how much I enjoyed the conversations during the lunch break. And really, I think, hopefully we can have more of that in the next break and in the happy hour. So I'm going to talk about making quality improvement part of our daily work. I have no disclosures for this talk, no conflicts. And what I want to do in the next 20 minutes is I want to give a brief introduction of some of the topics, some of the things that really were touched on on previous talks and talk a little bit about the quality metrics and the data. I'm going to talk about what I believe is the necessary requisite to any quality program, which is a culture, talk a little bit about that, and then end with a call to action with some actual tips or actionable items that we can implement on our daily work to really make quality a part of what we do every day. So we all have heard about the move from a fee for service to a value-driven health care that obviously has been going on for several years and has impacted how hospitals and some physicians get paid. It has a lot of good things, but also has a lot of problems. And it's something that I think is not going to go away. When we talk about value in health care, most people will talk about better quality, better outcomes at a lower cost as the ideal value formula. So today, we're going to talk about how do we incorporate that quality or improvement in quality to our daily work. Todd mentioned this at the beginning, but be very careful with surrogation, which is when the metric becomes the end in itself. And there are several examples in medicine, but outside of medicine, where people are so obsessed with the metric that they forget what the intent of what we're measuring is and really, I mean, have gone haywire and done things that are probably unethical or that are very problematic. So unfortunately, the metrics that we have in health care don't always equate to quality. So what is quality is the big question. And from my perspective, the simplest way of looking at quality is taking evidence-based medicine, which is the conjunction of our clinical expertise, the best available evidence from research, and our patient values and preferences to the bedside for our patients every day. That is what quality improvement really is. It's not a spreadsheet. It's not a number. It's not a metric. It's about taking the best available evidence-based medicine to our patients at the bedside. And that's what we should thrive for every day. The second part of this talk is really about the culture. You can't have a quality program without having the right culture. And unfortunately, a lot of us, and we talked about generations, but I think that it's true for Gen X, true for baby boomers in medicine. We were brought up in a environment where a lot of our M&Ms were about what was done wrong and how are we going to improve it, and really was not approached with that curiosity of what happened here and how can we make this work. So we have to move from a who did it to a what happened culture. And that is obviously a lot easier said than done, but I believe it has two basic requisites. Number one is psychological safety. And we've talked about this in other sessions at LEAD last year, so look it up on the science of team building. But psychological safety is a shared belief that a team is safe for interpersonal risk taking. And we've all probably seen or been teams where there's psychological danger, where people are afraid of admitting their mistakes. They like to blame others for problems. They are less likely to share different point of views. And ultimately, it leads to poor patient outcomes. What we want to build is an environment that is safe for people to admit when something was done wrong, that we can learn from failure. Everybody is willing to share their ideas. There is no bad ideas. Doesn't mean that we're going to do all the ideas, but everybody is willing to share. And ultimately, I think that leads to better innovation and decision making, which is the way that we really create quality at the bedside. There's different types of psychological safety. The reason why I share this here is you can see how every single one of these are required for us to really live quality improvement as a team every day at the bedside. So there's learner safety. Is it safe to discover, to ask questions, to experiment, to learn from our mistakes? There's collaborator safety. I feel safe to engage in an unrestrained way to interact with other colleagues, even if they're from different disciplines. We have mutual access to different groups. There's challenger safety. If I see something that doesn't make sense to me, I'm willing to challenge the status quo. A lot of the discussion today in the table was, how do we change things that have been going on forever that make no sense at our hospital? I'm willing to speak up to express my ideas. I think that we could do this a little bit better. But also, it's inclusion safety, where I know that my opinion is valued, even if it's not the one that we're going to go with, that we treat everybody in the team fairly. We talked about diversity earlier today. Diversity, obviously, has multiple aspects. But for people to feel included in a diverse team, we have to have a psychologically safe environment. So this is extremely important. We'll talk a little bit about how we get there. But the other requisite, I think, for quality is to change our relationship with failure. In medicine, unfortunately, I think we have been taught the wrong things associated with failure. We think that failure is always bad. That is not true. We think that learning from failure is straightforward. And usually, when I was a trainee, the response to every M&M was almost like, I'll try harder next time. I will be better next time. That's now how we improve care. It's by improving the systems and the team performance. And finally, I think a lot of people have this misconception that failure and high standards can't coexist. I would say, on the contrary, those high standard or high-performing places know how to embrace failure, and they know how to learn from it. So there are different types of failure. There's preventable failures, which, obviously, we don't want to accept. These are things that we should have systems in place to avoid. Why would you amputate the wrong leg? That's a preventable failure. That is 100% unacceptable. However, in the ICU, there's complexity-related failures, which relates to just how difficult it is to care for some of these patients. And it's the Swiss cheese model, where several holes have to align sometimes, but they happen, and we have to learn from those. And then there's intelligent failure. So if you do a business plan that is intended to build a new service line, you want to fail early if it's not going to work. And that's an intelligent failure. You can then pivot and move in a different direction. So not all failures actually have the same, let's say, reason to occur or the same impact on the team. So this just gives you a broader spectrum from a Harvard Business Review article on failure. There's, obviously, blameworth to praiseworth. So when people don't follow protocol and there's a failure, a safety failure, that is blameworthy. We have a protocol. We should follow it. Accountability is needed there. But on the other extreme, when people are fully engaged and they're doing exploratory testing, if that fails, that's great news. We've learned what not to do, and we pivot to something different. So I think our relationship with failure needs to change. We really want to make quality part of our daily work. And we have to learn how to learn from failure. We need to be able to detect failure. That's where valid and data that has integrity is so important. Todd talked about that. We have to be able to analyze it. And I think that analysis doesn't mean that the data dictates what we do. I love that you said, I mean, being data-informed as opposed to data-driven. And you say the same thing in failure. We have a sentinel event, and they immediately change everything. Well, let's stop and think, what happened? What do we have to change here? And then finally, there's room for experimentation. If we really want to improve quality, there's things that we have to do that are experiments and pilot studies to see how to do things better. In the context of clinical care, there's experiments that are clinical experiments that require clinical trials, IRBs. But in the daily care in the ICU, there are process experiments that we can do every day and try to learn from them and improve our care. How do we build this culture? I think as leaders, and we talked about what it means to be a leader, doesn't mean to have a position. It means that you have a vision and have people who follow you. It's framing the work accurately. Not everything we do is easy. We know that. But frame it accurately. Acknowledging our limits as leaders. Inviting participation. That's the humility of recognizing that everybody in the team knows something you don't know and might have the right answer. So invite people to participate. We have to respond productively to when people offer suggestions, but also when people are not doing what they expected from them and the team. And finally, we have to learn how to embrace failure. We should never shoot the messenger. We should embrace the messenger of bad news because that's really how we can improve. And that is something that I think a lot of institutions are better at. But many of our institutions are still on that journey towards a more safe place. So finally, in the last couple of minutes, I have just a call to action. Recognize four things that you can do every day to improve quality or to bring quality to your day-to-day work. So the first thing is multidisciplinary rounds. We talked about that earlier. Incorporate quality improvement into your multi-day rounds. That, I think, is a key of really moving things forward. You can do that in your documents that you use, your checklist. But make sure that there's discussions about how are we improving the care we're providing every day in rounds. Number two is team huddles. This is from an article that Laura Rock published in the New England Journal and Catalyst. And this is more centered around the pandemic. But I think that team huddles at the beginning, at the end of shifts, are great ways of focusing on quality. So at the beginning of the shift, you're really focusing on what are we going to try to do. You have several touch points with your team, RT, with a nurse, with your APPs during the shift. And at the end of the shift, you do a quick huddle debriefing. It can really take five minutes. But you can focus this on what are the things that we've done to advance the quality of our care today as a team. Number three is, we talked about this from the perspective of moral injury, but to pause and debrief on processes that we do in the ICU every day. So this is actually taken from the Navy SEALs. After every mission, they have what they called an after-assignment review. That is really a candor discussion of what were the intended results, what were their actual results for the mission, what caused those results, what would they do better next time, and what would they do differently. Sorry, what would they do the same next time, and what would they do differently? And by engaging our teams to talk about this after a code, after we put a central line, after we finish rounds, it just takes a couple of minutes. But if you do it in an organized way, it brings, again, that quality, the purpose of quality to the bedside on a daily basis. And finally, something that Todd mentioned, which I think we have the same picture, but I think it just speaks that really, I mean, this is important. It's sharing the data consistently in terms of making it visual to the rest of the team. It shouldn't be in the office of managers, right? It should be shared either in team meetings or on boards and really celebrated in terms of what is important for us. So we talked about what is quality. And in my perspective, it's taking the best available medicine to the bedside every day. It requires a culture that is psychological safe for people to give their opinions, to admit mistakes, to learn together, and to participate in improving care. And finally, there are things that we can do every day to bring quality to the bedside and make sure that everybody in the team is responsible for quality, not just the ICU director. So I'll stop there, and thank you very much. Thank you.

quality improvement

healthcare

learning from failure

psychological safety

evidence-based medicine