Leadership accountability for quality: A quality organization’s perspective

by admin admin | Mar 01, 2011

Micheline Ste-Marie, Associate Director of Professional Services, Montreal Children’s Hospital, McGill University Health Centre and President, Groupe Vigilance pour la sécurité des soins

Like many healthcare professionals, Micheline Ste-Marie believes that most physicians genuinely want to provide the best possible care to their patients. But good intentions don’t always translate into optimal results. Of course, it is difficult to identify which doctors are performing well and, perhaps more importantly, which are performing poorly, if no one is keeping tabs.

“We’ve never had any accountability structures for physicians, from the hospital administration perspective. Physicians are considered as private entrepreneurs,” says Dr. Ste-Marie. “I do think that the next step is accountability. For many healthcare institutions, the attitude has been that doctors know best, and hospitals have provided doctors with whatever they wanted in order to keep them on staff. Today, accountability is an issue hotly debated in many medical journals and a significant number of physicians are aware that something needs to be done.”

To improve quality and to make patient care safer, you have to have systems in place to help. You need technology and informatics.

Dr. Ste-Marie, a pediatric gastroenterologist, has practised medicine in Quebec City, Halifax and Montreal. She has also worked extensively in medical education, including a stint as Vice-Dean of Undergraduate Studies and Student Affairs in the Faculty of Medicine at Dalhousie University. In recent years, Dr. Ste-Marie has concentrated on improving patient care. She serves on the board of directors of the Canadian Patient Safety Institute and is President of Groupe Vigilance pour la sécurité des soins, a permanent group with expert and citizen representatives that advises the Ministry of Health and Social Services of Quebec on matters of patient safety.

“The focus of my life in medicine has been on quality of patient care,” says Dr. Ste-Marie. “In medicine, we are at the service of our patients, and they deserve the best possible care we can offer.”

Medical institutions have long claimed that quality improvement was a top priority. Yet few did much to prove it, says Dr. Ste-Marie. “Outcome results indicators were never thought about. As long as you had a policy and a quality improvement committee, everything was considered fine. There were a lot of words but not many results,” she says. “To improve quality and to make patient care safer, you have to have systems in place to help. You need technology and informatics so you can make decisions based on data.”

The problem is that the medical community is slow to adopt new and potentially useful technologies. In many Quebec hospitals, says Dr. Ste-Marie, information-gathering technology is barely more advanced than “Moses’ tablets,” consisting of little more than pencils and paper. Medical institutions don’t seem to mind spending millions of dollars on high-tech diagnostic tools, she says, yet few track how these tools affect patient care.

“It’s 2010. What is wrong with this picture?” says Dr. Ste-Marie. “How can I say that a piece of equipment that cost $14 million is working safely and effectively if I have no data? How can you be held accountable for delivering improved care in the future when you don’t know what kind of care you are delivering today?”

When hospitals do adopt effective data-gathering tools, the quality of patient care can improve quickly. For instance, when the Pediatric Emergency Department at Montreal Children’s Hospital implemented a computer-assisted triage tool called the Siurge-EVAL-U, the department was able to quickly gather and process patient data, such as information about medications, provide regular reports on significant administrative and clinical indicators, and make changes to improve care. For example, this enabled the department to flag nonurgent patients, who are now treated only for the problems that prompted their emergency room visits.

“If someone comes in with pain in their ears, you address the specific complaint, you treat, and then you send them back to their family doctors,” says Dr. Ste-Marie. “If it’s not an emergency, you go back into the primary or secondary care system.”

How can you be held accountable for delivering improved care in the future when you don’t know what kind of care you are delivering today?

The emergency department, which receives 70,000 visits a year, discovered that 60% of its patients fell into the non-urgent category. By putting such patients on a “fast track,” the department, which had been so chaotic that security was sometimes called in to make peace, was able to substantially reduce its wait times.

“That was because of data,” says Dr. Ste-Marie. “You have to have data.”

When data reflect quality of care, policies that compel hospitals to make data public can be effective in creating accountability. In Quebec, for example, hospitals paid more attention to reducing their C. difficile rates after the province began to regularly publish them. “Let’s say you get the results and see that you are number 25 out of 25,” says Dr. Ste-Marie. “You know that people can go to the web and see that. You don’t want people coming to your hospital with their own bottles of Javex. Embarrassment is great for motivation, and so, of course, is competition. But more than anything, public data make you aware of what you are really delivering.”

National organizations that assess healthcare quality, such as the Canadian Patient Safety Institute and Accreditation Canada, also have a role to play in keeping hospitals accountable to their quality goals. Some hospitals have a tendency, warns Dr. Ste-Marie, to put greater effort into improving health services only when those services are about to be put under scrutiny.

Another important way of creating accountability for quality in healthcare is to better involve the people for whom it exists: patients. If actively engaged in all aspects of the care they receive, patients will be better equipped to determine whether that care is sufficient and appropriate. “To be held accountable, you have to involve the patients,” says Dr. Ste-Marie. “You have to put the patients in the loop.”

Healthcare workers should never underestimate a patient’s intelligence or judgement, says Dr. Ste-Marie. Most patients are fully capable of understanding their conditions and can provide valuable insight into the care they need.

“My mother is 90 years old, and she is not a physician or a nurse, but she can make up her own mind. She can ask the right questions,” say Dr. Ste-Marie. “We have to focus on patients’ needs. I mean, why are we in this business? To make money? No, I don’t think so.”