IHI: A Multidisciplinary Approach to Improving Healthcare
Dr. Jonathan Phillips
The To Err Is Human report, published in 2000, was a landmark paper that spoke of the need for quality healthcare in America. There are organizations who were laying the foundations for improvements in healthcare even prior to this paper. In the 1980s, a project called the National Demonstration Project in Quality Improvement in Health Care enlisted help from industry leaders such as AT&T, Ford, and IBM to help healthcare organizations use industry-standard processes to improve quality and reduce costs in healthcare. This project had significant successes with over half of organizations achieving important outcomes such as reducing length of stay, fewer postoperative infections, and reducing waiting times in Emergency Departments. This project eventually became the Institute for Healthcare Improvement (IHI). They have established activities across Africa, Asia, Europe, and North America to become a leading international not-for-profit organization dedicated to improving healthcare. (1)
Some healthcare quality improvement approaches such as Six Sigma draw from industry and rely on standardized statistical approaches to control processes. The IHI has developed their own approach to change called the Science of Improvement. This approach applies “science that emphasizes innovation, rapid-cycle testing in the field, and spread in order to generate learning about what changes, in which contexts, produce improvements.” Instead of leaning heavily on statistics, it also incorporates a more multi-disciplinary approach that involves psychology, system theories, statistics, and other social science approaches (2)
The IHI has developed what they call the “IHI approach” which they shorten to “IHI-QI”. At its foundation, IHI-QI leans on a Model for Improvement which was developed by Associates in Process Improvement, and its asks 3 questions:
What are we trying to accomplish?
How will we know that a change is an improvement?
What change can we make that will result in improvement?
In contrast to Six Sigma which uses a DMAIC (Define, Measure, Analyze, Improve, Control) approach in the application of their projects, the IHI-QI model then uses a PDSA cycle for the practical application and evaluation of their projects
Plan: Stakeholders discuss what they want to learn from their study, what data will need to be collected, and what outcomes they will measure. They identify barriers and delegate roles.
Do: Team members carry out the changes that were identified in the prior step. Team members will also begin to collect data as well as challenges that they encounter.
Study: Team members finish gathering data, analyze the data, and compare it to their prior predictions. This is a good time to also study challenges that were encountered and how these challenges may have impacted the study.
Act: Based on findings from the previous step, the team will identify new changes to be made for the next PDSA cycle. These changes will propel the team back to the planning stage where they can repeat PDSA cycles in an attempt to bring about desired changes.
It is through these PDSA cycles that IHI-QI performs the ground-level interventions that bring about ground-level change. Often, PDSA cycles may be revised and repeated until processes are refined to bring about the desired change. (3)
(4)
In addition to their IHI-QI approach, the IHI was also a founding leader of care bundles within hospitals. In 2001, the IHI and Voluntary Hospital Association (VHA) worked together to develop two different ICU care bundles across a network of 13 intensive care units (ICU).
The IHI Ventilator Bundle included
30-45 degree head elevation
Daily extubation evaluations
DVT prophylaxis
Peptic Ulcer Disease prophylaxis
*You can find the IHI Ventilator Bundle and the Bundle Checklist at this link:
How-to Guide: Prevent Ventilator-Associated Pneumonia | IHI (6)
The Central Line Bundle included
Hand hygiene
Maximal barrier precautions
Chlorhexidine skin antisepsis
Optimal catheter site selection
Daily review of central line necessity
*You can find the IHI CLABSI Bundle and Checklist at this link:
How-to Guide: Prevent Central Line-Associated Bloodstream Infection | IHI (7)
These were implemented using the Model for Improvement that was mentioned above and then put into action through PDSA cycles at their individual sites. This bundle approach has proven successful in subsequent studies: one study showed that high compliance of the Ventilator Bundle (>95%) resulted in a 40% reduction in Ventilator Associated Pneumonia. These bundles became recognized nationally and have been included as recommendations from national healthcare quality regulators. They set the stage for future bundles including Emergency Department and ICU bundles for sepsis that have been developed. It is important to note that bundles are developed for specific settings (i.e. ICU) and their use does not automatically translate to other locations. (5)
Finally, IHI has contributed to healthcare quality efforts through structured educational opportunities. They provide free foundational healthcare quality courses to learners (including medical students, medical residents, and other healthcare profession students) through their IHI Open School. Over 200,000 students and residents have completed the courses to obtain an IHI Basic Certificate in Quality and Safety. For professionals with at least 3 years of experience, they also offer a Certified Professional in Patient Safety (CPPS) exam which may lead to certification. This may be obtained by a wide variety of healthcare workers including physicians, pharmacists, and nurses to show their commitment to patient safety. They have previously published a podcast and continue to provide both synchronous and asynchronous educational opportunities.
*You can find more educational opportunities at the IHI Open School website IHI Open School Home | IHI.
*You can find more information about the CPPS exam as well as an informational brochure at CPPS: Certified Professional in Patient Safety | IHI
What about you? Have you taken an IHI Open School course or participated in a PDSA cycle? If so, comment below!
Jonathan Phillips, D.O.
University of Louisville | Internal Medicine and Pediatrics
Dr. Jonathan Phillips is PGY-4 resident at the University of Louisville for Internal Medicine and Pediatrics. He attended Kentucky Wesleyan College for his undergrad and completed medical school at the Kanas City University of Medicine and Biosciences.
References
Blanton Godfrey. “Quality Management”. Accessed 09/29/2021. https://www.qualitydigest.com/sep96/health.html
“Science of Improvement”. Institute for Healthcare Improvement. Accessed 9/29/2021. http://www.ihi.org/about/Pages/ScienceofImprovement.aspx
Scoville R, Little K. Comparing Lean and Quality Improvement. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2014. (Available at ihi.org)
Scoville R, Little K, Rakover J, Luther K, Mate K. Sustaining Improvement. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2016. (Available at ihi.org)
Resar R, Griffin FA, Haraden C, Nolan TW. Using Care Bundles to Improve Health Care Quality. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2012. (Available on www.IHI.org)
How-to Guide: Prevent Ventilator-Associated Pneumonia. Cambridge, MA: Institute for Healthcare Improvement; 2012. (Available at www.ihi.org).
How-to Guide: Prevent Central Line-Associated Bloodstream Infections. Cambridge, MA: Institute for Healthcare Improvement; 2012. (Available at www.ihi.org)
