Innovation

Commitment to quality

Dr. Gerarda Cronin uses lessons from business school to help the Winnipeg Health Region deliver better hospital care

Benchmarking quality

BY NELLE OOSTEROM
Winnipeg Health Region
Wave, November / December 2009

It happens nearly every day. A child suffers a severe asthma attack and is rushed to hospital, where he or she undergoes treatment to bring the problem under contol.

In the past, an acute asthma attack often resulted in admission and an average of two to three days in the hospital for treatment. Some children might suffer a relapse and have to be re-admitted within 72 hours of being discharged.

Not anymore. Today that same child is more likely to respond to initial treatment and go home. If admitted to hospital, he or she will spend a day and half, on average, before going home. And, chances are he or she will not require a return visit to the hospital.

By any measure, the reduction in hospital bed days and re-admissions represents a real improvement in care for children with asthma, one that will benefit thousands of kids in the years to come and conserve scarce resources. But it also represents something else: a relatively new approach to thinking about health care, one that blends insights from the world of business with lessons learned in medical school.

In Winnipeg, this new approach is personified by Dr. Gerarda Cronin, Director of Quality and Decision Support for the Winnipeg Health Region's Child Health Program. A neonatologist by training, Cronin is responsible for identifying ways to enhance the delivery of hospital care for children in Winnipeg. To put it another way, you could say she is the Leader of Making Things Work Better for Kids.

And that she has done. In fact, it was the work of Cronin and her team that resulted in improved care for asthmatic children. As a result, the Children's Hospital in Winnipeg now has one of the lowest average lengths of hospital stay for children with asthma anywhere in Canada.

Since becoming the first Director of Quality and Decision Support, in 2002, the Irish-born doctor has been engaged in many projects, all designed to improve patient outcomes through the careful analysis of how care is delivered and, more importantly, how it can be improved.

Over the years, she has played a role in quality improvements as diverse as developing a protocol for the investigation of critical incidents to reducing lung damage in premature babies. Some of her research is conducted under the umbrella of the Canadian Neonatal Network, which collects and compares data from hospitals across the country with a view to improving neonatal outcomes. She is also very involved with the Canadian Association of Paediatric Health Centres, a recognized leader and advocate for advancing the improvement of health care for Canada's children and youth.

Cronin's journey from neonatologist to a leader in the field of quality care actually began soon after arriving in Winnipeg in the early 1990s. She was the first neonatologist to be assigned to work at both teaching hospitals in Winnipeg. It didn't take her long to realize that different hospitals often had different approaches to care, which would result in different outcomes for patients. "When I came to Winnipeg, the first thing I noticed was the variation between the two hospitals (St. Boniface General Hospital and the Health Sciences Centre). This was a new concept to me. The whole idea of benchmarking and practice variation was not something I was aware of until that time," says Cronin.

As time progressed, Cronin became increasingly interested in the idea of quality care and, in her quest to learn more, turned to a field more often associated with manufacturing than with medicine - quality management.

Quality management was first promoted back in the 1940s by American statistician W. Edwards Deming, who called his system Total Quality Management (TQM). Credited with improving American production during the war years, he was best known for teaching the Japanese how to apply quality principles, particularly in car making. Thus, companies like Honda and Toyota started making cars that were much more reliable then their American counterparts, a point not lost on consumers.

He famously developed fourteen points of management, one of which included driving fear out of the workplace so that workers could freely communicate their concerns.

Quality management has been applied to various fields, especially those that involve safety, such as the aviation and nuclear industries. For instance, in the early days of aviation, there were many crashes due to pilot error. As aircraft became more complex, the problem worsened because pilots had trouble remembering all the steps they had to perform during takeoff, landing and flight. In 1937, American Air Corps pilots were faced with the Boeing Model 299 - "too much airplane for one man to fly." It was then that they hit upon a solution for flying this ultra-complicated machine - a pilot's checklist. Pilots around the world have faithfully followed checklists ever since. Today, flying remains safer than driving.

Medicine is a relative latecomer in embracing quality management, although nursing pioneer Florence Nightingale was an early 19th-century champion. A brilliant mathematician, she was passionate about using statistical data to make improvements in the field.

"In the 1870s, Florence Nightingale wrote that, in her view, every hospital should have attached to it a unit or group of people whose job it was to analyze what went on in that hospital, the activities and the outcomes of those activities, with a view to providing feedback and changing systems to improve the outcomes," says Cronin. "So what she was really saying was that every health-care institution needs a quality management system. She was quite forward-thinking."

After much reading and attending many workshops and seminars, Cronin took the plunge and embarked on a sabbatical to pursue her MBA at the University of Manitoba's Asper School of Business. This is becoming more common in the medical field. In recent years, universities have started offering MD/MBA combined degree programs for doctors aiming to be managers and leaders in the health-care sector.

It was through her studies at the Asper School of Business that Cronin gained new insight into management systems and strengthened her leadership skills. "I really felt I needed more nuts and bolts (management/leadership) skills," Cronin says. "That's what got me to the point of doing an MBA." During her studies, she learned the importance of developing processes to review the design and implementation of health-care treatments, checks that would go beyond the traditional kinds of medical reviews that took place in a hospital setting.

One way in which she used her new knowledge and training was to launch a protocol for the investigation of critical incidents. Introduced in 2001, it is now in use throughout the Winnipeg Health Region. The protocol was designed to operate in a "blame-free environment where people can report adverse events and near misses without feeling threatened." The incidents are then investigated in the same way that airline accidents are investigated, with a view to making changes in the system to prevent future problems.

Implementing the investigation tool has helped the Region develop or improve other protocols - such as systems of checks and double-checks, and making it easier for staff to do the correct thing by having the right equipment available, for instance.

Cronin, who has been a staff neonatologist at the Health Sciences Centre and St. Boniface General Hospital since 1990, led Manitoba's Neonatal Resuscitation Program from 1992 to 2000 and has held several administrative posts.

But it wasn't until she became the Director of Quality and Decision Support for the Child Health Program in 2002 that she was able to work on applying the principles of quality management in more than an ad hoc way. "It's not something that can be done in the evening and on weekends," says Cronin. "I lobbied for quite some time to get the structure in place. And quality is a team sport."

The treatment of asthmatic children was one of the first projects she undertook after becoming director, and it illustrates how the Child Health Quality Team operates.

Asthma is the most common chronic disease in Canadian children. About nine per cent of all visits to the Children's Hospital Emergency Department are due to asthma. Since asthma takes up so much time and resources, and affects so many children, it's a good place to go looking for ways to improve care.

Cronin helped put together a multidisciplinary team that included medical staff, such as pediatric allergist Dr. Wade Watson and pediatric respirologist Dr. Hans Pasterkamp, asthma education co-ordinator Cathy Gillespie, and quality officer Leslie Galloway, as well as a parent of children with asthma. The team audited existing practices and made some interesting observations. One of them was that the system was slow in administering steroids - a highly effective treatment - to the affected children. Another observation was that efforts to educate families about asthma management were not consistent.

Under Cronin's leadership, the team developed care maps - similar to the idea early pilots had about developing checklists. The children's asthma care maps - sometimes they are called clinical paths or care pathways - were implemented for Emergency Department use in June 2004, while an inpatient care map came into use a year later.

"A care map is a tool that basically shows you exactly what the right thing is to do," she says. "So that rather than a pediatrician saying, 'Maybe I will or won't do this or that,' the pediatrician or the emergency room physician will decide, 'This child is eligible for the asthma care map, which means I must give steroids. I have a choice between two medications in doses that are tailored for success.' There are quite a few elements to it, but once they make those simple decisions, then treatment proceeds immediately . . .

"There are always the exceptional patients for whom a care map is not the right strategy, but they are the exception."

The team also rolled out information material for parents and did a lot of education for staff.

"We found that we were seeing dramatic improvements in the response of children to what was now a much more timely treatment."

Following the implementation of the asthma care map, the administration of oral corticosteroids within one hour of presentation rose from 61 per cent to 92 per cent. The average length of stay for children who had to remain in hospital dropped to 1.5 days from 2.3 days, thanks to closer ongoing monitoring of their condition and tailoring of their treatment accordingly.

"It's amazing how fast children get well when we are responsive to their needs."

Better education meant fewer relapses as parents received a written asthma discharge plan to help them prevent future attacks through such measures as identifying allergens in the home.

"We've been watching indicators such as the chances of children coming back to the emergency room, and basically it's extremely uncommon."

The emergency asthma care map was implemented at all Winnipeg Emergency Departments in 2006. As well, other pediatric centres and community hospitals across Canada have adopted similar methods based on this model.

Another project Cronin has been involved in concerns better outcomes for premature babies. She is a member of the Canadian Neonatal Network led by Dr. Shoo Lee, who is based in Toronto. Data collected from 17 neonatal intensive care units across the country in 1996-97 showed that mortality rates varied widely between hospitals - from 1.6 per cent to 5.5 per cent. A major focus of the network is to standardize and improve care at all neonatal units across Canada.

In a project carried out between 2002 and 2006, the network applied a methodology known as EPIQ (Evidencebased Practice for Improving Quality) to two groups of neonatal intensive care units - one group working to reduce nosocomial (hospital-acquired) infections and one group working to reduce chronic lung disease.

"The results were dramatic," says Cronin. The incidence of nosocomial infections in the first group of NICUs decreased by 34 per cent, while the incidence of chronic lung disease in the second group of NICUs dropped by 15 per cent. As well, within the latter group, hospital acquired infections dropped by an astounding 44 per cent.

Cronin is now playing a key role in a five-year project known as EPIQ 2, which will introduce this model of quality improvement in every neonatal intensive care unit in the country. This involves teleconferences and workshops to engage staff in every province in improving neonatal care on multiple fronts.

"So the potential ramifications of this, assuming we can be successful on a larger scale, are enormous because neonatal intensive care is one of the most expensive forms of care that there is, and because we're dealing with newborn infants, they have their whole lives ahead of them."

And in yet another of Cronin's endeavours, she has engaged the engineering department of the University of Manitoba to help improve patient flow at Children's Hospital. One idea is to use engineering know-how to determine the optimum number of monitored and intensive care beds - too many is wasteful of time and resources, too few results in too many elective surgery cancellations. They use a mathematical method Florence Nightingale would have loved - Monte Carlo simulation. It's a way of modelling outcomes when the factors at play are largely unpredictable, such as the flow of patients through an Emergency Department when factors such as H1N1 are present, for instance.

Needless to say, Cronin is a very busy person. In her work life, there is no typical day. She spends some of her time practising neonatal medicine, and some of her time teaching and working on one of the many projects she is involved in. These days, she keeps a suitcase at the ready for the next trip to teach or present at a conference.

She could not have pictured it would be this way when she entered medical school. The only child of intelligent parents with no access to post-secondary education, her mother and father wanted to make sure she had a good education, so when she was four years old, the family bought a house adjacent to University College, Cork, Ireland. "They took me around the campus and told me 'That's where you're going when you finish school.'"

Attending university required travelling a mere few footsteps. But those few steps became a lifelong learning journey that would lead her to Winnipeg, where she has been a rising star in the effort to improve quality in the health-care field.

Nelle Oosterom is a Winnipeg writer.

	About Wave Wave is published six times a year by the Winnipeg Health Region in cooperation with the Winnipeg Free Press. It is available at newsstands, hospitals and clinics throughout Winnipeg, as well as McNally Robinson Books. Read the Nov. / Dec. 2009 issue of Wave