Speaker 1: Quality is important to me because I think that we all have two jobs, the care that we give and improving the systems in which we work. That's our professional responsibility. I started my career as a nurse, but even before that I'm the oldest of nine children, a big Irish family. And when the first nephew was born to my sister, you can imagine what this Irish family was like. We were all responsible together to take care of this wonderful little kid, Robbie. When Robbie was two months old, he went to his doctor, had his first checkup, and the doctor told my sister that he was great. He was developing normally, everything was fine. At the end of the visit, he gave him his DPT vaccination. When my sister got Robbie home, he started to become ill. She brought him right back to the office, and he ended up in the intensive care unit for about a week. He eventually got better, and the whole family came together to make sure that he was safe. When he went in for his four-month checkup, the doctor said he was perfect, he was developing normally. And at the end of the visit, he said to my sister, I'm going to give him his DPT vaccination. And my sister said, don't you remember what happened the last time? He paused for a moment, and then my sister recounted what happened, and he said that had nothing to do with it. But then he paused, and he said, I'll give him half a dose, and he gave him half a dose, and Robbie died within 24 hours.

Speaker 2: When you think about the story of your nephew, do you think that's an anomaly? Do you think that it's a sort of a rare thing? Do you feel like it was indicative of a much broader problem, or do you think this really was kind of an unusual case that got you thinking on this?

Speaker 1: Well, it is not rare, perhaps that particular circumstance. But the fact that patients are harmed by their care instead of helped by their cares is unfortunately all too common. So my sister asked me three questions that changed my whole outlook on my career as a nurse. The first thing she said is, why do you keep records separate? Why are the hospital records separate from the doctor's office records? The second question she said is, why did he not know that that wasn't the right thing to do? And then the third thing she said, why didn't he listen to me? And those three questions really changed my outlook on what we need to improve in quality and health care and how we need to go about it. In some cases, it's a failure of information. An example, one of our staff here was taking his father home from one of the hospitals here in Boston after having an aneurysm in his brain repaired. And as the nurse was preparing to discharge his father, my staff member went and said to the nurse, do you know what his situation is when he gets home? The staff member's mother is totally incapacitated, and his father was her carer. And the nurse had no idea. Now, you might not think that that's harm, but I do think it is. To send a patient home to a circumstance without complete understanding is harm. Patients developing pressure ulcers in a hospital is harm. Ventilator pneumonias are eliminatable now. And so I think these all represent professional challenges to us, because we do know how to eliminate these.

Speaker 2: So what's the challenge? I mean, why does this happen? Why do these harms occur? What's underlying it?

Speaker 1: Well, I'd say two things. One is, in our professional education, we're taught how to care, how to fix things. We're not taught how to improve. Several years ago here at IHI, we were trying to get improvement built into the curriculum for medical schools and nursing schools, healthcare administration programs. We found it very hard to get people to integrate that curriculum and to teach cross-professionally. The second problem is we work in broken systems. And in our educational processes, we're taught to be heroes. We're taught to fix it for the individual, not to fix the process and the system. So two things, I think. We need to build improvement capability, the science of improvement, into every curriculum, into every professional program. And then we have to be able to see. We have to learn that when we're in a situation, not to fix, but to see. And once we see the system, we can make it better for all.

Speaker 2: Those are two great points. And certainly, as a clinician, the notion of improvement as a part of my job is not something I spend a lot of time thinking about. And I suspect most clinicians, not very much time. And then the second notion that you bring up, very much we think about fixing it for individual patients, because that's our job, but never sort of taking the step back and saying, how do we fix this, not just for my patient in front of me, but the patient I might have a month from now, or your patient, that I will never see.