‘We cannot have quality without equity going forward’

Dr. Kedar Mate on July 1 takes over as president and CEO of the Institute for Healthcare Improvement. He does so against the backdrop of a global pandemic and unrest over racial inequities. Mate, who was IHI’s chief innovation and education officer, says that now, more than ever, the industry needs to rely on a science- and evidence-based approach to problem-solving. Mate replaces Derek Feeley, who left the organization to return to Scotland. Mate spoke with Modern Healthcare quality and safety reporter Maria Castellucci. The following is an edited transcript.

MH: This is an interesting time to take the helm of a healthcare organization. What are the main goals at the start of your tenure?

Mate: This is going to be a challenging time. It already is a challenging time. And as we work through COVID and associated social disruptions at large—the police protests, the racial challenges that we have in this country, there’s an election on the horizon that will be quite important for healthcare—we know that this is an important and pivotal moment.

We also know healthcare is not likely to be the same both during COVID and after it. So what’s going to guide the redesign? One way of thinking about it is to let some of the finances and cost considerations lead the redesign. Another way is to let the desired outcomes guide the design. If we follow the latter path of letting outcomes guide

the design, then I think the quality sciences—the work that IHI has done over several decades now—could be the route to that redesign.

And if you think about other big challenges, big historical moments, it’s exactly what other industries did coming out of World War II, for example, in Japan. They let quality lead, and we got much better cars, much safer manufacturing, better food production, all at much lower costs.

IHI’s first priority will be to be a part of the redesign— to lead the redesign of healthcare—to get better outcomes at much lower costs.

No. 2, and very close behind, will be an emphasis on safety and effectiveness. If we can tease out a bunch of themes from this experience with COVID: being prepared, having safe management systems, having infection prevention and control practices embedded in our

organizations. That has been so important before the pandemic (but) it’s even more important now.

We’ve already gathered a lot of the best practices on what to do for hospitals, nursing homes, clinics, and we’ll be continuing to offer those evidence-based practices to help modernize safety systems, taking account of technology, importantly at this crucial juncture. As we expand telehealth and make it part of our clinical routines, ensuring that those encounters can be safe and highly effective is part of the next stages of our healthcare evolution.

All of this includes an emphasis around psychological safety. We’ve seen challenges to the workforce with personal protective equipment, but also resilience challenges to the workforce during this period. So an emphasis on safety, broadly considered, (should) include how our systems can be optimized to ensure our staff and our patients and families are safe.

A third priority is that, again, with the social disruptions that we’re seeing over the history and legacy of racism in our country, we’ve always minded equity as an aim at IHI. But it’s now very clear that we just cannot get to better care and better outcomes unless we all get better.

We cannot have quality without equity going forward. We can’t be safe without equity going forward. And that will be a third area of emphasis for me in my time at IHI.

MH: On that first priority, is there concern that quality might fall by the wayside as healthcare organizations are trying to make some tough financial choices?

Mate: There’s certainly a possibility of that. I don’t think that systems would desire to move away from quality. I think it’s a matter of what might get left behind as we try to pursue a corrective path that might lead to financial stability.

Quality could get left behind, not intentionally, but if we don’t pay attention

to it. The other concern is that it may get siloed into a measurement exercise.

“If nothing else, this (pandemic) has demonstrated the true interrelatedness of public health to acute care, to post-acute care.”

MH: What are some clear shortcomings that have come up in response to the pandemic?

Mate: Several things come to mind. One is that the virus had an insidious way of prying its fingers into every major weakness that was present in our system on some level.

Systems that did not have a strong relationship to their public health agencies were challenged. We had been systematically underresourcing and supporting public health over a decade, and that was exposed.

Racial inequities were exposed as part of this. The challenge of the care continuum … was exposed by this pandemic.

The response going forward is going to be: How can we change some of those areas? How can we be more prepared and ready for what might be a second wave or what might be a future pandemic or future challenge that we might experience?

What we’ve observed at IHI is that systems with a clear, well-organized management approach— whole-system quality, huddle structures, daily communications—tended to just activate those existing elements to confront COVID. And they were largely very successful at transitioning those management systems to work on a new threat.

Yes, the threat was unexpected, but their approach to managing the unexpected wasn’t all that challenging or new for them.

Second, we’ve got to invest in stronger infection prevention and control practices and become more conscious of the infection prevention control practices across the continuum.

And that leads me to my third point. If nothing else, this (pandemic) has demonstrated the true interrelatedness of public health to acute care, to postacute care.

Without a well-functioning evidence-driven approach to reforming and improving public health and reforming or improving post-acute care, the acute-care hospitals stuck between those two will be challenged with receiving people from the community and moving them out of the acute-care setting into the community when the time is right.

That will be a major challenge and a major area of investment and improvement going forward.

Lastly is more of a public consciousness of disease. We all now have to become experts in some form of infection prevention and control. Going to the grocery store has become an exercise in understanding some form of infection prevention and control.

So raising the public understanding of related safety, of quality, and some of the concerns around public health and clinical understanding of this particular condition has become more important than ever. And that takes science-based leadership.

MH: What does the trend of higher COVID rates and deaths in nursing homes tell you in terms of the focus on quality of care among the elderly population? Might this be a turning point for how the industry invests in that population?

Mate: I sure hope so. I don’t know yet whether it will, and we’ll do what we can to help bring attention to these issues and also bring the evidence to these issues and try to support better care across the care continuum for older adults in hospitals, outpatient environments, as well as in the post-acute and long-term care settings, like nursing homes.

I think there is a tremendous opportunity for us to build a more coherent, coordinated system that’s properly incented to behave as such, and can help ensure that patients and their family members get the best possible care, regardless of what care setting they’re in. That’s what the Age-Friendly Health Systems initiative that IHI runs is really about— trying to ensure that older adults, regardless of where they are, get the very best of what we know right now in terms of the evidence.

MH: We’ve seen telehealth explode in response to COVID-19. From a quality perspective, are there considerations or more investments that you would suggest as we see greater adoption of this platform?

Mate: I think that we should be building our systems around this very exciting opportunity. It widens access enormously and provides new opportunities and it might even help us with the challenges around workforce and capacity.

There is a question around how to do this safer and more effectively than ever before. And how do we organize and create the appropriate set of criteria for what constitutes a circumstance that would be best addressed over the phone. What requires video? What requires someone to come in to be seen? How can we ensure that the myriad issues that have since arisen around documentation and ensuring that people are getting the proper care they need are being addressed?

There are also questions around what’s possible with technology, what can be done safely, and how can we increase the safety and effectiveness of those encounters so that we can get the most value out of this really exciting and really dynamic and new form of advancement.

This is not a new thing with telehealth. Every new piece of technology, whether it’s a new drug, a diagnostic or a service delivery mechanism, adds both promise and risk.

MH: Do you hope to see in the next few months more research on how it has worked out?

Mate: We should, absolutely, follow the evidence around this. And posit what could be done to make it safer, test those hypotheses, validate them with evidence. IHI looks for the best of what we have today and then we seek to share that as widely as we possibly can, and get others to try to adopt those standards and practices. ●