Quality Catalyst - Igniting Improvement And Inspiring Excellence

A Story from the Frontline

By Michaela Malouf

Names, locations, and identifying details have been changed to protect the privacy of those involved.

I knew I wanted to specialize in oncology after my very first shift on a medical oncology and palliative care floor in my final year of nursing school. I was deeply moved by the grace of my colleagues — some with 20 or 30 years of experience — as they comforted patients and their grieving families. I still remember sitting with an elderly patient who shared with me stories of the best and worst days of his life. Those quiet, candid conversations in the early hours of the morning taught me more about the meaning of life than any textbook ever could.

When I graduated, I was thrilled to secure my first RN position on that same unit I had grown so fond of. But on my very first night as a staff nurse, I felt a heaviness in the air that was different from the usual grief and loss I had come to expect.

I smiled at Anne, a colleague who had mentored me as a student. She was tough at times, but generous with her knowledge, always ready to step in and support others — the kind of nurse who held the team together. But that night, she didn’t return my greeting. She sat at the nurse’s station surrounded by flowers, cards, and homemade cookies. Something was off.

Puzzled, I asked another colleague, Sasha, what was going on. She hesitated, her eyes filled with tears, before finally saying, “It’s Anne’s anniversary.”

Confused, I wondered what kind of anniversary could bring such palpable sadness. Then Sasha explained: years earlier, Anne had been caring for a young man, newly diagnosed with cancer. His chemotherapy was ordered to be given over four days. But through a tragic error, it was administered over four hours. He survived the night but died in the ICU the next day.

Anne had carried that weight ever since, grieving his loss every year. And now I understood the collective despair that hung over the unit — it wasn’t just Anne’s grief. It was something her colleagues also carried with her.

Later that night, Sasha walked me through what had happened. This was long before electronic records, when chemotherapy orders were handwritten in paper charts and transcribed onto medication administration records (MARs). Each MAR had only seven days’ worth of space. When the week was up, nurses would transcribe everything onto a fresh MAR, double check it against the old one with another nurse and continue documenting from there.

On that particular day, the double check never happened. The unit was overwhelmed, short staffed, and Anne was the only nurse with chemotherapy experience. Tracking down another nurse felt impossible with so many critically ill patients needing urgent care. So, in that pressured moment, she bypassed the safety step and hung the chemotherapy herself.

I don’t need to explain the outcome. But what struck me, as a brand-new nurse, was that this could have been anyone. It could have been me.

And what also struck me was Anne’s courage. She had stayed. She chose to continue working on the same unit, alongside the same colleagues, despite carrying the memory of that tragic day. It reminded me that in nursing, one decision made under pressure can change everything — not because of bad intentions, but because of impossible circumstances.

Why Workarounds Happen

What happened that night wasn’t about carelessness. It was about impossible circumstances. Anne didn’t skip the double check because she didn’t care — she skipped it because the unit was stretched beyond capacity, and she was trying to do right by her patients. That decision was human, understandable… and devastating.

In health care, we’ve all been there. Faced with too many tasks and not enough time, we take shortcuts: skipping a double check, documenting later, clicking past an alert. These choices feel small in the moment, but they’re signals of something bigger — signals that the system isn’t working for the people inside it.

The Hidden Risks of Workarounds

The trouble with workarounds is that they don’t just solve today’s problem – they also hide tomorrows. When we “make it work” in the moment, leaders never see the broken processes, the missing staff, or the tools that don’t fit the job. Over time, these fixes create:

• Inconsistency — different staff take different shortcuts, creating variability in care.
• Safety risks — bypassing intended safeguards removes checks designed to protect patients.
• Moral distress — staff know they’re compromising standards, which erodes wellbeing.
• Masked root causes — organizations lose the chance to learn what’s really broken.

Turning Workarounds into Learning Opportunities

What if we treated workarounds not as individual failings, but as valuable clues? Every time a nurse, physician, or aide has to bend the process just to get through the day, that’s feedback about where our systems are letting people down. If we listen, these moments can point the way toward meaningful, lasting improvement.

Here are a few ways we can do that:

• Create safe spaces to share workarounds without fear of blame.
• Collect them systematically, just like near-miss reports.
• Look for patterns — are workarounds clustering in certain units, times of day, or types of tasks?
• Co-design solutions with the staff who know the problem best.
• Celebrate honesty and courage — staff who surface workarounds are not troublemakers; they’re catalysts for change.

Closing Reflection

Anne’s story will never leave me. It taught me that none of us are immune to the pressures that make workarounds feel necessary. But it also taught me that courage isn’t just about persevering after tragedy — it’s about creating a culture where we don’t have to rely on workarounds in the first place.

Every workaround is a signal. If we’re willing to listen, it can guide us toward safer, stronger, and more supportive systems for patients and staff alike.

Further Reading on Workarounds in Health Care

If this story resonates, here are a few studies and cases that explore the broader impact of workarounds:

• Tucker, A. (AHRQ). Workarounds and Resiliency on the Front Lines of Health Care. PSNet.
• Boonstra, A., et al. (2021). Persisting workarounds in Electronic Health Record System use. BMC Medical Informatics & Decision Making.
• Koppel, R., et al. (2008). Workarounds in Barcode Medication Administration Systems. J Am Med Inform Assoc.
• Halbesleben, J., et al. (2010). Rework and workarounds in nurse medication administration process: implications for work processes and patient safety. Health Care Management Review.
• Clark, A., et al. (2025). Do healthcare professionals work around safety standards, and should we be worried? A scoping review. BMJ Quality & Safety.

Michaela is a Clinical Quality Consultant with Cancer Care Alberta's Quality Safety and Practice Integration team. Michaela is passionate about improving patient safety and pulls on her experience as an Oncology nurse to bring a front-line perspective to addressing practice and patient safety concerns within Cancer Care.

Helping Patients with Chronic Lymphocytic Leukemia (CLL)

A chat with Nan Cox-Kennett, Nurse Practitioner with the Hematology team at the Cross Cancer Institute.

What was the problem you encountered with CLL patients?

Imagine logging into MyAHS Connect and seeing a pathology report that reads: “consistent with chronic lymphocytic leukemia (CLL)”. You’re left wondering—what is CLL? What does this mean for your life? You turn to the internet for answers, diving deep down the rabbit hole of Dr. Google. You begin trying various supplements, unsure if they’re helpful. You might have a family physician doing their best to support you, but the wait to see a specialist stretches on.

In the fall of 2024, this was the reality for many patients at the Cross Cancer Institute, where a shortage of specialists and clinic space led to longer than normal wait times for a hematology consult.

That’s a tough situation for patients. What did you do to change things?

Ideally, hiring more staff and expanding clinic space would be the solution—but those changes take time. One of the biggest challenges we noticed was that when patients finally had their appointments, a significant portion of the time was spent addressing misinformation they had gathered during their wait.

We asked ourselves: What if we could offer a group teaching session via Zoom, led by the Nurse Practitioner for Hematology?

The hematology team supported the idea, but we faced logistical hurdles. We needed to figure out how to conduct group sessions while maintaining patient privacy and obtaining consent—especially since many participants would be learning about their cancer diagnosis for the first time.

That sounds complicated. How did you address those challenges and can you tell us about the sessions?

After reviewing the waitlist, we found that about 30% of patients had early-stage CLL that didn’t require treatment. These individuals also had no language or cognitive barriers. Another 20% had a pre-cancerous (non-malignant) condition. Together, this made up 50% of the waitlist—an ideal group for virtual education.

We consulted with the legal team and developed an invitation letter for a group teaching session titled “Understanding Your Blood Results.” Patients who contact the clerk to participate are considered to have given consent to receive information in a group setting.

We created two separate sessions: one for CLL and another for non-malignant conditions.

A virtual clinic was set up within Connect Care where staff can book patients into sessions. Prior to the session, each patient receives in the mail a one-page instruction sheet with Zoom login details.

When patients join the session, a clerk helps them log in and, if the patient prefers to remain anonymous, change their Zoom profile name to Anonymous. They are also given the option to turn their camera on or off. Once set up, they are admitted into the Zoom room.

Each session lasts 30-45 minutes and includes a PowerPoint presentation, open discussion, and general questions about the diagnosis. No personal health information is shared. Patients remain on the waitlist in their original position and later receive an in-person consult with a specialist.

What has the impact been? Are the virtual sessions helpful?

The response has been overwhelmingly positive. About 90% of invited patients participated in the virtual sessions. Many expressed gratitude for the clear, accessible information.

Patients have expressed that they feel better informed when they arrive for their first consult and are prepared with relevant questions. As a result, appointments are more efficient, and clinics run more smoothly.

Overall, the virtual teaching sessions have had a meaningful and positive impact—both for patients and the hematology team.

Nan Cox-Kennett is a Nurse Practitioner with the Hematology team at the Cross Cancer Institute. She is a valued team member with over 23 years of experience. Nan is passionate about finding practical solutions to address challenges for patients.

How understanding accountability tendencies can transform your team.

By Michael Sidra

Have you ever wondered why some people are always on top of their work and others need a nudge – or two or three– to get something done?

Are you (or someone you know) always willing to do things for others but letting their own stuff or self-care slide?

Or – maybe, you’re the kind of person who prides themselves on questioning every new process or ask that comes your way.

I used to think that holding myself accountable had to do more with staying focused and following-through.

It’s more complicated than that though.

According to Gretchen Rubin’s book, “The Four Tendencies”, we all approach accountability differently.

And

How we approach accountability impacts how we do improvement work.

Here’s how …

Accountability Tendencies

Gretchin Rubin’s work essentially boils down to a simple question: How do we respond to expectations?

We all have expectations for ourselves - Inner Expectations. For example, we want to exercise more or eat healthier or improve our relationships at work or at home. We also receive expectations from others - Outer Expectations. For example, deadlines from our managers, professional standards, or requests from peers, family and/or friends. Regardless of where the expectation comes from, according to Rubin, each of us have our own way of responding.

Rubin suggests that there are four tendencies that people have when it comes to managing our inner and outer expectations: Upholders, Questioners, Obligers, and Rebels. Everyone can fall under each and all these tendencies depending on the situation. However, it’s useful to think about our dominant tendency – that is the tendency we tend to default to most often.

1. Upholders: The Dual Duty-Fulfillers

Upholders respond to both outer and inner expectations. If they promise to follow up and set a personal goal to leave work on time, you can bet both will get done. Their motto might be, “Discipline is my freedom.”

Since upholders are disciplined and driven to meet expectations, they are often organized, self-motivated and reliable. You can always count on upholders to get the job done and on-time.

On the other hand, upholders tend to struggle more when rules are unclear. They need clear expectations and often have limited room for ambiguity so when expectations are fuzzy or not clearly articulated, they are not happy.

2. Questioners: The Logic-Seekers

Questioners scrutinize all expectations – it has to make sense, or they won’t do it. For a Questioner, it’s not enough to be told to do something—they need to understand why. External requests become internal commitments only when justified, so they might say, “I’ll comply—if you convince me why.”

Questioners are often analytical, independent and value logic and efficiency. If they are convinced, they will get the job done, on time and under budget.

However, if questioners are not convinced, they resist getting on with the work and tend to procrastinate. They can also suffer from analysis paralysis – needing to have the full justification before committing to work on something.

3.Obligers: The Team Players

Obligers deliver for others but struggle to meet their own goals unless someone else is watching. They will not miss a shift or let teammates down but may neglect personal growth or self-care aims. For Obligers, it’s a “You can count on me, and I’m counting on you to count on me” type of outlook.

The key for them is external accountability so they tend to be more team-oriented, dependable and attentive to others needs. However, in the process of tending to others needs, they can neglect self-care and be more prone to burnout, and resentment.

4. Rebels: The Resisters

Rebels resist all expectations—both outer and inner. They need freedom to act on their own terms and timelines. Attempts at micromanaging rebels often backfire. Their rallying cry could be “You can’t make me, and neither can I”.

Rebels are often independent, creative and tend to show up unapologetically as they are. But they struggle to keep a routine and reject authority – even their own. Structure feels constraining – they would rather do things on their own terms.

Who do you know that’s a rebel?

Accountability tendencies for Work and Life

Understanding accountability tendencies is especially useful for healthcare teams, where collaboration, clarity, and follow-through are critical. When we recognize how each person responds to expectations, we can tailor communication, delegate tasks more effectively, and reduce friction. For example, giving a Questioner the rationale behind a new protocol can lead to stronger buy-in, while pairing an Obliger with a supportive accountability partner can help them thrive. These insights can improve performance and build trust.

Perhaps even more powerful is knowing your own accountability tendencies. It helps you understand why certain strategies work for you—and why others don’t. If you’re a Rebel, traditional goal setting might feel stifling, but framing tasks as choices or challenges can help boost motivation. If you’re an Upholder, you might need to watch for burnout from overcommitting.

Self-awareness allows you to work smarter, not harder, and to advocate for the conditions that help you succeed.

For me, I probably fall somewhere between a questioner and an obliger.

What’s your dominant tendency?

Take a moment to reflect—or even take Rubin’s quiz—to find out. Once you know, use that insight to shape how you approach your work, your goals, and your relationships.

Start with yourself, share the concept with others (that’s what I’m doing here), and see if that helps.

- Michael

Michael is the Senior Program Lead of the Provincial Systems, Programs & Performance team in Cancer Care Alberta. He dedicates his career to improving patient outcomes and enhancing health system performance by optimizing processes and delivering innovative solutions to complex issues.

Start Smart: Pick the Right Problem to Solve.

By Deanna Cooney

Let’s be honest: not every workplace hiccup needs a full-blown process improvement (PI) initiative.

So how do you know if you’re dealing with a real opportunity for change or just a one-off annoyance?

The key is knowing what makes a good process improvement (PI) problem.

It’s not about fixing every little frustration. It’s about spotting issues that are clearly defined, impactful, and worth the effort.

When you focus on the right problems, you avoid wasting time and resources - and set your team up to make changes that truly matter.

A good process improvement problem should:

• Be Clear and Well-Defined: Vague problems lead to ineffective solutions. The problem should be specific and measurable (SMART goals) – What’s the problem we’re trying to solve?
• Have an Unknown Solution: If your problem has a known solution, that solution should be implemented. If the solution is unknown, then you have a good PI initiative.
• Be Impactful: The issue should significantly affect productivity, overall satisfaction, cost, patient, staff or quality - So what and who cares?
• Be Recurring, Not Isolated: If it's a one-time error, it might be better resolved through troubleshooting rather than a dedicated process improvement initiative.
• Be Root Cause-Oriented: The best problems to solve are those that address the fundamental inefficiencies rather than just the symptoms.
• Be Feasible to Improve: Some problems may be too complex or costly to fix relative to the benefits gained.

Image used with permission from Kevin White and Rakesh Sharma (AHS)

Steps to Identify a Process Improvement Problem

1) Understand the problem you are trying to solve.

Is it clear and well defined, is the solution unknown, is it impactful and recurring and root cause orientated and is it feasible?

2) Observe & Collect Data.

Start by gathering information on workflows, performance metrics, bottlenecks, complaints or issues.

An example of an effective data collection tools is the Measurement & Data Collection Worksheet.

3) Engage Stakeholders.

Frontline staff, managers and providers can provide valuable insights into process inefficiencies and workarounds.

4) Use Root Cause Analysis Tools.

Tools like the "5 Whys" or Fishbone Diagram help pinpoint the underlying causes.

5) Assess the Effort-Impact/Cost-Benefit Matrix.

Tools like the Priority Matrix will help consider the impacts of the brainstormed solutions and help with prioritizing the ideas.

6) Prioritize Issues.

Focus on the problem(s) that align with organizational goals and have a measurable impact.

Common Examples of Good Process Improvement Problems

• Manual Tasks Slowing Down Workflow: Automating repetitive actions can save time and reduce errors.
• High Defect Rate in Production: Quality improvement efforts can prevent rework and waste.
• Long Wait Times: Streamlining procedures or optimizing staffing can enhance the experience.
• Communication Gaps Between Departments: Improving collaboration tools or standardizing communication protocols can boost efficiency.

Real improvement begins with choosing the right problem.

When teams zero in on issues that are clearly defined and actually doable, they’re much more likely to create changes that stick.

Whether it’s improving patient care, lightening the load for staff, or helping departments work better together, a well-framed problem sets the foundation for smart, lasting solutions.

It’s all about boosting efficiency and making the experience better for everyone involved.

Deanna is Senior Process Improvement Consultant with Cancer Care Alberta's Quality, Safety and Practice Integration Team. Deanna is a Certified Lean Six Sigma Black Belt and Certified Manager of Quality and Organization Excellence with over 15 years of experience in healthcare improvement.

Do we need one?

By Michael Sidra

Let’s be honest — working in health care can feel like trying to juggle a dozen balls while running a marathon.

No matter how organized we try to be, most days are just a blur of urgent requests, shifting priorities, and a never-ending to-do list.

In all this chaos, it’s hard to carve out time to reflect on what we could be doing better.

But here’s the thing: if we want to provide safer care, prevent burnout, and actually make improvements that last, we need more than good intentions.

We need to embed systems and processes into our operational and support structures that keep us focused on continuous improvement.

This is where a quality management system (QMS) can help. A QMS embeds quality improvement into the fabric of our work.

I will explain how, but first, let’s define a quality management system.

Quality Management Systems

While there are many definitions of a Quality Management System (QMS), they are all essentially describing a purposefully designed system that minimizes patient harm and enhances outcomes. The Institute of Medicine defines a QMS as a structured approach including processes, and structures that are designed to systematically minimize harm and enhance patient outcomes [1].

For me, a QMS has three essential components; say how we do what we do, do what we say we are going to do, and continually get better.

Deciding on how – this is the ongoing process of examining evidence and developing clinical and non-clinical best practices such as the development of clinical guidelines, and workflows. It involves the continual refining and updating of processes, procedures, and workflows so we are always providing the best evidence-based care.

Doing what we say – beyond documenting what we do and do it – consistently. This may seem like a “no brainer” but practically, this speaks to sharing of information, implementation of practice changes, and change management. Which can be a challenge in a complex adaptive system like healthcare.

Continually improving – we measure, evaluate and continually improve. To do this, we need to have access to data and evidence.

To me, a QMS is the “how” of imbedding quality into our structure. Quality Dimensions help to define the “what” of quality improvement.

Dimensions of Quality Improvement

A Quality Management System has several dimensions that address various areas of improvement. For example, the Health Quality Alberta (previously Health Quality Council of Alberta) recently released an update to their quality dimension. They added two dimensions (Equitable and Integrated) noting seven dimensions for quality as follows,

• People-centred,
• Accessible and timely,
• Effective,
• Efficient and sustainable,
• Safe,
• Equitable,
• Integrated.

The Alberta Quality Dimensions for Health | Health Quality Alberta accessed July, 2025

The Institute of Medicine (IOM) outlines similar type of quality dimensions:

• safety,
• effectiveness,
• patient-centeredness,
• timeliness,
• efficiency,
• equity.

While these frameworks use slightly different words, they are describing similar foundational aspects of quality improvement.

Quality dimensions serve as guideposts in a quality management system. Efficiency, safety, patient centered care, etc. are all things that a high performing healthcare system does well and continually improves.

The quality management system outlines structures, processes and accountabilities that drive safe, high-quality care. For example, in Cancer Care AB, we have clinical experts in treatments for specific malignant tumor types e.g., Lung cancer treatment, that come together regularly to review evidence and update clinical guidelines. In this example, the function, process and responsibilities of the Tumour Teams would be a component of a high performing quality management system.

Do Quality Management Systems Actually Work?

Evidence in peer reviewed articles, show that a structured Quality Management System improves safety, quality, and team engagement.

Here are a couple of quick examples.

Mayo Clinic Cancer Center: Clinical Research Quality Management System

The Mayo Clinic Cancer Center introduced a Quality Management System (QMS) in its Clinical Research Office, drawing on ISO 9000/9001 principles [7].

Key elements of the program included:

• Establishing governance and oversight
• Assigning a Quality Management Coordinator
• Completing comprehensive staff training
• Creating dashboards for key performance indicators

Benefits included establishing a culture of quality improvement, engaged staff, and improved processes.

Another example is from MD Anderson Cancer Network in Texas. They implemented a comprehensive Quality Management System (QMS) for their radiation oncology program [8]. It included:

• Utilizing standardized protocols and checklists to ensure uniformity across multiple sites and teams.
• Employing real-time data collection and centralized monitoring to track compliance and performance metrics.
• Conducting regular audits, peer reviews, and multidisciplinary meetings to identify gaps and drive process improvements.
• Integrating feedback processes for clinicians and staff to report issues and suggest enhancements.
• Emphasizing education and training to maintain high competency among all personnel.

The program demonstrated high efficacy in maintaining treatment quality, reducing errors, and fostering a culture of safety and accountability. The large-scale, prospective approach allowed the center to manage quality across a geographically dispersed network, ensuring that all patients received consistent, evidence-based care.

A robust QMS in any health system enhances care delivery by standardizing excellence, engaging stakeholders, and adapting to evolving needs.

A Quality Management System for Cancer Care AB

We (CCA) currently have useful structures and processes that form the foundations of a comprehensive quality management system (QMS).

However, we need to bring it together, clarify roles and responsibilities, decide on quality metrics and co-design a way to continually share learnings.

A QMS will help us identify how our structures interact with each other, how we share learning, clarify measurement and co-design a process for ongoing improvement.

Stay tuned for more on CCA’s Quality Management System…

-Michael

Michael is the Senior Program Lead of the Provincial Systems, Programs & Performance team in Cancer Care Alberta. He dedicates his career to improving patient outcomes and enhancing health system performance by optimizing processes and delivering innovative solutions to complex issues.

References:

[1] https://www.ncbi.nlm.nih.gov/books/NBK557505/

[2] https://hci.care/how-to-implement-a-quality-management-system/

[3] https://pmc.ncbi.nlm.nih.gov/articles/PMC6502556/

[4] https://pubmed.ncbi.nlm.nih.gov/38001556/

[5] https://asq.org/quality-resources/articles/case-studies/implementing-the-healthcare-quality-management-system?id=7195e26041da4ced9bf9f8080eb33743

[6] https://hsph.harvard.edu/exec-ed/news/change-management-why-its-so-important-and-so-challenging-in-health-care-environments/

[7] Smith, S. C., & Gronseth, D. L. (2011). Transforming research management systems at Mayo Clinic. Research Management Review.

[8] Ludmir, E. B. et al. (2024). Implementation and Efficacy of a Large-Scale Radiation Oncology Case-Based Peer-Review Quality Program across a Multinational Cancer Network. Practical Radiation Oncology.

What is an A3 Storyboard?

By Deanna Cooney

Would you like to see completed initiatives at a glance? Wouldn't it be nice to see the process from start to finish on a single page?

Well, you’ve come to the right place! That’s exactly what an A3 is all about.

An A3 storyboard is a visual tool used in the A3 problem-solving process, which originated from Toyota's lean management practices (TPS – Toyota Production System). It is named after the A3 paper size (297 mm x 420 mm or 11.7 in x 16.5 in) on which it was typically created [1].

The storyboard format helps to systematically document and communicate problem-solving efforts, making it easier to understand project findings and impact.

It tells the story of how the initiative achieved it’s goal(s) and highlights how the process was completed. It should have enough information so the reader has enough understanding -as if being told by the initiative lead.

How is an A3 Storyboard Used?

The A3 storyboard is used in various stages of problem-solving and contains distinct sections for each of the AHS Improvement Way (AIW) phases:

1. Define Opportunity: It begins with background information and clearly defines the problem and goal statement.
2. Build Understanding: This phase involves analyzing the current state to identify and understand the root cause(s). This phase substantiates the problem and goal statement with data analysis, value analysis, and RCA (root cause analysis) tools such as the fishbone, 5 Whys, etc.
3. Act to Improve: This phase involves identifying, prioritizing, planning, testing, refining (PDSA – plan-do-study-act) cycle(s), piloting proposed changes from start to finish and monitoring data. Once the data shows the desired outcome(s) is achieved over time, the changes are fully implemented.
4. Sustain: Process data monitoring continues to ensure the outcomes are achieved. Process owners are responsible for “trigger points” and response plan and utilization if required.
5. Change Management: In all four phases, Change Management is required to reinforce change. Tools such as a Communication Plan, stakeholder analysis ADKAR (Prosci) are used.
6. Shared Learnings: What are the lessons learned? What worked? What didn’t work? Can this initiative be scaled and spread in other areas?

Benefits of Using an A3 Storyboard:

1. Clarity and Focus: The A3 storyboard helps to clearly define the problem, ensuring that everyone involved has a shared understanding [1].
2. Visual Communication: By presenting information visually, it makes complex data more accessible and easier to understand [2].
3. Collaboration: The storyboard format encourages collaboration and communication among team members, fostering a collective approach to problem-solving [2] and shared learnings.
4. Systematic Approach: It provides a structured method for addressing problems, ensuring that all aspects are considered and nothing is overlooked [1].
5. Continuous Improvement: The A3 process promotes a culture of continuous improvement by encouraging regular review and refinement of solutions [2].

In conclusion, the A3 storyboard is a powerful tool for summarizing results of projects.

Its structured and visual format helps teams to communicate effectively, systematically address challenges, and drive continuous improvement.

Consider using it in your work and projects by using an easy-to-follow A3 Storyboard Template.

Deanna is Senior Process Improvement Consultant with Cancer Care Alberta's Quality, Safety and Practice Integration Team. Deanna is a Certified Lean Six Sigma Black Belt and Certified Manager of Quality and Organization Excellence with over 15 years of experience in healthcare improvement.

References

[1] How to Start the A3 Problem-Solving Process

[2] A3 Problem-Solving - A Resource Guide - Lean Enterprise Institute

Healthcare Complexity and Quality Improvement.

By Michael Sidra

We’ve all been there… endless opportunities for improvement, but no time to make it happen.

With the fast pace of today’s healthcare, continuous improvement becomes a “side of our desk” type of work.

But it needs to be the way we do business - incorporated into everything we do.

I don’t have a magic bullet for how to do that (sorry), but I suggest there is a mindset that can help us get there.

The key to continuous improvement, in my humble opinion, is to have the mindset of a qualipreneur.

(Yep, I made this term up but stay with me…)

A Qualipreneur is anyone that identifies and actions quality improvement opportunities.

Before jumping into what that means, first let’s explore what quality improvement actually is …

What is Quality Improvement?

Although we all have an idea of what quality improvement (QI) means to us, it can mean different things to different people depending on where they work, their exposure to QI in the past, and experiences with different types of QI work.

In the larger healthcare world, there are many definitions for quality improvement. For example, the Institute for Healthcare Improvement defines quality as “the endeavor of continuously, reliably, and sustainably meeting customer needs”.

Healthcare Excellence Canada defines quality improvement as “The degree to which healthcare services produce the desired health outcomes and measure up to current evidence and knowledge.”

However, when you look at all these definitions some common themes emerge; it’s a continuous process, creating reliable systems, improving patient outcomes, evidence-based and sustainability.

For me, the simplest and best description of continuous QI, is how Dr. Atul Gwande describes it:

“Better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. But above all, it takes a willingness to try.”

Dr. Atul Gwande’s “Better: A Surgeon’s Notes on Performance”

The promise of Quality Improvement

So we can say that quality improvement is about making the systems better for patients and staff/providers. More specifically, the aims of quality improvement are described as:

• Improve patient outcomes
• Enhance patient satisfaction
• Improve efficiency and value for money
• Improve staff and provider experience

These are often referred to as the quadruple aim of healthcare improvement.

Yet.

Despite these aims, healthcare is still struggling.

According to the Canadian Institute for Health Information, in Canada, 1 in 17 hospital stays involve at least one harmful event (2023-24).

Canadians are also not happy with the current state of healthcare. According to an Ipsos Feb. 2023 survey, 60% of Canadians rate quality of healthcare as good (down 12 points from 2020) and only 43% of Canadians rate timely access as being good.

If quality improvement is the answer, and every system uses QI, why are we still struggling?

This is a very complex question and likely has many driving factors. I believe one of the main drivers though is that quality improvement is highly dependent on people’s ability to navigate an increasingly complex environment.

Healthcare is evolving rapidly from a standardized system to more personalized medicine. This is probably even more pronounced in cancer care. With the increasing role of cancer genomics, development of targeted treatments, and trends towards more personalized supportive care, caring for patients with cancer is becoming increasingly more complex.

These advancements are great for patient outcomes. In cancer care, for example, we see increasing survival rates in several tumour groups.

However, from a health system perspective, this adds more pressures on clinicians, staff, and on physical spaces.

So does quality improvement help us address this increasing complexity?

I think so, but it needs to be applied in the right context.

Let me explain.

The Complexity of Healthcare

The Cynevin framework provides some insights here. The Cynevin framework was designed by David Snowden as a lens in which to view the different states of reality that can exist in any organization.

In-fact, the name Cynefin is a Dutch word that means place of belonging or habitat.

The Framework has four quadrants and a fifth element in the middle, called disorder. It starts from the bottom right (obvious or sometimes described as simple state), to the top right (complicated state) then top left (complex state), then finally the bottom left (chaos).

When you are in the disorder state (the middle shape), you don’t know which quadrant applies to your reality and in the chaos state things are happening, but you don't know why, or it’s too chaotic to understand.

For this analysis, we will ignore the disorder and chaos states and focus on the other three states (Obvious, Complicated, and Complex).

The quadrants to the right (Obvious and Complicated) describe a world where we know and can understand the issues/problems we are experiencing.

In the obvious state, there are best practices, and we know what to do - we just have to figure out how to do it. This could be non-compliance to different clinical or operational standards. To improve, we simply apply the best practice to our work and while it may not always be easy to do, at least we know what needs to be done.

In the complicated state, we may not know immediately how to improve, but here is where quality tools such as PDSA cycles, Root-Cause analysis, Process mapping etc. can help us define the problem and identify the solution.

Moving on to the top left quadrant, the Complex state, this is where healthcare issues often sit. In this state the solutions are not easily predictable - they are unknown unknowns.

One way to describe the difference between Complicated and Complex is to look at the difference between a manufacturing environment and healthcare.

A widget manufacturing company for example, can reduce variation of the inputs - parts coming into the process. Having specifications for these parts, before they enter the plant allows the manufacturer to configure a process that is uniquely and efficiently designed for the incoming parts.

In healthcare, on the other hand, the inputs are people which cannot be standardized. Variation is inherent as every person is different in their health issues, and values.

For example, you might have two patients that have the same type of surgery, but one patient might be obese with a history of alcohol abuse and another patient maybe anemic with a history of cancer. While it’s the same surgery, the difference in patient history, characteristics and values necessitates a unique approach.

In this example, the surgeon needs to adapt both their clinical and interpersonal approaches for each patient.

This type of variation is inevitable and contributes to the Complexity we encounter in healthcare.

So, what can we do about it?

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Quality is Everyone’s Business

The only way to truly transform healthcare is adopt a “qualipreneur” mindset. That is, if everyone incorporates continuous improvement into their work.

Everyone from policy makers to clinical staff, and providers.

Every interaction in healthcare matters.

Something as simple as a smile from a nurse can make a big difference in how patients feel about their healthcare encounter.

“A little patience, a kind word, a listening ear, are more valuable to my well-being than the medication I get”

Terminally Ill Patient

Everyone in healthcare needs to become “Qualipreneurs”. While there is room for larger QI project, the impacts patients feel immediately is the individual improvement we make in our work every day.

Qualipreneurs are able to recognize Complicated and Complex situations.

For example, issues around drug inventory management, clinic scheduling or digital technology implementation, are all places where there are known or knowable solutions and, in these situations, traditional quality improvement tools are a great way to go.

In other situations that require both technical expertise and understanding patient needs and values, traditional quality improvement tools may not be the best place to start.

A standardized approach would not work, and variation is not only expected but necessary.

In these situations, the qualipreneur is better off trying to truly understand by asking good questions, sensing the environment and the people’s response, and adjusting their approach and how they respond to the information they are receiving.

This is referred to as “Probe, Sense, Respond” in the Cynevin framework.

A probe, sense, respond approach does not jump into a solution. Instead, it involves patients in their care and honours their individual values and differences- while at the same time applying clinical best practices.

In some cases, patient values might differ from clinical recommendations. Other times, patient expectations are not the same as what medicine can provide.

This is the Complexity of Healthcare.

By being qualipreneurs - where everyone takes a quality lens to their work, and understands how to handle complexity, we have a better chance of building a resilient, highly reliable and continually learning and improving health system despite the increasing complex of the healthcare universe.

Yes, it’s easier said than done.

But.

That’s why it’s called “continuous improvement”.

It will take every one of us to get it done.

It is NOT impossible.

Because better is always possible.

Michael is the Senior Program Lead of the Provincial Systems, Programs & Performance team in Cancer Care Alberta. He dedicates his career to improving patient outcomes and enhancing health system performance by optimizing processes and delivering innovative solutions to complex issues.

What is it and what's in it for you?

By Michael Sidra

Welcome to the launch of Cancer Care Alberta’s own quality improvement and innovation blog called: Quality Catalyst - Igniting Improvement And Inspiring Excellence.

I’m Michael Sidra and I have the privilege of working with you at CCA as the lead for Provincial Systems, Programs and Performance (PSPP). If we haven’t met before – nice to e-meet you.

This blog is curated by the PSPP teams (although we’re counting on your expertise and contributions). The PSPP portfolio supports clinical and operational teams to continually improve. Our team’s vision is “To be the most trusted healthcare improvement team anywhere. Because better is possible.”

Why a blog?

Sharing information, resources and successes is a key feature of high-performing organizations.

AND

There is world-class expertise right here in CCA.

The Quality Catalyst blog will publish blog style articles written by subject matter experts with the aim of sharing learnings and fostering a culture of innovation and continuous improvement.

But there is more.

Our hope is that the Quality Catalyst will be a place for leaders, improvers, and lifelong learners to connect, share ideas and learn from each other. It’s not just one person or group writing – we invite everyone to share learnings, celebrate successes and add improvement ideas or innovations.

The Invite

While there will be a few “CCA All” emails to generate some awareness about this blog, we will send the blog to only those who subscribe. To subscribe to the blog posts, visit the blog space and click Subscribe on the right side of the page.

If in the future you decide you no longer want to get the blog, you can easily unsubscribe.

Let's learn, teach, and improve together. Because better is possible.

Thank you!

-Michael Sidra

p.s. Do you have expertise you’d like to share? The Quality Catalyst isn’t just about content—it’s about connection. Join us in exchanging ideas, collaborating, learning and building meaningful partnerships.

p.p.s. If you’ve read this far then we should definitely be friends 😊 Go to the blog page and Subscribe (right hand side of the page).

Michael is the Senior Program Lead of the Provincial Systems, Programs & Performance team in Cancer Care Alberta. He dedicates his career to improving patient outcomes and enhancing health system performance by optimizing processes and delivering innovative solutions to complex issues.