Quality czar points out safety problems, suggests solutions

TORONTO – Ontario’s healthcare system is falling short on many quality measures, says Dr. Joshua Tepper (pictured), a family physician and the president and chief executive officer of Health Quality Ontario. But instead of simply focusing on the failings, he said, it’s time to create strategies to do better.

“We’re doing a horrible thing by showing people graphs and data that they’re not doing well, and not telling them how to do better,” he said. Dr. Tepper spoke at the annual Mobile Health Summit at the end of January, organized by the Strategy Institute, a conference company.

He stressed that quality is a skill, and that healthcare practitioners should be educated in quality techniques as part of their training. “You should know the basics,” he said, about collecting and assessing quality metrics.

He asserted that clinicians and healthcare MBAs and MPHs shouldn’t graduate without knowledge of quality techniques such as PDSA (Plan, Do, Study, Act) cycles, run charts, tests of change and the seven basic tools of quality, a common method of troubleshooting quality problems.

For those who don’t have this knowledge, he said, “You don’t need a PhD degree in quality, you need a two to three week course.”

As well, healthcare professionals should be striving to do things a little bit better each day, to improve the workings of their facilities and to ameliorate the condition of their patients. In a video, he showed how using iPods for a cognitively unresponsive patient completely changed his daily experience, bringing back memories of better days and improving his mood for the better.

“If you’re a nurse or in healthcare IT, you should be doing things a bit better each day,” he said.

Dr. Tepper did point to serious problems in the healthcare sector, particularly in the area of long-term care. His organization conducted a study of 628 of the province’s nursing homes and found that:

• The incidence of Stage 2-4 pressure ulcers ranges from 2% to 14% from one facility to another. “That’s a huge variation,” he said. Pressure ulcers result from lying in the same position for too long, and can become infected. “They’re incredibly painful and debilitating,” he said.
• Use of daily physical restraints ranges from 0 to 45% of patients in homes, depending on the facility. These restraints should be avoided whenever possible, he said, as they’re associated with “physical and emotional harm.”
• The use of anti-psychotics in patients without psychosis ranges from 4% to 60%, from one facility to another. This practice is often used to sedate agitated residents, but should be avoided whenever possible, he said, as it associated with a higher death rate.
• Patient falls range from 5% to 30%, depending on the facility. Dr. Tepper reminded the audience that falls in the elderly are serious matters, and that many who experience a fall will never recover: “For the elderly who fall and break their hips, the odds of being dead in a year are incredibly high.”

He observed that Ontario’s 600 to 700 nursing homes, with the exception of some of the chains, “operate in isolation from each other,” when they should be collaborating. “We should be working as a group, and learning from each other.”

“Alone, we can only do so much on quality,” added Dr. Tepper. “Together, we can do a lot.”

He emphasized that technology could be of great help to long term care facilities when it comes to quality, but noted that the sector traditionally hasn’t invested much on the technological front. “It hasn’t been a sector that has adopted technology, even compared with home care, which isn’t setting the bar very high.”

Unfortunately, many long-term care centres still don’t have electronic patient records, he said.

Dr. Tepper identified several other areas in which technology could be effectively used in long-term care:

• Medication optimization, including the over-medicating of residents.
• Remote patient monitoring
• Assistive technologies
• Remote training and supervision
• Disease management
• Cognitive fitness
• Social networking

He observed that the Internet of Things could be of great value in keeping tabs on frail seniors in long-term care. One example is already being used in forward-thinking hospitals, where “smart beds” contain sensors to determine when patients need turning to avoid bedsores.

Sensors are also used to detect when frail patients are attempting to leave their beds and are in danger of falling. Nurses are alerted, and can find out why the patients are trying to get up, and to take appropriate actions.

Some of the biggest problems occur at the transition points in care, when patients leave hospital for long-term care facilities or to go home.

There is often little communication among caregivers about care plans and new medications – which can result in the patients getting sick and returning to hospital. “When patients are discharged, how do we know they’re staying on their meds?” he asked. Often enough, they stop taking the meds that were prescribed at the hospital, as the long-term care facilities or home care providers didn’t know about the new prescriptions.

‘Medication reconciliation’ systems, tied together by electronic communications, are needed to keep all care providers on the same page, said Dr. Tepper. “Right now, there are elements of quality, but we don’t have a system of quality,” he said. “There are fractured entities.”