experimentRoss, Amabile and Steinmetz 1977 • Eighteen pairs of students were randomly assigned to be: • questioner • told to come up with 10 questions they knew the answer to • contestant • 24 observers watched • They new the questioner and participant roles were randomly assigned • They new the questioners were coming up with their own questions • Observers rated the questioners and contestants on their ‘general knowledge’ • Observers rated the questioners knowledge as superior

38. Quiz show experimentRoss, Amabile and Steinmetz 1977 • Eighteen pairs of students were randomly assigned to be: • questioner • told to come up with 10 questions they knew the answer to • contestant • 24 observers watched • They new the questioner and participant roles were randomly assigned • They new the questioners were coming up with their own questions • Observers rated the questioners and contestants on their ‘general knowledge’ • Observers rated the questioners knowledge as superior

39. Most public health interventions involve individual solutions Pallas et al. International Health 4 (2012) 20–29 • Knowledge and skills enhancement • Standards and guidelines • Leadership and management • (supervision) • Organisational structure • Incentives • Process re-engineering • Organisational culture

40. Summary • Despite talking about system change many QI initiatives still focus on changing individual performance • Reasons for this include: • Fundamental attribution error • Traditional focus in health care education on individual performance • Lack of emphasis on building skills to identify and solve system issues QUESTIONS/COMMENTS

41. What are some possible solutions?

42. Maternal mortality in a Delhi hospital in 20135854 deliveries

43. Women assessed only twice in six hours after delivery

44. Poll: What change did the team make? • Train nurses in how to do assessment • Re-emphasize the importance of following standard care • Add new nurses • Assign new patients specific beds and keep BP equipment in one place

45. First change: re-emphasize standards Solution: Letter from medical superintendent re-emphasizing that nurses should assess women 6 times in the first 6 hours.

46. Poll: What will happen? • Fewer assessments will take place • No change • More assessments will take place

47. Sustained improvement!

48. 0.16% of women identified with complications

49. Poll Why has the number of assessments gone up but the number of women identified with complications has not? • The hospital does a great job of preventing complications • The nurses do not know how to effectively assess women • The nurses are not doing effective assessments because they don’t care • The nurses are not doing effective assessments because something in the system is making it hard

50. Why has the number of assessments gone up but the number of women identified with complications has not? • The hospital does a great job of preventing complications • Not likely – the mortality rate in 2013 was very high • The nurses do not know how to effectively assess women • Not likely – measuring vitals and identifying complications are not that difficult • The nurses are not doing effective assessments because they don’t care • Not likely – no one likes mothers dying • The nurses are not doing effective assessments because something in the system is making it hard • This seems most likely