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Quality Improvement in Healthcare - YouTube
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I'm dr. Mike Evans and today's talk is
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on quality improvement or qi in
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healthcare so i suppose the first
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question is why should you or I care
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about quality improvement I mean to be
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honest it sounds a bit boring SEO would
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have on her or his corporate objectives
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but actually if you dig a little deeper
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pretty cool maybe more of a philosophy
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or an attitude about how to make
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something better I know that I think
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about it it's really the attitude I'm
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looking for my patients the ability and
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desire to tweak their habits seeing if
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this change improves their life and if
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it does to try and make it standard
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practice you see for my patients to make
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these changes require skills but it's
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also an outlook the humility and
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self-awareness to say hmm
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I've got room for improvement the
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ability to gather better approaches try
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them on and see if they work and then
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adapt them until they do well if my
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patients can do that I think they
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deserve the same from us in the
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healthcare business so I suppose the
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next question is if we have the attitude
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how do we actually improve how do we use
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Qi to make care better well
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the improvement business has been around
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for a while organizations like Toyota
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and Bao Labs and leaders like Walter
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Stewart W Edwards Deming and Joseph
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Juran polished and simplified the
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science of improvement and then along
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came a pediatrician named Don Berwick
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and he wondered if we could translate
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the science of building better cars or
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electronics to healthcare dr. Berwick
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also wondered if there were lessons
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about systems we could learn from the
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kids he saw at his clinic the systems
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thinker is is a is a perpetually curious
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person who never thinks they have the
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whole answer but is always willing to
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know what the next step take is if you
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watch a child you'll see this happen
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children and their growth and
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development are innately systems
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thinkers they're always trying the next
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thing they're they're probing the
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material they're listening to the noise
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they're thinking about what the next
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thing to do is and they're not in the
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job of solving problems forever
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they're in the job of taking the next
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step I think those are elements what it
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means to be a system thinker at the core
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of it is constant curiosity about a
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world that you will never
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understand fully but you might take the
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next step to understand a little better
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okay we've never dropped a vid into our
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vids you know and and Don is thoughtful
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so I kind of thought it might improve
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our messaging let me know if you thought
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it did or didn't in our YouTube comments
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dr. Burwick went on to co-found
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Institute for Healthcare Improvement or
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the IHI and started focusing on the
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low-hanging Healthcare Improvement fruit
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which is mostly reducing errors for
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example in Canada a researcher named
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Ross Baker led a study in 2004 that
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showed of 2.5 million annual hospital
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admissions about 13.5 percent were
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having adverse events with one in five
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of those people dying or experiencing a
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permanent disability in the u.s.
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Institute of Medicine estimated that 44
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to 98 thousand people were dying from
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preventable errors every year that's up
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to four jumbo jet crash
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often these are errors we know how to
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prevent but is often the case knowing
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what's the right thing to do and
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actually doing it are two different
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things
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in 2006 Berwick and his colleagues
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challenged hundreds of US hospitals to
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bridge this gap and felt strongly that
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some is not a number and soon is not a
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time and so said the goal of saving a
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hundred thousand lives in 18 months they
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started with this simple notion every
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system is perfectly designed to get the
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results it gets so how do you change the
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result well you change the system that
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produces it changing the system requires
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change agents and in my province realize
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health quality Ontario HQ oh and an
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order to like it recognise that it's
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tough to balance proactive and reactive
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care in the field but if they can help
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or incentivize or not just towards a
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more reflective practice and improve
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outcomes we can actually create a better
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user experience for us all now making
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the sounds simple like pushing a button
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but getting people to change even a
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simple behavior like hand-washing can be
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very complex and exasperating
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but these seemingly small behaviors can
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have a ripple effect on health a 2010
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study calculated inadequate hand-washing
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cost 247 deaths each day from
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preventable hospital infections and that
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that's just in the u.s. so let's jump
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back to simplicity how to improve seems
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to boil down to three questions in a
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cycle improvement starts by setting a
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name so question number one is what are
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you going to improve and by how much so
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for example we are going to get 70
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percent of the staff to wash their hands
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before and after seeing patients by
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December 1st great we have a name so
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let's start testing some changes okay
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not so fast now you need to ask question
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- how will you know if it changes an
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improvement we need to choose some
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things and measure them what is doable
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and reliable and that will tell us if
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the changes we are making are leading to
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an improvement is someone documenting
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doctor or nurse hand-washing is it
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self-report is it the amount of soap and
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disinfectant used okay we have a name
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and now we have some measures next up is
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question 3 what changes can you make
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that will lead to the improvement to
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start we just want to test one
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with something called a PDSA cycle plan
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the tests do the test study the test
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results and then act based on those
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results
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maybe it's new soap dispensers or little
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bottles with gel maybe you read about
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the study that changed the signage from
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wash your hands to protect yourself to
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wash your hands to protect your patients
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which resulted in a third improvement
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over a two-week period maybe its reward
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or audit and feedback or asking patients
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to check just pick one and get started
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then you test other changes and the PD
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essays just keep rolling fine-tuning the
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change based on what you're learning
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saying to yourself here are some ways we
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can improve let's try them out by
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dropping them into our practice in a
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thoughtful way that fits with our clinic
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and our patients let's measure how we do
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adapt adopt or discard simple right but
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powerful and it actually works at my
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hospital st. Michaels in Toronto elderly
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patients with fractured hips were often
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waiting more than two days for surgery
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this way it was painful with increased
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chances of conditions like delirium and
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depression longer recovery times and
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even death the care team scratched their
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chins mapped out and redesigned every
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step of the journey to surgery in order
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to fast track these patients they
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created a code hip called as soon as a
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patient arrives the streamline them to
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the urgent list for surgery rapid triage
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essential testing priority consults from
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anesthesia and internal medicine and so
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on all these tweaks led to a jump from
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66 to over 90% having surgery within 48
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hours now these changes don't happen
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without engaging the human side of
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change one thing you'll discover is that
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it's possible that the people you work
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with might not be as into hand-washing
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or urine infections or diabetes as you
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are I know crazy but this leads a three
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piece of advice first is the concept of
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innovation fatigue often your workmates
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are getting overloaded with requests for
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practice change which are
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well-intentioned but can be overwhelming
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my own approach is to take a page from
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motivational interviewing mi recognizes
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some of our natural inclination as
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problem solvers is to
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things provide advice and argue for
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change but the reality is that not
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everybody is ready for change both mi
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and Qi recognize that ambivalence about
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change is normal the building readiness
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and confidence for change a shared
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agenda requires careful listening and
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strategic questioning the ability to
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roll with resistance more of a dance
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than a directive I would say actually
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sometimes resistance to change can
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actually be an opportunity in qi
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creating diversity or disruption can
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actually be an opportunity something to
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build on my second point is about
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priorities I think we have to
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acknowledge the patience and your fellow
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clinicians may have certain priorities
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on the day the talking about depression
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or headaches may trump your diabetes
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flowsheet
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or even that focusing on their non
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diabetes issue might in fact be more
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helpful for patient self-management be
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shifting sands the transition from silo
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care or the reality of the emerging
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science of complex care sure asking
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what's the matter but also asking what
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matters to you a great example is in
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Timmons a small town in rural Ontario
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where they wondered if they could do a
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better job of handling complex patients
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in the emergency department so people
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seen in the emergency more than 14 times
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or admitted more than three times a year
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they started with standard assessment
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tools identified diagnosis and related
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problems generated care plans but
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unfortunately patient use didn't
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decrease the team then flipped their
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approach to what's called patient
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discovery where they identified health
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and lifestyle challenges from the
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patient's perspective and combined that
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discovery with motivational interviewing
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techniques this new patient centred
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approach resulted in more than an 80%
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reduction in emergency room use in
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admissions finally after having done
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many interventions my mantra is how can
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I make it easier to do the right thing
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maybe easier it's about sharing the load
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at Kaiser Permanente front desk staff
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can actually check and book for
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preventive screening everyone can help
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in qi all these points of the softer
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side of good quality improvement then
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when we look at the science of
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innovation it's less about big cognitive
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leaps and and more about agility small
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incremental
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they build on the ideas of others and
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engage their own genuine curiosity
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regarding what motivates and inhibits
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the individual and systems path to
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change the main point is start find
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something you can improve and get going
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look it's hard to summarize improvement
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and not get into bumper-sticker
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territory but I I would advise not to
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let what you can't do stop you from what
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you can do it's time to entertain
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complexity but but focus on simplicity
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asking yourself what can I do by next
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Tuesday I have a meaningful Nederland
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and test some changes to start moving
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that needle towards an important goal
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hope this helps and thanks
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