Before I had even started my first position as a practicing ICU physician, I was a quality improvement convert. Somewhat through serendipity, I ended up at the 2004 Institute for Healthcare Improvement (IHI) National Forum where the famed Donald Berwick proclaimed, “Some is not a number; soon is not a time. Join me in saving 100,000 lives.”
That was it for me. I had already learned of the (not often spoken of) patient safety and quality issues in health care and I was now convinced that there was a need for improvement and a science and methodology to get us there. The Institute of Medicine even proclaimed an expectation of a 50 per cent reduction in patient safety incidents within five years of the publication of its To Err is Human report.
And so, health-care improvement entered the race to change health care. The goal was relatively clear – use iterative testing and learning to implement strategies known to improve processes and outcomes; develop clear aim statements and measures; and adopt evidence-informed methods that are tailored to local contexts such that they “stick” and achieve the intended goals of the quality improvement initiative. Although around for years prior to 2004, the quality improvement industry boomed with a growing number of conferences, training programs, journals specialized in publishing QI project findings, and much more. Not long after, policymakers, legislators and funders caught wind and entered myriad incentive/ disincentive funding strategies, scorecards, metric targets and laws that mandated quality improvement as an annual activity with publicly posted plans in which success was tied to executives’ salary (e.g., Excellent Care for All Act). Akin to sports, spectators, coaches, managers and owners joined in to watch and influence the race of improvement.
But another race participant exists, also set to change health care. This participant is burnout.
But another race participant exists, also set to change health care. This participant’s goal, however, is to degrade health care and produce worse outcomes, not better. This participant is burnout. Even prior to the COVID-19 global pandemic, burnout amongst the health-care workforce was a major issue. Year over year, the health-care workforce has the highest number of lost days due to illness or injury. Survey after survey shows a high degree of mental and physical health toll amongst nurses, physicians and trainees. Nursing turnover and unfilled positions have been a growing problem; one that has a large financial impact as overtime, agency use, training needs and disability-related costs climb. A Harvard Business School study estimated that physician burnout costs the U.S. health-care system $4.6 billion in billings a year from reduced hours and costs associated with finding and hiring replacements. Not only is burnout an issue for the workforce and those who fund it, but burnout also results in worse care delivery. Two relatively recent systematic reviews demonstrated an association between higher levels of burnout and increased patient safety incidents, poorer patient outcomes and experience.
So, as the health-care improvement race participant sets the pace and path for better outcomes, the health-care degradation participant undoes the improvement or works silently elsewhere to cause harm and decrease value. Unlike the improvement participant, there are (one hopes) no fans or coaches cheering this runner on. Its involvement is more insidious.
Who is in the lead at present? The COVID-19 pandemic thrust the degradation participant ahead, resulting in a level of burnout not seen prior. Nurses and physicians are leaving the profession, staff are off sick or quarantining and those remaining are exhausted in carrying the extra workload. Add higher than normal patient volumes and the conditions in which the degradation participation wins are set. The current state of the health-care workforce has never been as dire and the call to intervene is coming from all stakeholders.
And what about the state of improvement? The IOM goal of 50 per cent reduction in patient safety incidents in five years was not met. Research demonstrates that only about 20 per cent of published QI studies document application of core QI methods. Positive improvement results are obtained but fail to be sustained. However, the 100,000 Lives Campaign has been successful; there are also many reports of QI interventions, even large-scale ones that produce significant and sustainable results. Those that apply the science of improvement and focus on the local context tend to have greater success.
This is not a 100-metre dash nor a marathon; the race never ends.
As the improvement industry matured the science moved to addressing system-level issues in addition to local quality and safety issues. IHI introduced the Triple Aim; a framework of integrated approaches to simultaneously improve care, improve population health, and reduce costs per capita. When the wellness of the workforce was seen as a required ingredient or enzyme to achieve Triple Aim outcomes, so it became the Quadruple Aim (and, more recently, improved health equity has been added as the Quintuple Aim). This means greater investment in the factors known to increase the likelihood of ongoing and sustainable success in quality improvement activities and simultaneous local, organizational and system-wide meaningful implementation of strategies aimed at improving workplace wellness. With both, the improvement participant will advance in the race while the degradation participant will lose energy and stamina and trail further and further behind.
Unfortunately, this is not a 100-metre dash nor a marathon; the race never ends. It will require constant attention, resourcing, investments and innovative methods to accelerate improvement and squash workforce degradation. Like the Olympics, it will need data, analytics and expertise to boost performance, push boundaries and break improvement records.
The bottom line is that this race is happening, and we cannot see health-care improvement and workplace wellness as two separate pursuits. We need coordinated strategies, with a set of metrics that monitor both improvement in health-care delivery and in those that deliver it; with spectators that cheer for the former and boo the latter. The race needs to be broadcast to all those who stand to benefit or lose . . . that is, all Canadians.
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