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by Dr. Joshua Tepper

Everything I learned about quality…

I am rapidly completing my five-year tenure as President and CEO of Health Quality Ontario (HQO). I am probably a bit nostalgic and reflective by nature and so this transition time has led me to think about what I have learned in the last five years about quality improvement (QI).

It is helpful for context to know that while I probably brought a certain set of useful skills and knowledge to the role of CEO, I did not have a strong background or formal training in QI. These reflections then are not about a lifetime (or decades) of thinking about QI, but rather just the last few years.

To be clear, this is not a reflection or effort at summation of the good work that HQO and its partners have done in the last five years. Rather, this is a personal look at what I see as key themes in the still emerging and rapidly evolving space of quality improvement in health care.

I acknowledge that I have written about some of these ideas in other blogs. Also a recent set of comments (not really a speech) at the graduation class of an IDEAS cohort also touched on some of these themes. However I can also safely say that I have never put all of these ideas down in one place and further that this is by far the longest blog I have ever written. In fact, Pat Rich who helped me edit this said I should call this piece “The Long Goodbye”.

As a simple literary device I will bucket these ideas as “8 P’s”

Precision: One of the most frustrating challenges I had in my early months at HQO was recognizing that the term ‘quality’ was used ubiquitously but had very different meanings ranging from the exceedingly narrow to the broadly generic and numerous permutations in-between. In my first week I was challenged by the leader of a provincial health care association to have Health Quality Ontario help solve this.

HQO asked a remarkable group of leaders and thinkers to help us tackle this problem and they created the Quality Matters framework that adopted the Institute of Medicine (now the National Academy of Medicine) approach of defining quality as having six dimensions. We have worked at HQO to make those six dimensions, the framework and the accompanying roadmap a provincial touchstone for quality improvement efforts.

Perseverance: One of the classic images of quality improvement (just search for images for quality improvement on the internet) is the PDSA cycle (Plan, Do, Study, Act). And almost inevitably in this image are three to five of these cycles progressing nicely upwards. There is great truth in this image. Quality improvement is not a single act or effort, but rather numerous efforts with a discipline and science of reflection after each effort and careful calculation before the next.

There is also a deep falsehood implied in the classic image of these ascending cycles. The suggestion is that each cycle leads to improvement. Not true. Most QI programs don’t incrementally ascend, but often fail. Many QI projects never work out at all and of those that do, almost all have real failures, along the way. But failure is not bad and contains within it the seeds for future improvement.

By not talking more about the reality of failure we don’t prepare our teams, our managers and ourselves to be resilient in the face of failure. I am deeply proud that Health Quality Ontario in partnership with Women’s College Hospital held one of health care’s first conferences on Failure.  We need to be ‘failure ready’ to undertake QI.

Payment: This is always a tricky and controversial topic, but it cannot be ignored. There is no doubt that QI efforts can cost money, but it is also clear that there is much we don’t know about the best way to pay individuals or systems to effectively motivate improvement efforts. We typically fail in being able to capture the return on investment from QI efforts as the benefits may show up months to years later and/or in other parts of the health care system than where the QI efforts are being made. We need to continue to research the payment models that appropriately support QI.

Pay it forward – OK, I am cheating a bit here to make it fit. By ‘pay it forward’ I mean the ability of one QI project in one part of the system to be replicated in another. Often called ‘spread and scale’ (not pay it forward) this is one of the greatest challenges facing QI. I am increasingly convinced that for almost any given problem in health care there is some group or some organization, if not in Ontario, then in Canada or internationally, that has found a successful innovative way to significantly resolve it. However, the challenge we (and health care systems around the world) have is how to successfully replicate these successes. In many respects this is the ‘gordian knot’ of QI. While there is no clear Sword of Damocles, programs like ARTIC, and others are trying to unravel the problem. This is going to remain a high priority for QI to succeed at scale that leads to broad movement on key metrics.

Preparation: Quality improvement and the application of Implementation Science is a purposeful effort of using a defined set of tactics, skills and knowledge. We cannot expect the health care system to improve without equipping a critical mass of people who have these abilities and knowledge. I often compare this to the change in medicine to embrace evidence-based medicine. We had to fundamentally change our education systems for physicians to teach the skills of critical appraisal. Today, there are more programs to teach QI (from a few hours in length to entire PhD programs) available…and they are often oversubscribed. However, when you think about the hundreds of thousands of people at the front-lines and in the management levels of health care, I hear the words of Canadian improvement guru Dr. Ross Baker who says we are still at a ‘homeopathic dose’ of training.

Providers: When I started at Health Quality Ontario, I was quickly introduced to the Institute for Healthcare Improvement (IHI) Triple Aim as the ultimate goal for QI efforts.   At the same time, I started to hear from health professionals that they often felt that QI was a burden and that some of the QI initiatives felt punitive in nature. This is not a recipe for engagement or long- term success of a movement that relies on the efforts of front-line health professionals. In 2014 I read an important article advocating that in addition to improving the patient experience of care, improving the health of populations, and reducing the per capita cost of health care, that we add a fourth element of improving the experience of health care providers. Good QI feels like ‘the work’ not ‘extra work’ and should constructively engage health professionals. This is increasingly important as we hear more about burnout among doctors, nurses and others.  Also, it is critically important to recognize that providers also include the legions of unpaid family or friend care providers who can be incredible enablers of QI, but who also suffer from burnout and poor engagement.

Patients – Partnering with patients has to be part of the improvement process in healthcare. In the last five years this has become the norm rather than the exception. At HQO we have gathered and designed a number of tools and resources that empower all people living in Ontario to participate in their care and help facilitate partnering between patients, families and health providers.

However, we are still in the early days of patient engagement in QI. For example, we still don’t always know the best way to consistently have meaningful engagement (not tokenism) and often we don’t have enough diversity in the patients with whom we engage.

Philosophy – One of the greatest tensions and areas of confusion I have noticed is between a philosophy of improvement vs a philosophy of quality assurance vs the philosophy of performance management. While these three terms are often used interchangeably, they are actually very different approaches to the management and assessment of care.  While there is some overlap between the three they typically need different types of data, use different sets of analytical tools and speak to a different focus. All three have a role to play in health care.  However, we need to be mindful of their differences. We need to be mindful about which philosophy we wish to pursue in a given circumstance and how they might co-exist in some balance.

Pioneer – I am still struck that despite all the writing, discussions, initiatives, conferences, etc., how relatively nascent QI is in the world of Canadian health care. We are still really in the first generation of wide spread discussion and clear articulation of QI in Ontario and Canada.  Being a pioneer can be very exciting, but it is also daunting.

We need to recognize that we are still in the relatively early days of improvement compared to other industries and we need to be willing to try different approaches, find excitement in the uncertainty, apply scientific rigour to our efforts and (per my comment on perseverance above) be ready to fail and be resilient in the face of that failure.

We also need to celebrate pioneers, bring them together and give them community. Online settings like Quorum or our annual conferences like Health Quality Transformation and the Quality Improvement and Patient Safety Forum provided a home for pioneers to share stories, gain wisdom and set sights on the next new challenge to be tackled.

People:  I know, I promised seven and this is at least number eight if not higher… but it is also the one that I will remember the most. The community of those who are committed to improving our health care system is a very special one. These are people from all walks of life and in every corner of our system. These are the people who share a deep and abiding passion (yes, I am sneaking in a final P word) for quality health care in Ontario. These are the people who think our health care system is great today, but tomorrow – somehow, in some way -   must be even better.


3 comments on article "Everything I learned about quality…"

Kathy Smith

Thank you Joshua and I wish you well as CEO at North York. My extensive work at CCO and MOHLTC as a PFA and a research reviewer has led me to the same reference point: healthcare has a long way to go with QI. Embedding patients in that process is the way to go. Just as consumer experience drives economics, patient experience should drive healthcare changes. At the start of the Third Millenium, we must all move forward with smart technology solutions for a truly sustainable, quality-driven healthcare system.

Brenda Laurin

Joshua, I want to thank you, as an amazing leader of HQO, you and your team were my first Patient, Family and Public Advisors Council that I have had the priviledge of working with and you all have set the bar high. I came to HQO with a "bad taste in my mouth" when it came to dealing with certain aspects of our health care system, yet through some other amazing experiences, I knew that there was a silver lining somewhere. You and your team have shown me where that silver lining is and how I can help to bring and grow that lining in other areas. I am so proud to have been part of "this strange little government agency" that is so positive, caring and compassionate. And I am honoured to have met and worked with you. May you have continued success in all your future endeavours; please continue to spread and share your positive, caring and compassion to all who have the honour of working with you.

julia Ducey

How long will the improvements take, months, years etc.? Oshawa Long term care, still has not done anything about care in the evenings of residents. we have been there every night, no staff in sight, residents alarms going off and no staff around to check out the alarm for a very long time. Its a safety concern, what if there was a life threatening issue and the staff is busy somewhere else. There should always be staff at the sections front desk at all times. It should not be without.

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