Qualipreneurs
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.
