Quality Catalyst - Igniting Improvement And Inspiring Excellence

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.

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.

This week’s blog post is from Deanna Cooney and it explains the benefits of the A3 storyboard tool and how to use it.

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.

Happy Reading.

-Michael

What is an A3 Storyboard?

By Deanna Cooney

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.

References

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

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

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.