Big data, at global level, wowsers!

 If you ever wanted to be wowed by beautifully displayed health data. Here it is: 

https://www.who.int/data/gho 

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About the global health observatory: 

"The GHO data repository is WHO's gateway to health-related statistics for its 194 Member States. It provides access to over 1000 indicators on priority health topics including mortality and burden of diseases, the Millennium Development Goals (child nutrition, child health, maternal and reproductive health, immunization, HIV/AIDS, tuberculosis, malaria, neglected diseases, water and sanitation), non communicable diseases and risk factors, epidemic-prone diseases, health systems, environmental health, violence and injuries, equity among others". Accessible at: https://www.who.int/data/gho/info/about-the-observatory

Is data everything?

Dr. William Farr and his support of for the theory of "Miasma" had thoroughly examined data to back their hypothesis. UCLA's Epi page has details https://www.ph.ucla.edu/epi/snow/farrgraph.html 

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Dr. William Farr, wasn't a lonely crusader who could be easily dismissed as sometimes is the case with public health researchers; he was the assistant commissioner for the 1851 census and a career employee of the government's General Register Office. And he had the data to support his idea. Still, it wasn't quite what caused cholera as we all know now. Of course this was before the germ theory or the epidemiological triad was put into practice; and before confounding identified as a variable lurking to cause spurious associations.

Aren't we glad that scientific methods have come such a long way (molecular bio-surveillance and all),  but this makes me quite sure that some axioms will always hold true.

 Data without context is nothing!

What’s in the name?

Rechristening QAPI 

QAPI is Quality Assessment and Performance Improvement Committee -  an approach endorsed by CMS

"A rose by any other name would smell as sweet" said Juliet trying to make a point we all understand.

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So I ask again: What's in the name?

Everything.

A name is often the first thing we learn about a thing or a person and falling to our humaneness, we form judgments about it; so I would say that this first piece of information is especially important.  It can lean someone in a positive or a negative direction.  And those first impressions can set the stage for future interactions. 

For our means and purposes the name QAPI is okay for a group that is sitting somewhere assessing performance and pondering on ideas that may or may not lead to improvement (apologize for dull clichés). People like to spell it as QUAPI giving it an extra U probably because they like to spell a thing by how they think it sounds – if it sounds like the irritating noises a wet duck would make then it must spell like that too. Or maybe because the decisions or actions in “QUAPI” move so slow that it’s only natural to compare it to a duck’s gait. Of course who wants to miss an opportunity to call something futile without actually calling it futile, especially if it’s a meeting?

I know of a story where a medical director of a clinical service in an attempt to sound witty mocked in a QAPI meeting full of members at the precise time when the power point presentation stuck – as they sometimes do in meetings: sloppy “QUAPI” and oh the room cracked up! What a powerful reclaiming of the ground by the know-all of the clinical processes – doctors! These quack-quack-quapi meetings have done an excellent job PDSAing at various hospitals and departments and, in the ugly development phase, the name is not helping. You can’t really blame the high school kids for that, can you?

Instead of further diminishing the importance of the QAPI committees let’s look at why are the quality professionals self-inflicting themselves with a title that only reminds them of their lame moments. Let’s take a stab at renaming the slow duck.

How about COAST? Clinical Outcomes and Systems Excellence Team. I am sure there can be many renditions with multiple clever sounding acronyms, but it’s a start. Notice that it also removes the term “committee” from the title – which made the whole thing, I think, very stiff and unapproachable. How can the  proletariat staff get closer to bourgeois lawmaker- Mr. Moneybags? They form their own team because you win a football match with a team (not committee but a team!). We’re always in search of a David vs a Goliath story. Not to disappoint anyone, but there’s none to be found here. Except that, David birthed Goliath and now it’s being having to manage.

Acronym COAST may remind you of the coast of a battle field where you’re side won, vacation memories (okay may be counterproductive because might have to thinking why you are here, not there), or something else, anything, but a slow moving wet duck. 

Error Vs Adverse Event

The hallmark report from the Institute of Medicine, USA, "To Err Is Human" released in the year 1999 estimated that up to 3.7 % of all hospitalizations suffer adverse events, and about half of them are likely due to errors (preventable adverse events).

It also quantified the actual damage by estimating that up to 98,000 hospitalized Americans die due to medical errors. To put this in context, this number is higher than total deaths due to motor vehicle accidents. Several other developed countries have similar national reports which have spurred call for action from different sectors of the society, but many are still unaware of the magnitude of the problem.

To better understand the issue, let me first introduce some necessary vocabulary in this post.

  Errors are failures of planned actions to be completed as intended, or use of wrong plans to achieve what is intended.

  Adverse events are injuries caused by medical intervention, as opposed to the health condition of the patient. A larger proportion of the adverse events are due to errors and in this case are better called preventable adverse event

  Negligence is a term used for adverse events that are purely due to low professional standards of healthcare professionals. Obviously these events may create some legal liability just because of their nature.

 Near Misses are serious errors that do not result in adverse events

 Not all adverse events are errors and not all errors result in adverse events (some are near misses). All cases of negligence are preventable adverse events. Most preventable adverse events are because of errors.

 The concept is beautifully explained by Dr. Robert M. Watcher in his writings. In an attempt to demonstrate the difference between an error and adverse event, a figure inspired by his explanation is as below:

Who is your Quality Professional ?

Quality Professional (QP) can come from any background, but must have appropriate experience and/or education (degree or certificates) that arms them in exploiting concepts and tools of Quality improvement.

 

“It takes all kinds to make the world go round.”
-Trent Shelton.

 

More importantly it is pertinent that she/he is blessed with a certain personality; you can call them a person of Quality (pardon the pun). Which means they have high integrity necessary to investigate adverse events objectively and let the chips fall where they may. They should be curious to dig for data, scientific in their approach, and brave to run with the truth.

They should be non-threatening and non-manipulating and should also appear to be so. Now, they don't have to be persona grata but someone that everyone trusts to not besmirch their reputation or ensnare them in a blame-game or wrongly encourage them to blurt something unprofessional.

Because  the pendulum of physician involvement swings from complete non-commitment to "I have all the great ideas". A QP should be able to sniff out those patterns. People-reading also helps to predict degree of involvement from concerned parties. QPs often find themselves having to appeal to human values to promote the just causes of patient safety.

Soft skills are as important if not more in this job. Some physicians are reluctant paying attention to non-clinical matters. They don't want to speak to "administration" or even non-physicians in some rare cases. Sometimes they'll be interested in a Quality Improvement project, but only if it leads to a academic publication.

The other kind is enthused about change, but only if they get their way. They will want to propose a solution even before the QP has finished stating the problem. They feel they know the system inside out and of course no one is brighter than them. Beware of this group - this is worse than the former because they will take you on a path (their path) that you may end up spending much time and resources to no avail.  Teams should first discuss the problem in a multidisciplinary setting where all stakeholders are represented, draw process maps if need be, get feedback from the teams that will be affected by the proposed solution and only then implement the proposed plan.

 A person who has a stomach for drama, can herd (both perky and lazy) cats, has eternal optimism, but a realistic view can be successful as a quality professional It's a tough job, but one that is hugely rewarding.