Every year, medical staff inadvertently cause thousands of patients to die, due to infections acquired in the very place where they go to get well – the hospital. Many of these deaths could be prevented with proper hand washing.
But how do you maintain constant vigilance against an invisible microbial threat?
Seema Marwaha, a Canadian physician and filmmaker, came up with a novel approach for reminding her colleagues about the importance of good hygiene. She produced a cheeky video that shows a physician examining a patient. But rather than being invisible, the bacteria appear as green goo on the patient. The doctor's hands, stethoscope and white coat end up covered in the slime. The doctor neglects to wash afterward and spreads the mess throughout the hospital and on everyone he touches.
Posted on YouTube and the website of Toronto General Hospital where Marwaha was working at the time, the video went viral. "I started getting calls from hospitals around the world asking me to send them copies of the video," she recalled. So far, she had distributed the short flick to 11 countries, illustrating how a little creativity can go a long way in overcoming some serious problems. The 90-second video, which was part of a larger awareness campaign, helped significantly boost hand-washing rates.
It is just one of many projects to come out of the Centre for Innovation in Complex Care (CICC) at Toronto General, part of the University Health Network, a collection of medical institutions in the city's downtown. The centre is gaining a reputation for its pioneering approach to health care's woes. Through brain-storming and collaboration, it has tackled issues ranging from poor bedside manners to evaluating stroke patients. And its successes are making the CICC a model that other medical institutions are starting to follow.
The centre was created seven years ago on the premise that the best ideas for change come from those working on the front lines. But at the same time, there was a recognition that much could be gained by tapping into the expertise of people in other fields. Dr. Dante Morra, a specialist in general internal medicine, and a handful of his colleagues took over a vacant room in Toronto General and turned it into the centre's headquarters, which quickly became a meeting place for sharing ideas.
"Basically, it's a bottom-up innovation shop," said Morra, who is the medical director of the CICC. "We just started solving problems and more and more people would come to us for help."
Once a week, a broad cross-section of people – physicians, nurses, social workers, dietitians, pharmacists, engineers, designers and staff from other hospitals – gather at the centre to solve problems.
Each project goes through what's called a Pyramid of Innovation. Someone will propose an idea and come up with a plan for putting it to a test and assessing the results. Other members of the centre offer suggestions and lend a helping hand. And when they lack expertise internally, they will reach out to others who may be able to assist them. The ultimate goal is system-wide change. "It's not enough just to fix something in our hospital ward. We have to find a way to scale it up across the province and even beyond," said Morra. "So it is big thinking, big vision with small steps."
He points to one CICC project that is laying the foundations for a national screening program for patients with atrial fibrillation – an irregular heart rhythm. These patients are at risk of heart attacks, strokes and sudden death. Their underlying heart problem often goes undetected or is not properly treated, and they are readmitted to hospital many times. An effective screening program could identify these patients so they can get the treatment. In the process, it could save the health-care system money by keeping patients out of hospital emergency wards.
Dr. Howard Abrams, executive director of the CICC, noted that there are other patients who also consume a disproportionate share of health-care resources partly because no one is co-ordinating their care. They tend to be older and suffer from three or more chronic conditions such as heart failure, lung disease, diabetes and arthritis. "There are a number of conditions that really aren't curable, but you can manage them over time to reduce their disability," said Abrams. "But these patients can't be managed by physicians alone." It requires the help of nurses, pharmacists, social workers – and even people who are outside the health-care system, said Abrams. A defining feature of the CICC is that the traditional hierarchy of the medical system – with the physicians on top – is stripped away.
The CICC's unique approach is attracting international attention. Dr. Ed Wagner, a senior investigator with Group Health Research Institute in Seattle, has travelled to Toronto so he could assess the centre first hand and implement some of its lessons back home.
"I was struck by the interesting teams they have put together to solve problems," he observed. "It's not just medical people, but engineers and other folks that bring some very different perspectives to the problems of complex, chronically ill patients."
The CICC even has projects run by patients – a rarity in a large medical institution.
For instance, Robert Hawke, a comedian, actor, and former thyroid-cancer patient, helped develop a program that teaches physicians what the health-care system is like from the patient's perspective.
Although Hawke felt he received generally good medical care, one unpleasant encounter with a physician still makes his blood boil. He had waited months for the results of a particular test. When he arrived at the specialist's office, Hawke was told the results had been lost. The specialist would not answer any of his questions. Instead, Hawke was rushed out of the office because the doctor was late for dinner with friends.
Hawke created a comedy routine, called NormVsCancer, about his medical experiences including those times when "my needs weren't met and I felt I wasn't treated like a human being." He thought physicians could learn a few things from his play. Morra agreed and he urged Hawke to produce patient-centered course material that is now taught to medical students. "As a patient, he identified a very real problem and we just enabled his passion and energy to get into the health-care system," said Morra.
Meanwhile, the CICC will soon be embarking on an expansion of sorts. Morra has accepted a new job as the chief of staff at Trillium Health Partners in Mississauga, Ont. He assumes the post in February and is already planning to create a similar innovation centre at his new suburban workplace that will collaborate with the CICC in downtown Toronto. "We are going to be creating a network of ways of changing the health system," he said.