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The aim to provide excellent care is a universal aspiration of health care providers. But most providers are so busy working to deliver that high quality care that they have few opportunities to reflect on how to get closer to the target of excellence. Last week I had the privilege of spending two days in Boston with two of my colleagues from Markham Stouffville Hospital learning about Quality Improvement at a course from the Institute for Healthcare Improvement (IHI).

This blog entry is a personal attempt to solidify the lessons I learned, in hope that I will be able to apply them well. Here is what I learned to do:

1. Focus on the system

A senior executive at Toyota famously said “We get brilliant results from average people managing brilliant processes. We observe that our competitors often get average (or worse) results from brilliant people managing broken processes.” One of the speakers at the IHI meeting paraphrased this to say that “B teams in an A system always beat A teams in a B system.” Now I happen to think that I work with brilliant people. But clearly our system and our processes need to be surpassingly brilliant in order for us to get great results.  A couple of the essential parts of successful systems are the concepts of simplicity and standardization. In the delivery of care we need to “make the right thing to do the easy thing to do.” If the system is too complex the standards will not be consistently applied and the outcomes will suffer.

2. Start small

Not everybody wants to talk about quality. If you’re inspired to make changes to improve quality, start with a coalition of the willing. Focus on a small number of indicators that you want to improve. Start by telling a human story – a story of a patient who has been affected by the quality of their care. Then identify at least one way that care can be improved based on a reflection from the story.

3. Aim high

Arguably the best speaker of the whole course was Dr. Richard Shannon from the University of Pennsylvania. He gave a talk on “Setting Audacious Goals”. He advised not to be afraid to aim to be “best in class”. People want to work with a team that is truly great. He reminded us of the easiest starting point for excellence in health care: Do no harm. No one should get hurt by the care they receive. From there we should go on to address each desired health outcome with an aim not just to achieve some kind of regional standard, but to achieve genuine excellence.

4. Engage the whole team

Dr. Shannon went on to say that excellence comes from “the complete engagement of all the wisdom and skill embedded in each worker.” This point resonates powerfully for me. As a leader in health care, I really want to engage my whole team. Dr. Shannon talked about harvesting the “intrinsic motivations” along with the talent and energy of every team member. The habit of asking everyone to participate in solving problems will build trust as well as talent. This reality has been well expressed in the past by Kouzes and Posner who state that “Leadership is the art of mobilizing others to want to struggle for shared aspirations.”

In Boston with colleagues

5. Build quality out of values

Several speakers at the conference stated that improvement is driven by core values – not by incentives and penalties. This is a tricky part. The whole team needs to be driven by the value of excellent care. And the leaders need to not only espouse those values, they have to live them! On the topic of the moral imperative to provide great care, I love what Dr. Don Goldmann of Harvard Medical School had to say. He reminded us of the famous quote (usually, though not entirely accurately, attributed to Martin Luther King Jr.) that “the arc of the moral universe is long, but it bends toward justice.” Then Dr. Goldmann adapted that line by saying that when it comes to health care “It’s not just the cost curve we have to bend; it’s also the justice curve.” The drive for improvement is the drive for justice – the fact that everyone deserves excellence in the care they receive.

6. Remember that quality care saves resources

Ultimately, leaders in health care have to be concerned with resources. In fact, we are mandated to be “good stewards of finite resources.” Not all providers (or their patients) like to be reminded that the resources are finite. Dr. Shannon’s presentation on the business case for Quality Improvement, demonstrated that if you improve quality, your productivity will automatically improve. He repeated emphasized the economic opportunity embedded in improved quality and the elimination of harm. Investing in quality improvement will bring returns. “We balk at the costs of improvement but never consider the lost financial opportunity associated with poor performance.” (Shannon) However, it was advised that providers often have to show that you can improve care first and then you can document the cost-saving.

7. Tolerate risk

My learning style is one of active experimentation, so this theme of risk tolerance resonated with me. Disruptive innovations to improve quality can seem risky at first. And not all interventions in system change will be successful.  Dr. Don Goldmann suggested that we should “Fail frequently, quickly and well.” This reminded me of that quote from Samuel Beckett: “Ever tried. Ever failed. No matter. Try Again. Fail again. Fail better.” It’s pretty clear that health care systems will be in need of perpetual transformation. And transformation involves some risk. I’m ready to take on some risk in the systems where I work. Even if the changes aren’t perfect, we should always be able to learn – and then start again with a new cycle for improvement.

So I’ll wrap up this blog post with a favourite West African proverb that speaks to the need to keep working toward our goals. Top quality health care in a resource-restricted system seems like a daunting aspiration. But it is an achievable aim. In Cote d’Ivoire it is said: “The river may be wide, but it can be crossed.”


In case you are interested, here is the list of books I just ordered based on hearing more about them at the conference. I can hardly wait to start reading!

1. The Innovator’s DNA: Mastering the Five Skills of Disruptive Innovators
2. The Checklist Manifesto: How to Get Things Right
3. Thinking, Fast and Slow
4. Chasing the Rabbit: How Market Leaders Outdistance the Competition and How Great Companies Can Catch Up and Win

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