Welcome to another HiQuiPs Expert Corner. In this edition, we asked Dr. Eddy Lang three questions about Quality Improvement (QI) given his impressive track record of system improvements.
Dr. Eddy Lang is the current Department Head of Emergency Medicine and a Professor at the Cumming School of Medicine, University of Calgary. In addition, he serves as the Clinical Department Head for Emergency Medicine and a senior researcher at Alberta Health Services, Calgary zone. As the Scientific Director at the Emergency Strategic Clinical Network, he strives to contribute to improvements in emergency services for patients across Alberta. He also maintains a position as Deputy Editor for the Canadian Journal of Emergency Medicine.
How has the healthcare QI arena changed over the past twenty years?
Quality improvement was a vague concept as it made its way into healthcare and has increased its presence over the past twenty years. It started as a very niche area and has expanded to include nurses, physicians, administrators, and many allied health professionals. With increasing knowledge of the field, more expertise has been needed. This is noted with an increase in QI education in medical curricula, and specialized programs.
One main challenge that has arisen over the years is QI work being done in silos. Learning from others’ experiences can prove to be very powerful. Especially when innovative work is being accomplished, there needs to be a transparent way to be able to share this widely and efficiently. While academic journal publication of QI work has been increasing, there remains a great opportunity to share local QI initiatives – both positive and negative findings.
With the increasing focus on quality improvement in healthcare and the identified need to share experiences, QI specific repositories have begun to be explored as a means of reducing the siloed nature of QI work. These would essentially act as ‘databases’ or ‘hubs’ for QI initiatives to be documented and shared amongst QI practitioners.1 However, these repositories are relatively scarce and inconsistencies among those that do exist are common, highlighting the need for continued development of more standardized ways of sharing initiatives in the realm of quality improvement.1
What is an important concept you have learned during your career in leading change and QI projects?
Obtaining clear and timely data is essential to guiding QI work. Clear data can guide a better understanding of the scope of the problem, root causes, and intervention effectiveness. Using clear real time data can also improve operations and the administrative burden.
One local example was looking at utilization of urine testing as part of the routine psychiatric patient admission order sets. Data on its use showed that it was increasingly ordered but did not add important information affecting patient management. By relying on data from the baseline period and post removal from order sets, no complications were noted with reduced testing. Ultimately, the real-time data on this issue helped to reduce the number of patients required to provide samples as part of routine care.
Data collection has to be planned and optimized, for example as part of regular electronic patient record entries. QI practitioners can work with their local health informaticians to build sustainable means of data collection without increasing burden on front line staff. Automation of data collection and embedding ways to validate data collected are also important considerations.
As discussed in previous posts, there are a variety of methods to collect data for healthcare quality, and having a standard and routine way of collecting quality data is of utmost importance.2 Additionally, it is essential to consider the type of measures that will be used prior to starting a QI project.3 The indicators selected should be monitored over time to ensure they are actually measuring what they are supposed to be without repercussions as part of the process of validation.4
Collecting a wide variety of data can also be used as an audit and feedback mechanism for clinicians. This may highlight variations in local or regional practice. Moreover, it may help in developing further quality indicators.
In the audit and feedback process, collected data is compared to targets or standards to provide practitioners with insights into quality of care and areas for improvement.5 In addition to individual clinician feedback, this process can also be used to inform larger scale programs.
For example, in Ontario’s Emergency Department Return Visit Quality Program seen across larger volume emergency departments, chart review is mandated for patients with return visits leading to hospital admissions.6,7 Data collected from these types of larger scale programs can be used to identify gaps, driving further QI initiatives and contributing to the development of quality indicators.
What are three skills you think that QI practitioners should obtain to assist with their work?
QI is a vast field with many potential areas of focus and expertise, but I would focus on the following three:
- QI practitioners should have a solid understanding of core data analysis and presentation such as the use of run charts, Statistical Process Control Charts, etc. An understanding of the theory, and hands-on work with the data is important.
- A lot of QI work also deals with people management and behavioural change. An aptitude for the core theories and ongoing practise in project management skills and behavioural change is essential to a successful QI enterprise.
- QI practitioners are system level thinkers, so an understanding of their system is important. This includes processes that involve different parts of the system beyond their local context. For example, processes that affect the emergency department span the prehospital field, triage, the local ED context, interactions with other allied health in the ED, as well as other consulting services and inpatient settings. Hospital processes from infection control to environmental services, to porter systems are all part of their local system.
QI is becoming increasingly integrated into healthcare across a wide variety of practice settings. Having a solid foundation and understanding of concepts at the core of QI work, including optimizing data collection and system level thinking, are skills and qualities that QI practitioners should strive to develop to assist in their work. With the field of QI continuing to grow, there should be an emphasis on sharing results to dismantle its currently siloed nature and aid in the collective growth of QI across the healthcare system.
That’s it for this edition of Expert’s Corner. If there are specific QI/PS/HI topics that you would like to read about, let us know!
Junior Editor: Jocelyn Price
Senior Editor: Lucas Chartier
- 1.Bytautas J, Gheihman G, Dobrow M. A scoping review of online repositories of quality improvement projects, interventions and initiatives in healthcare. BMJ Qual Saf. 2017;26(4):296-303. doi:10.1136/bmjqs-2015-005092
- 2.Taher A, Trivedi S, Mondoux S, Chartier L. HiQuiPs: Quality of Care and the ED. CanadiEM. Published August 1, 2018. Accessed June 17, 2021. https://canadiem.org/hiquips-quality-of-care-and-the-ed/
- 3.Parpia C, Vaillancourt S. Better Measurement in Quality Improvement. CanadiEM. Published December 3, 2020. Accessed June 19, 2021. https://canadiem.org/better-measures-in-quality-improvement/
- 4.Cameron P, Schull M, Cooke M. A framework for measuring quality in the emergency department. Emerg Med J. 2011;28(9):735-740. doi:10.1136/emj.2011.112250
- 5.Kamhawy R, Chan T, Mondoux S. Enabling positive practice improvement through data-driven feedback: A model for understanding how data and self-perception lead to practice change. J Eval Clin Pract. Published online October 30, 2020. doi:10.1111/jep.13504
- 6.Emergency Department Return Visit Quality Program. Health Quality Ontario. https://www.hqontario.ca/Quality-Improvement/Quality-Improvement-in-Action/Emergency-Department-Return-Visit-Quality-Program
- 7.Chartier L, Ovens H, Hayes E, et al. Improving Quality of Care Through a Mandatory Provincial Audit Program: Ontario’s Emergency Department Return Visit Quality Program. Ann Emerg Med. 2021;77(2):193-202. doi:10.1016/j.annemergmed.2020.09.449