A New Face of Improvement

Esther was 88 and in pretty good health. But over the last few nights her breathing became difficult and edema in her legs forced her to sleep sitting up. Her daughter suggested she call her home nurse, who in turn referred her to her primary-care physician. Getting to him required an ambulance call, as Esther could no longer negotiate the stairs from her third-floor walk-up. 

The doctor sent Esther to the hospital via another ambulance. An assistant nurse greeted her at the ED, then she waited some time before seeing another doctor, who examined her and ordered x-rays and an admission. More encounters with more nurses and staff followed. 

By now, according to those who conceived her, six hours have elapsed, and Esther has met around 30 people. The process of helping her, though, has barely begun. 

Esther is a composite, developed by a team of Swedish healthcare providers seeking to improve coordination and patient flow for elderly citizens in a six-municipality region of that country’s south. The idea of their “Esther Project” was apply a human face to abstract debates about healthcare systems that could sometimes overlook their most important component: the patient. Her experience was imagined as one typical for a senior living alone. 

“The idea was to put a name on a mythical patient, and then when we’re designing improvements, we can actually focus our attention on ‘Esther’,” says Dave Williams, PhD, an improvement adviser with the Institute for Healthcare Improvement (IHI), which works with healthcare organizations and others around the world to refine care processes and achieve better patient outcomes. “With the Esther Project they realized this patient was going through this whole system and touching all these different people, and they all had parts of the puzzle. They could all contribute—or potentially harm Esther—along the way. By understanding the whole stream of care and all the elements in their organization and system, they were able to refine and improve the quality of Esther’s experience.”

Issues and Answers

The IHI works to facilitate that kind of improvement. Its faculty member Mats Bojestig, MD, helped develop the Esther Project, and it served as national program office for a broader improvement effort the project inspired. In the U.S. the IHI’s work impacts healthcare, including EMS, in substantial ways; with our continuing integration into American healthcare systems, that will only increase. 

“The EMS component is critical,” says IHI Executive Director Frank Federico, RPh. “As we think about the continuum of care, the earlier we can get patients, the better. EMS can be a major player in the continuum and a vital cog in the wheel of providing great care. Our role is to provide the improvement knowledge and skills and look for interventions and areas where we can provide the best support.” 

That means sharing both improvement theory and best practices and lessons learned from systems around the world. “The intent is not to be the expert and tell you what to do,” says Williams, “as much as bring you the methods and connect the people and try to find innovations that can be shared.”

Esther’s was not primarily an EMS case, but it did exemplify how the IHI’s approach can lead to positive changes throughout systems. Dissecting Esther’s experience, members of the improvement team combed over their system and found a lack of coordination and care loaded with redundancy, waste and possible errors. 

Ultimately they realized that an insufficient capacity for planned care was causing patients to seek urgent care in inappropriate ways. For example, if Esther had headaches, referral to a neurologist could take three months. So instead she’d go to the ER for more immediate help. Thus what appeared to be an unmet demand for inpatient admissions was found to actually be a need for better access to specialty care. 

The solution was to create acute-care teams, with primary docs, nurses, home nurses and specialists, to decide collaboratively what was best for patients. A PCP whose patient had an acute-care need could page a specialist, and they’d consult quickly by phone. If they decided to hospitalize, the patient would be admitted directly, bypassing the ED. Specialists also started allowing same-day patient visits and working closely with docs and home nurses to help deliver certain interventions. 

The results: a 21% decrease in hospital admissions over five years; a 28% decrease in hospital days for heart failure patients; and a decrease in waiting times for neurologist referral appointments from 85 days to 14.

Sound a bit like the community paramedic/mobile integrated healthcare discussions we’ve been having? 

Says Federico: “It wasn’t until they developed Esther and walked through the system with her that they were able to understand the complexity that exists in a healthcare system, all the different handovers that occur, and how each handover is an opportunity for information to be lost or misunderstood. They also learned to see the system from the perspective of the patient, who can often be left with a feeling of, Don’t these people know what they’re doing? How many people do I have to see?”

Model for Improvement

The IHI’s change method of choice is the Model for Improvement. Developed by Associates in Process Improvement, it’s a basic framework for accelerating beneficial change based on PDSA (plan, do, study, act) cycles. It poses three fundamental questions: 

• What are we trying to accomplish?

• What changes can we make that will result in improvement? 

• How will we know change is an improvement? 

The IHI spells out steps for utilizing the model to improve: forming improvement teams, setting aims, establishing measures, and then selecting, testing, implementing and spreading changes. The key characteristic is small-scale, rapid-cycle testing that yields actionable intelligence that can then be applied to broader groups. 

“For example, we know there’s a problem with medication safety,” says Federico. “We can always write a policy and say, ‘This is how things should work.’ But when you put it into practice, we know this method of implementation doesn't always work well. The question is, how do you develop the right procedures to support that policy? Policies are necessary, but policies alone are not sufficient. With the Model for Improvement, you would say, ‘How can we comply with that policy? Let’s test on a small scale how we might develop procedures to do that. How do we make sure each member of the EMS team knows how to use those procedures?’ 

“Often you’ll find someone’s developed a very complex way to complete a task, and through testing, especially by engaging the people on the front lines, you can find an easier method. Then you complete some rapid-cycle tests to ensure your idea gets you to the result you want.” 

Americanizing Esther

Closer to home, lessons of the Esther Project are being applied by American Medical Response through its Caring for Maria program. Behind the humanizing face of a 78-year-old with various chronic conditions, AMR is working to reduce variation and achieve reliably good results in clinical care, patient safety and patient satisfaction across “things that matter,” or that evidence shows EMS can make a difference in (stroke, STEMI, pain, etc.). 

As outlined in a 2012 informational program, its process reflects the collaborative approach ?of the IHI Breakthrough Series and uses the Model for Improvement: 

• Reviewing evidence and developing driver diagrams to create change packages; 

• Learning sessions encompassing review of company data and identification of targets (i.e., answering the three questions); 

• PDSA rapid testing; 

• Identifying and disseminating better practices; 

• Implementing them broadly, monitoring the results, and tweaking as needed. 

One focus area was ensuring patients receive adequate pain relief.  A traditional approach might be to construct a training program for providers, deliver it, then audit whether they’re doing it successfully. Instead AMR started by creating driver diagrams, which are visual displays of mechanisms shown to help achieve better pain management. 

“That may include things like using a pain scale before and after, or using certain other kinds of assessments or processes related to their discomfort—for instance, are they nauseous?” says Williams. “It’s basically coming up with a package of things that are important to achieving this outcome.” 

For more on AMR’s work and its outcomes, check out this month’s EMS 2020 podcast at [add URL]. But the general idea is that any agency can tackle any problem using this model of targeted interventions and small-scale, rapid-cycle testing. 

“That’s a big part of the IHI concept: testing with one, with the intent of all in mind,” says Williams. “We want to start on the smallest scale possible. We’re doing big projects but breaking them down. At first maybe I just want to figure out what it takes to do a pain scale—how do I get that to be done reliably on one patient? Now, what’s it take for me to treat that patient? And we try to learn everything we can about how to make this process reliable.” 

Triple Aim

The Esther and Maria projects both reflect the IHI’s well-known Triple Aim: 

• Improving the patient’s care experience (i.e., quality and satisfaction); 

• Improving the health of populations; and

• Reducing the per capita cost of healthcare.

The Triple Aim heavily informs current U.S. healthcare reform efforts, and in 2010 the IHI’s former president/CEO Don Berwick, MD, was named by President Obama to head the Centers for Medicare and Medicaid Services. Berwick resigned in 2011 amid strong Republican opposition, but the appointment was an indicator of the IHI’s influence among the nation’s healthcare leadership. 

The EMS-related CMS innovation grant projects currently underway in Nevada, Washington and Colorado embody the Triple Aim as well, and the entire CP/MIH movement is much in its spirit. 

“If you haven’t already, you’re at some point going to be hit by the concept in your community,” says Williams. “Everybody is moving in this direction of trying to improve access, streamline it, and do it in ways that are cost-effective. It’s something EMS should be paying attention to. 

“One, it’s a huge opportunity to become engaged with your partners in a way you may have hoped to for years. And two, this could dramatically change the way EMS service is being delivered. Communities are starting to look at reducing ambulance utilization, because these are patients who should be served in other ways. That’s good for patients, but it could have big implications in terms of your operations and revenue. Being conscious of that is huge.”

For more: www.ihi.org.