New U of T Master’s Meets Demand for Better Health Care

Many patients get a urine culture at some point during their hospital stay.  Only a few will have an infection that needs treatment, but many more will test positive, triggering further tests and treatment with antibiotics that may be unnecessary or harmful.

What if there was a way to limit urine cultures and still catch dangerous infections?

Dr. Jerome Leis, a recent graduate of a new master’s program in Quality Improvement and Patient Safety at the Institute for Health Policy, Management and Evaluation (IHPME), set out to answer this question in 2012.

With principles he learned in the program — including ways to identify systemic gaps in health care and how to lead change in large organizations — Leis and his colleagues at Mount Sinai Hospital designed a new protocol for ordering urine cultures among hospitalized medical and surgical patients: doctors had to call to request urine cultures, rather than receive test results automatically.

The impact of the change was stunning.

The protocol generated fewer than four calls to the lab per month, reduced unnecessary antibiotic use significantly, and was not associated with any untreated urinary tract infections.  When urinary tract infections were present, the team found, clinicians had no problem calling the lab. Staff treated all patients appropriately.

“Most efforts to reduce the use of antibiotics focus on educating clinicians in how to respond to positive urine cultures,” says Leis, now an Infectious Diseases specialist at Sunnybrook Health Sciences Centre who for his efforts recently received the 2013 Physicians’ Services Incorporated Resident Research Prize and the Harry and Rose Perlstein Graduate Award. “But by looking upstream to the test level, we found we could improve the use of health care resources, limit unnecessary courses of antibiotics and keep patients safe.”

This quality improvement project is one of many underway across Ontario’s health care system, a growing number of which are led by graduates of IHPME’s program — the first quality-improvement master’s in Canada. The institute launched the program last year with U of T’s Centre for Quality Improvement and Patient Safety, amid strong demand from health care professionals and a push from the Ontario Government to improve health care and lower its cost.

“Since 2010, Ontario’s Excellent Care for All act has really heightened awareness of quality improvement in health care,” says Ross Baker, a Professor at IHPME and Director of the new program. “We realized we needed a flexible program that teaches quality improvement skills for mid-career professionals, and for younger trainees looking to specialize in quality improvement as a career.”

Andrea McInerney is a Quality Improvement Coach with Partnering for Quality, which supports over 230 doctors and primary care teams in their efforts to improve chronic disease care in the South West LHIN. She has worked in quality improvement for five years. She was drawn to the program for its modular course offerings, which allowed her to continue work, and for its major-project component.

For her major project, McInerney set up a system to group primary-care patients with seasonal flu symptoms in standing blocks of time, in which staff counselled them together and followed up with short one-one-one sessions. The system, the first of its kind in Canada, allowed patients with more serious conditions continuous access to their primary care provider during peak flu season.  

“I was delighted to see a master’s program in what I do,” says McInerney. “And I appreciate its academic focus on quality improvement methodology, which will allow us to measure our intervention and hopefully avoid unintended consequences as we roll it out in other clinics.”

Emily Musing is a Patient Safety Officer and Executive Director of Pharmacy, Clinical Risk and Quality at University Health Network. She has worked with another recent graduate of the IHPME program, Sandra Nelson, and expects to see more. “Graduates typically have a background in health care, so they bring a practical perspective on how to apply the quality improvement principles they’ve learned in the program,” says Musing. “This provides an advantage for their future employers, who will need to spend less time educating and integrating them into the health care system.”

Nelson, a clinical practice leader based at Mount Sinai Hospital, used a questionnaire at University Health Network to elicit patient perceptions of how care providers ensured their safety. She collected information on hospital-acquired infections, and on potentially harmful miscommunications among staff and between staff and families. Musing says the approach provided valuable information that staff may not otherwise have captured in patient charts.

A further advantage, says Musing, was that patients indicated the face-to-face interviews increased their satisfaction by ensuring staff understood and valued their insights.

“Twenty years ago, patients just followed doctors’ orders,” Musing says. “Now, we have a very engaged population. They demand accountability, and they’re pushing health care professionals to raise their competency. Educational institutes like IHPME are integral in enabling health care professionals to meet the needs of today’s patients.”