In Conversation With… Edward Kelley, PhD
Approach to Improving Safety
Setting of Care
Editor's note: Edward Kelley, PhD, is Director of Service Delivery and Safety for the World Health Organization (WHO). He has done extensive research into measuring and improving health systems performance and disparities in quality and access across priority populations. We spoke with him about his work with WHO and the global impact of the organization on patient safety.
Dr. Robert Wachter, Editor, AHRQ WebM&M: As you began to get involved in international patient safety, what were the major differences you confronted in thinking about patient safety around the globe as opposed to in the US?
Dr. Edward Kelley: When Crossing the Quality Chasm and To Err Is Human came out, and then accompanying reports like An Organization With a Memory, there were very few global experts in safety. The World Alliance on Patient Safety was the first global effort to put patient safety on the international map. Many experts came and you could fit them around one table. Nowadays you couldn't. Part of the challenge we face at WHO is we had lots of activity with partners in the US and in the UK. But we had difficulty convincing people in the Southern Hemisphere, particularly Africa, that safety was a relevant topic that they should be looking at. A colleague who was former Minister of Health in Uganda said to me, "We cannot tell people that hospitals may be giving them infections or we may even be killing them occasionally. We have enough trouble getting people to come to our health centers and our health facilities to get care." There was a real fear that we were introducing something new rather than what it really was: turning the whole quality approach on its head talking about eliminating preventable harm.
RW: So are you saying that getting people into the health care system is such a challenge in certain parts of the world that talking about safety will scare them? Or is this higher on Maslow's triangle, in that they're just not ready for it yet?
EK: Yes, that's a good question. There was a messaging issue and then an information issue. On the one hand we revisited the messaging issue and said, "Look, this is not a new topic. This is the same thing you've been trying to do which is give people the best quality care possible, but we're going back to basics, back to 'do no harm', and talking about elimination or eradication of preventable harm." In the public health world, we understand eradication. Go back to smallpox, polio, tropical diseases like guinea worm, and others where we're talking about eradicating a disease. The public health world in the Southern Hemisphere understands that. They say, "Yes, we can do that." That's the messaging part.
But the data part was really taking some of the landmark studies on adverse events, modifying the chart review methodology, and working with partners in the developing world to look at adverse event rates. Every single country came up with almost the same figures: about 1 in 10 hospitalized patients would experience an adverse event. We repeated those results across Latin America with a big study sponsored in part by the Spanish government and then a big study in the Mid-Eastern Mediterranean and African region and again saw rates of at least 1 in 10 if not higher. Those two put together really turned the tide in terms of getting people to focus on safety.
RW: I guess the natural thing for folks in the US to think is it must be really hard doing this work in the developing world because of the lack of resources and technology. Spin that the other way: What about this work is made easier by working in the developing world?
EK: Of course there are issues around resources. One of our first programs, which we said we would not only do data work but we would also really challenge countries to address important issues. Our first global challenge was around improving infection rates and working on hand hygiene. In a number of countries where we worked, reliable water supply was a big issue. So we had to work on other solutions like making alcohol-based hand rub available. There are many ways in which working in these settings is much easier than, for instance, in the United States. You're never working with tabula rasa anywhere. There's always a health ministry, previous programs, lots of actors whether they be development partners like USAID or ministry partners. There tends to be a broader openness to improvement programs. If you can say, "Look, we did this in Uganda and it reduced infection rates by this much," people are ready to jump right on it. In many of these settings, the health system tends to be more centralized, so you can roll out programs much more quickly. Finally there is a lot of social networking; young nursing and medical students in a course from IHI might have heard about Wachter's lecture and downloaded slides somewhere. An incredible cross-fertilization occurs. So the openness to local innovation and South-South collaboration where people use the Internet to solve problems across these communities of practice that frankly just didn't exist. That platform wasn't there when we started 20 years ago. All of that makes it a lot easier to make progress in the developing world than you might have seen a couple decades ago.
RW: One thing we confront working at a large health system is that it has big hospitals and little hospitals. How do we roll out programs that are relevant across the board for those scale variations within the target audiences? You have that times 200 given all the countries and variations in resources and culture and history. How do you even begin thinking about that issue of scale and spread given the size and variation in your audience?
EK: It's an issue, I think, no matter what. Whenever we talk about scale and spread, I always point out that it comes from the analysis we did with the National Health Care Report at AHRQ and then again at the OECD afterwards said that variation in terms of performance and both process of care and outcomes of care within a country per se, at-risk groups versus the rest of the population, or rural versus the more urban population, always are greater within countries than they are between countries. Some of the biggest challenges countries will face are always going to be within their own borders rather than say, WHO working with Sudan versus working with France. That said, obviously there are major differences between France and Sudan in terms of the type of program you would implement. To just give an example from one of our close colleagues, Peter Pronovost, WHO has a special Patient Safety Office at Johns Hopkins. We've maintained that for 2 years and very special relationships that we've had in terms of bringing some innovations from the US overseas.
We have taken some elements of the CUSP approach around bloodstream infection and are trying to adapt that for work in preventing surgical site infection in African hospitals. The basic elements of the protocol are all the same. You talk to clinicians in Kenya at one of the sites and clinicians in Baltimore at Hopkins, and they have the same issues around staff motivation, too many patients, how to get people to do the right thing all the time. But we did have to modify the language. We had to simplify a lot of tools. We had to look at new elements of how to collect the data and minimize the amount of data we collect. So one piece is adaptation. Then the other piece is really one of WHO's strengths, it's a big organization. We have offices in 154 countries so we depend on those country offices to help us pitch the message and pitch the program at a level that will work locally and be the same everywhere. In this, WHO differs from a lot of other organizations in that the WHO office will be there afterwards to help sustain that program. So those are the two real main approaches that we take to try to adapt and scale up in a wide variety of settings where we work.
RW: What you would see as the biggest success story within your work and the work of your organization, let's say in the last 5 years in the safety field?
EK: Internationally it would have to be our global challenges. So these were big G, big C, Global Challenges. These were formal programs where we really set out and said, "Look, we'll create a burning platform around a particular issue. We'll look to create an intervention package that could be applied in every country in the world, and then we'll really challenge WHO's stakeholder groups to put that into place." And we worked on it with them. The first one was on infection prevention and control and really working on hand hygiene. It was the fastest campaign WHO ever had. It was based on a multimodal approach very similar to some that have worked well in the US that looked at technical implementation, plus communication and leadership strengthening. And it was based on "five moments." So that was where we challenged ministers to really improve hand hygiene in their countries.
We worked on the second one with Atul Gawande and it came from Harvard with the Safe Surgery Checklist. That was where we said, surgeries happen all over the world. If you look at the global burden of disease, surgery potentially touches every single subcategory of disease listed in there. So we should be able to come up with something that makes surgeries safer all over the world. We came up with this simple checklist that has obviously been modified many, many times for many settings. But the core piece was there. Being able to come up with a Global Challenge relevant all over the world and to put it in place and sustain it has probably been our biggest success.
The third challenge that we're getting ready to launch in about the next year will be on medication safety. So we'll no doubt be talking more about that. Very close behind it we started, before it was popular to do so, this whole program on patient stories and our Patients for Patient Safety program. That was one of the first things we started over a decade ago, which was really bringing patients and their stories of harm as a motivating factor for improvement.
RW: It struck me as you were describing the challenges, you mentioned Atul Gawande for the surgical one and obviously Didier Pittet for the hand hygiene. How important is it to have an internationally recognized champion to give these programs a face?
EK: That has been one of the keys, because it really has meant that there's an immediate legitimacy to the program. That legitimacy of an individual you trust is very important in the same way that you might try to sell a brand. Beyond that, it's also someone who is really able to be out there and speak with very deep professional credentials in an area leading the essential and emergency surgical care programs, but not people of international recognition. Similarly in infection prevention we have one of the world's experts working on the team. At the same time, WHO wrestles with this because it's still in the end a WHO program. People come up to me at conferences and say, "I was wondering if you had copies of Atul Gawande's checklist?" Or "I wonder if you have copies of Didier Pittet's guides to hand hygiene?" And I'll have to sort of quietly correct them and say it's also the WHO checklist and also the WHO hand hygiene work. On balance it's been fantastic working with them, and selecting a champion for the medication safety challenge will be a key element.
RW: As computers integrate themselves into all aspects of our lives and health care, where is that challenge for you? You have a lot of different countries that are probably at different stages in their technological journey.
EK: This is one of the big new driving forces that will really shape how WHO does its work. On the one hand, WHO struggles with trying to ensure that it's serving the underserved nations, but also driving innovation. In this regard, WHO has had many discussions about big e-health questions like whether there will or will not be a dot-health domain and what the WHO has to deal with on global policy issues. But when you think about what does the digitization of the world mean for improved patient care and health services, we have made the jump to considering our focus to be around creating integrated people-centered care, working with countries to deliver that, and quality and safety are part of that. Our own department has been renamed Service Delivery and Safety.
I think every country has an opportunity to look at electronic and digital tools to advance that. In some countries that's going to mean putting electronic health records in people's hands, giving them access. I just saw an excellent presentation from Estonia about patients having access to their own radiology images: parents-to-be being able to securely access online images of their in utero baby. Those will be some things that we'll look at in terms of people-centered care. But it can also mean in very developing settings where mobile phone use is expanding to gathering basic data and improving vital registration systems, because you have better possibilities for electronic data capture, even in very resource-limited settings. There's potential and the issue will be being able to flesh out some guidelines for how countries should proceed with investment for the different levels of development that WHO deals with.
RW: It's an interesting question. You wonder whether we're at the early stages of a set of world flattening forces with technology and health care. I had a meeting with a Silicon Valley investor who is originally from India and he told me his motivation for doing his work is, "I think about trying to get a physician to see patients in some of these towns in India. It's just not going to happen, or not going to happen easily. Yet if we can figure out a way for patients around the world to tap into expertise that right now they don't have access to, that could be transformative." So is that part of what we're trying to do, and if we are, how does that infrastructure get built?
EK: That is a big piece of it and in many countries there's probably a parallel effort that needs to precede that around building that health literacy. In terms of empowering patients, families, and communities to be more involved in their health care, in terms of having access to information as well as seeking the correct care at the right time, and taking care of their family members. WHO estimates that about 70% of care around the world is provided by family members. It's not a formal workforce. Having them hooked into better information sources would be key. But we'll still have to do a big investment in terms of building some of that health care literacy around why is that important for your role. Then some of these tools, either through Internet or mobile phone programs, can fall on fertile ground.
So clearly there's a lot of experimentation out there in this regard. Both better information for frontline health workers doing higher level jobs that used to be done by higher level people, either because they're getting just-in-time training for a particular task or because they're hooked in electronically to some kind of clinical center somewhere. There's been some good research, but there definitely needs to be more examination of the conditions that make this right and the Maslow's Hierarchy of Needs around this type of investment. What should come first and then what should be your goal in terms of the investment has not really been defined. Countries tend to jump to the top of the pinnacle before thinking about what basics need to be invested in. You cannot suddenly throw out access to your medical record by mobile phone if you've never talked to patients about why they should care about their own health.
RW: As you think about your office and enterprise, what are things that you cannot accomplish over a short time horizon, but 10 years from now it would be transformative if we did x?
EK: It's a timely question because WHO's working on that as we speak. We've looked at quality and quality information methods, focusing on safety, and then talking about value. Now I see in many countries there's going to be a big global focus on what the international community calls universal health coverage. But this will be a big theme for WHO in the next decade. It will underpin any discussion around what you would term the post-Millennium development goal era. So in developing countries we will move away from thinking about tuberculosis, maternal and child health, HIV, malaria as separate things.
Then in the transitional countries and in the developed world thinking about: What does our national diabetes program tell us? What is the National Heart, Lung, and Blood Institute telling us? These separate disease-by-disease approaches and thinking about a whole people-centered approach. What are the entire needs of our patient population? How can we design a system that lets them efficiently access the care that they need? In many cases, it's about providing self-care in a more people-centered way and more efficiently than we can provide with medical personnel, and having patients involved in the design of all sorts of elements of the system. So that would be our vision that we would see in 10, perhaps even more, years. Countries would have active people-centered care policies, through national legislation. Every new hospital that they opened would start with discussions from the patients that were going to be served there regarding, what are the key services that you need? When do you need them? And in what kind of ways can we offer them to you? So that type of integrated approach around preventive services all the way to palliative care, putting people at the center. Somehow that will have to be at the center of the vision. All this work on providing safe care, providing high quality care, all of that will really flow from that vision.
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