Roots of quality improvement in health care

Deming—the father of quality improvement William Edwards Deming was an engineer, mathematician, physicist, statistician, author, professor, and consultant who is perhaps best known for his work in quality improvement (QI) and management. His work in applying statistical methods to manufacturing processes was instrumental in Japan’s economic revival after the Second World War. Several decades later, the US became aware of Deming’s genius and he was recruited by many of the largest companies in America. By 1986, Deming’s teachings on quality and management helped turn the Ford Motor Company into the most profitable American car company, surpassing General Motors for the first time in 6 decades.[1,2] The foundation laid by Deming was soon adopted by pioneers of QI in health care. His method and teaching of focusing on process rather than individuals, and on eliminating waste, have shaped the way we approach QI in health care today. 

Quality improvement in health care
QI is the continuous effort of all stakeholders in health care to make changes that lead to better outcomes, system performance, and professional development.[3] Pioneers of health care QI initially met with only limited success, but support grew once the public’s attention was focused on how QI could favorably affect the issue of medical errors.

The Institute of Medicine (IOM) was the catalyst for this change. In 1999, it published the report To Err Is Human: Building a Safer Health System, which highlighted medical errors, in an effort to incite the public to lobby for change. Similar to Deming’s work, the report identified the problem as being rooted in the system, not individuals. It received the wanted attention and was featured in major newspapers in the US. The IOM then published a follow-up report in 2001, Crossing the Quality Chasm: A New Health System for the 21st Century, which advocated for a redesign of the health system with six quality measures for improvement: safety, effectiveness, patient-centred care, timeliness, efficiency, and equality. 

These two seminal reports also represented the start of the Canadian movement for QI in health care. Several provincial and national reports and commissions raised awareness and concerns with safety and quality care, and once the quality gap was demonstrated, dedicated quality agencies were established and early initiatives began. 

QI in cardiology
The field of cardiology joined QI initiatives with the development of the Canadian Cardiovascular Outcomes Research Team (CCORT), which aims to measure and improve the quality of cardiac care. Initial projects undertaken by CCORT include the Canadian Cardiovascular Atlas—a “report card” on cardiovascular health and delivery of cardiovascular care in Canada. CCORT then developed the first Canadian quality indicators for cardiovascular primary care.[4]

In 2006, in an effort to address the burden of cardiovascular disease, the Canadian Heart Health Strategy and Action Plan (CHHS-AP) was formed. The CHHS-AP steering committee created a strategy for cardiovascular care, covering a full range of health care stages, and identified gaps in data. The strategy document, Building a Heart Healthy Canada, was published in 2009. 

One of the few recommendations from the strategy that was successfully implemented was the creation of a national cardiovascular database, which linked existing regional databases. The focal task identified in the strategy document and delegated to the Canadian Cardiovascular Society (CCS) was to find a way to benchmark the quality of cardiovascular care in Canada, with the ultimate aim of evaluating efficacy and cost-effectiveness of interventions and care. Two CCS committees were formed: the Data Definitions Committee and the Quality Indicators Committee. These two committees have since become the Canadian Cardiovascular Society Quality Project.

National QI initiative
In Canada, because health care is delivered provincially, quality metrics that many provinces collect are not shared nationally. However, The CCS recently sponsored the first-ever Canadian National Transcatheter Aortic Valve Implantation quality report as a demonstration project and shared the results of several quality, structural, process, and outcome indicators at the Canadian Cardiovascular Congress in October 2016. This was an exciting achievement, but it highlights the challenges of patient-level data sharing across provinces. For example, the quality-of-life data weren’t consistently collected in all hospitals, and outcome indicators weren’t stored in the same format across provinces (e.g., data were obtained through vital statistics in some provinces, and through the Canadian Institute for Health Information or the Discharge Abstract Database in others). Additionally, very few health-funding agencies or QI agencies in Canada provide funding for QI projects. Still, the quality report represents the start of national data exchange in all areas of cardiovascular care, with the ultimate goal of improving heart-health outcomes.

British Columbia QI initiatives
Patients with complex chronic conditions often navigate multiple care interfaces and consequently may experience fragmented care and poor outcomes.[5] This is particularly apparent in large urban environments where family physicians are often disconnected from hospital care and may not have collaborative working relationships with specialists. 

About 10 years ago, specialists and family practitioners (FPs) at Providence Health Care (PHC) were becoming increasingly distressed about this situation and how it affected the patient journey. In response, PHC initiated a needs assessment and community consultation process in late 2009 to identify gaps in current service delivery for patients with chronic disease. Focus groups with specialists, FPs, and patient groups were held, with several themes emerging: the need for improved communication, improved access to specialty care, and improved relationships between FPs and specialists.  

In 2010, a partnership was formed between PHC and the Shared Care Committee (SCC) (a joint committee of the BC Ministry of Health Services and Doctors of BC) in collaboration with Vancouver Coastal Health (VCH) to: 

1. Identify gaps in the care process for patients.
2. Develop and test prototypes for improvement.   

The goal of the overall project was to redesign collaboration and interaction between specialists and FPs to improve population health outcomes, improve patient and provider experiences, and reduce per capita system costs. Two quality improvement initiatives resulted from this work: the Rapid Access to Consultative Expertise model, and streamlining the cardiology referral process. 

Rapid Access to Consultative Expertise (RACE)
Rapid Access to Consultative Expertise (RACE) addresses a critical challenge faced by specialists and FPs. It is an innovative model of shared care that was built on the encouraging results from a 2008 PHC pilot project where FPs could page a cardiologist and connect usually within a few minutes.[6]

RACE allows FPs to call one phone number and choose from a selection of specialty services for real-time telephone advice. The call is then routed directly to the specialist’s cell phone or pager for “just in time” advice. The prototype began with five specialty areas, but has now grown to include over 30 specialty areas, based on the needs of FPs. Since beginning in 2010, RACE has logged over 30 000 calls.  

Guided by the Institute for Healthcare Improvement’s Triple Aim principles (improve care, improve population health, reduce per capita cost),[7] the RACE model aims to reduce costs by avoiding unnecessary emergency department visits and face-to-face consultation, streamline patient care, enhance the patient experience, support FPs, and use specialist services more appropriately. A formal structured evaluation was conducted by Scott Lear, associate professor, Faculty of Health Sciences, Simon Fraser University, and Pfizer/Heart and Stroke Foundation Chair in Cardiovascular Prevention Research at St. Paul’s Hospital.8 The methodology of the evaluation was twofold: qualitative interviews/focus groups and quantitative surveys.  

Overall metrics from the first 3 years include the following (> 5000 calls, data based on 40% of calls):
• 78% of calls answered within 10 minutes.
• 90% of the calls lasted less than 15 minutes.
• 60% avoided face-to-face consults.
• 32% avoided emergency department visits.

The estimate of direct costs indicates a cost avoidance of up to $200 per call.

The RACE model of care is now in use throughout British Columbia and is currently being spread nationally through a collaboration led by the Canadian Foundation for Healthcare Improvement. RACE enriches family practice by providing a collegial and CME-eligible experience that directly links physicians learning to practice in real time. One frequent FP user of RACE describes his experience as “a return to the old-time relationship that existed between specialists and family doctors, where there was time for hallway conversations and discussion about individual patients.” 

Streamlining the cardiology referral process
In 2015 the Vancouver Division of Family Practice approached the SCC about access challenges to cardiology services in the region. Cardiology wait times were increasing and there were inefficiencies with the referral process. The situation was highlighted in a survey of 50 Vancouver FPs: 69% of them reported not knowing which cardiology clinic or specialist to refer to, and 85% reported not knowing if the clinic or specialist had received the referral.  

Through a process of consultation and engagement, a group of cardiologists, FPs, patients, clinic assistants, and administrators subsequently developed a regional cardiology referral process to improve patient care. A single form (the Vancouver Coastal/Providence Health Care Regional Cardiology Referral Form) (Figure: part 1, part 2) replaces dozens of existing forms, and provides FPs with information to guide them in referring directly to private cardiology offices or to any of the 30 cardiology specialty clinics located within VCH. Concise specialty clinic descriptions are provided, and an acknowledgment of referral component is included.

The form was trialed over 3 months, and during that time 72 referrals were made between 40 FPs and 20 cardiologists. Seventy-five percent of the referrals were acknowledged, and the average time to acknowledgment was 5 days. Of these, 42% were acknowledged within the target time of 72 hours. Of note, 82% of referrals were directed to specific cardiologists and 18% were directed to hospital-based specialty clinics.

Pre- and postevaluation surveys of the form showed that:
• All surveyed FPs reported an increased knowledge of cardiology services when using the new form.
• 38% of cardiologists reported that referrals contained more relevant information when the new form was used compared with 6% when using other forms.
• 67% of FPs and 62% of cardiologists said the referral process had improved when using the new form. 

More recently, digital versions of the form have been integrated into Pathways (https://pathwaysbc.ca) and physician electronic medical records, and can be viewed by more than 1000 community physicians. Uptake of the form continues to increase across the region.  

Interdisciplinary collaboration can lead to concrete results in the referral process. As a result, this quality improvement project is being seen as a successful model of shared care that other specialties are looking to emulate.

Conclusion
Quality improvement projects can vary in scale from national to local and still have a large impact. In addition to the benefit of changing local practice, local projects can often contribute to knowledge about QI in health care and be generalizable to larger-scale initiatives. 

Competing interests
None declared.

Additional reading
Canadian Cardiovascular Society. National quality report: Transcatheter aortic valve implantation. Accessed 1 April 2017. http://ccs.ca/images/Health_Policy/Programs_and_Initiatives/CCS%20National%20Quality%20Report_TAVI.pdf.

Canadian Heart Health Strategy and Action Plan. Building a heart healthy Canada, 2009. Accessed 1 November 2016. www.waittimealliance.ca/wp-content/uploads/2014/05/CCS-Building-a-Heart-Healthy-Canada.pdf.

Institute of Medicine. Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press; 2001.

Institute of Medicine. To err is human: Building a safer health system. Washington, DC: National Academy Press; 1999.

This article has been peer reviewed.

Dr Young is in her final year of a cardiology fellowship at the University of Alberta, and is concurrently completing an MSc at Queens University in health care quality. She also holds an MBA with a focus on strategic management in health care from the University of Calgary. Dr M. Ignaszewski is in her first year of a cardiology fellowship at Cooper University Hospital in Camden, New Jersey, after having completed an internal medicine residency at SUNY Upstate in Syracuse, New York. Ms Wilson holds a Master of Science in Nursing and is director of the Providence Health Care Chronic Disease Management Strategy. Mr Baloo is a chiropractor and Shared Care project lead at Providence Health Care. Dr Gin is a clinical professor in the Division of Cardiology, UBC Faculty of Medicine; head of the VGH Division of Cardiology; and medical director for the Regional Cardiac Program. He is a fellow in the Canadian Cardiovascular Society, sits on the Canadian Cardiovascular Society Executive, and leads the Canadian Journal of Cardiology committee. Dr A. Ignaszewski is a clinical professor in the Division of Cardiology, UBC Faculty of Medicine; head of the PHC Division of Cardiology; and physician director of the PHC Heart Centre. He is affiliated with the hospital’s Heart Transplantation Program, Heart Failure Program, and Healthy Heart Program.