Getting better at getting better: Advancing quality and safety in healthcare

Abstract

Scaling the innovative models of care, policies, practices, and technologies that deliver true value requires deliberate, focused effort. We need to simultaneously apply practical strategies that enable change agents to drive meaningful, sustainable impact to address particular challenges that a health system is facing, alongside implementing proven, evidence-informed approaches that broadly strengthen health system foundations. Both approaches matter; it’s not about choosing between them. Rather, we need to respond to the health system’s specific and immediate needs, while also growing culture, capacity, systems, and tools that enable transformation in quality and safety.

Introduction

It seemed like a typical Sunday morning when I went to visit my friend Susan. ¹ Her husband, Andy, was receiving palliative care at home and usually had a nap early in the day. We would go out for a coffee while he slept and then visited with him later when he woke.

But that morning, Andy’s pain levels spiked. Because his palliative home care team didn’t work on Sundays, Susan called an ambulance. In alignment with their care protocols, the ambulance took him to the emergency department. The staff did their best in a chaotic and busy environment, but it took more than 2 days to access Andy’s care plan and to address his needs. As a result, he ended up spending precious days towards the end of his life in the place he and Susan least wanted to be.

It did not have to be this way. At the time, smart and creative innovators were trialing new care models that enable paramedics to provide palliative care in the home. But these approaches had not yet spread to the city where Susan and Andy lived.

Since that Sunday, though, innovative care models that began in sites in Nova Scotia, Prince Edward Island, and Alberta have spread to seven provinces. Following a process to identify proven innovations, participating teams took part in a guided improvement journey that included: engagement with patient and family/caregiver advisors; seed funding to support implementation; customized learning opportunities and coaching; peer-to-peer sharing and learning; and evaluation support. ¹

Through this effort, more than 7,500 paramedics were trained to support patients who have a palliative emergency, require pain and symptom management, or have an unexpected health event in their homes. The results: over half of the time, people receiving palliative care stay at home, rather than having to go to the emergency department. ² And 87% of the time, patients and families said that the services improved the presenting complaint.

Better care ‐ at scale ‐ happens by design, not by luck

Everyone wants, and deserves, excellence in healthcare. There are many, many points of light across the country—models of care, policies and practices, technologies, and other innovations that offer true value. But all too often they are only available to the lucky few who won the lottery by living in an area or being connected to a care team that uses them.

Scaling these approaches so that they reach further, are available to more people, and achieve deeper gains requires more than good intentions. Merely trying harder, spending more, or yelling louder will not achieve the quintuple aim of better patient experience, population health, healthcare provider well-being, efficiency, and equity.

Instead, we need to apply proven, evidence-informed approaches to strengthening health systems. Julio Frenk and colleagues ³ argue for the importance of “diagonal” approaches. They combine a focus on specific priority interventions (“verticals”) as ways to strengthen the structure and function of health systems, while simultaneously addressing foundational gaps in ways that enable more general progress but tend to have longer time spans (“horizontals”). Both approaches matter; it’s not about choosing between them.

Applying this lens to advancing quality and safety means that we need practical strategies to respond to the health system’s specific and immediate needs, while also growing culture, capacity, systems, and tools that are foundational to high-performing health systems. For instance, the collaborative described above included both efforts to train paramedics in palliative care competencies, as well as supporting participating teams to strengthen patient and family engagement and activate policy and structural enablers for paramedics to work to their full scope of practice. By undertaking work at both levels thoughtfully, these approaches can complement each other and achieve more significant impact than either would on its own (see Figure 1).

Figure 1.

Towards transformation in health systems.

Responding to today’s priorities with solution-focused innovation

Health systems across the country and around the world face a range of challenges that require urgent responses. By tackling specific safety and quality goals effectively, it is also possible to nurture and develop a system’s resilience and its capacity for transformation more broadly.

Deciding what changes to focus on

The specific issues that inspire change-makers in healthcare are diverse. One may be passionate about reducing administrative burden on care providers or making sure everyone has access to high-quality primary care. Another might be focused on the experience of people receiving mammograms or reducing colorectal surgery complications. Efforts that move forward on these types of specific, tangible improvements complement investments in the foundational elements of high-performing health systems.

Large-scale change, even in addressing very specific issues, rarely happens with the stroke of a pen. Often, it occurs through relentless incrementalism, the culmination of a series of actions taken over time by different people that together add up to large-scale change. Waves of shifts from inpatient to day surgery, the many complementary innovations that have contributed to continued improvements in cardiac surgery survival over many years, and rapid development of COVID vaccines that built on decades of research offer three illustrative examples of the possibilities. Similarly, in the Paramedics and Palliative Care Collaborative described above, it took time to scale up training, protocols, and response capacity. Teams across the country advanced together, sharing and learning with and from each other.

Even when significant effort is expended, success is not guaranteed. In some cases, for instance, hard-won improvements implemented over years eroded during the pandemic—such as diagnostic and surgical access or more accommodating policies that recognize that family and other essential care partners are not just visitors to name just two. So an important focus is to sustain proven innovations so that they keep happening, in a dynamic way that allows for continuous improvement and adaptation to changing circumstances.

Likewise, not all innovative practices, policies, or systems should spread everywhere. Some work well in a particular context but are dependent on features unique to that environment. They will fail elsewhere. Others may have worked well at one time but are no longer optimal. And some simply don’t work as anticipated. Success depends on being able to actively contain or retire these innovations, just as it does on advancing those with more promise. Evidence-informed tools can help to differentiate between the two, as well as to identify where you need to adapt an innovation to local context to move forward successfully. ⁴

Evidence-informed resources

Over the years, we have collectively learned a great deal about how to identify promising innovative practices, programs, and tools that are ready to be adopted elsewhere, as well as how to determine where adaptations will be required to be successful in the short- and long-term. If you are making decisions about where and how to advance change, tools that leverage this evidence may be helpful, including:

• • Readiness to spread assessment aids champions and leaders understand whether a potential improvement is suitable for successful spread. ⁴

• • Readiness to receive assessment aids organizations to assess how ready they are to adopt an improvement proven in another context. ⁵

• • Long-term success tool and action planner aids organizations to assess risks and strengths in 12 areas that are known to influence the long-term success of an improvement initiative. ⁶

Advancing quality and safety

The process by which an innovation is put into real-world practice matters greatly. High-quality implementation involves active, purposeful processes that draw on and reinforce the foundational elements of high-performing health systems. It is evidence-informed and leverages tested approaches to change, such as implementation science, behavioural science, and social movement theory. Change at scale typically occurs across different levels of influence, with dedicated resources and focus. Continuous monitoring and learning are also key to success.

Guided improvement journeys are a proven way of advancing quality and safety. ⁷ They bring together a learning network designed to support teams to go further, faster as they realize improvements for the people they serve. Together, participating teams tackle shared challenges using evidence-informed solutions, while also gaining lasting quality improvement skills. Developed out of the Breakthrough Collaborative Series ⁸ model, these journeys typically involve three stages:

• - Design: Working with a few teams to test and refine interventions or actions, as well as to and identify champions.

• - Spread: Foster use of a bundle of proven interventions or actions beyond their original implementation context, typically engaging design-stage champions to support the process.

• - Scale: Reach all who can benefit in a geographic area or population group, which often requires different partnerships and approaches than the spread stage.

Areas of focus and duration can vary depending on the nature of the innovation involved. See the sidebar for an example on a rapid response program that began with design and extended into spread.

LTC+: Accelerating pandemic response

Almost 4,000 long-term care residents in Canada died between the beginning of the pandemic and mid-May 2020. ⁹ Overall, about eight in ten of Canada’s COVID-related deaths during this period were in long-term and residential care. Outbreaks in long-term care quickly became the largest patient safety issue in the country.

At the Canadian Foundation for Healthcare Improvement (now Healthcare Excellence Canada), we heard directly from homes affected in the first wave of the pandemic, as well as from those who had not had outbreaks but were keen to prepare for the future. Thanks to the generosity of residents and families, people who worked in homes, public health, and others who shared their experiences in the first wave—complemented with research evidence—we identified six promising practices for reducing risk. Examples included core infection prevention and outbreak response, enabling safe family presence, and supporting people who work in homes. ¹⁰

We started working with 40 long-term care and retirement homes on a guided improvement journey (called LTC+: Acting on Pandemic Learning Together) in the summer of 2020. Homes completed a self-assessment relative to the promising practices. They then developed a unique action plan and had the opportunity to access coaching, virtual learning opportunities, peer-to-peer connections, seed funding, and more to support its implementation. Over time, more than 1,500 long-term care and retirement homes with over 177,000 resident beds joined this effort.

Despite the many concurrent challenges that they faced during the pandemic, most homes reported capacity development and improved outcomes. At the end of the program, more than three-quarters of survey respondents “agreed” or “strongly agreed” that LTC+ had helped them to increase awareness of (84%) and capacity to implement (85%) promising practices aimed at strengthening pandemic preparedness and response. ¹⁰ Most (78%) also reported gains in one or more of resident health, resident experience, staff work life, and efficiency of care. Almost one-third (32%) reported improvement in all four areas.

High-performing health systems need strong foundations

Leading health systems in Canada and around the world employ a common series of six levers that enable excellence, resilience, and health system transformation. ¹¹ Investing in these foundational elements of high-performing health systems lays the groundwork for advancing specific solutions to address a wide range of challenges, of the type described above.

Focusing on population need

Understanding the people an organization serves, as well as their diverse health needs and expectations, is central to health systems’ abilities to align strategies and services to their communities’ priorities. This enables high-performing health systems to set responsive population health goals, target resources and monitor performance against them, and adjust as needed.

Engaging people with lived experience

Engagement-capable, resilient environments that prioritize cultural safety are where excellence thrives. Engaging people with lived experience allows health systems to tap into a wealth of ideas and knowledge about the design, delivery, and evaluation of health services.^12,13 It also supports direct accountability to the people most affected by healthcare decisions.

Truly living “nothing about me, without me” takes a sustained effort to enlist and support a diverse group of partners with lived experience to contribute, to ensure leadership support and strategic focus, and to prepare and support staff to work collaboratively with patients and essential care partners. In doing so, it is important to consider how to augment conventional approaches to ensure equity in engagement opportunities.

Creating supportive policies and incentives

Institutional, professional, regulatory, funding, legislative, and other policies and incentives can accelerate innovation at the point of care—or get in the way. This is true at many levels within the health system. For instance, advancing the ability of paramedics to provide palliative care in the home required changing some local service requirements regarding patient transport, provincial scope of practice and other regulations and policies, and federal rules regarding who could administer certain medications. Likewise, rapid growth in the use of virtual care during the pandemic was accelerated by changes in payment models and other policy enablers. ¹⁴

Building organizational capacity

Leadership at all levels is essential to building organizational capacity. Key roles include setting improvement priorities and goals, ensuring appropriate resources and support, developing improvement skills and experience, modelling positive behaviours, and recognizing progress.

This work must also span organizational and system boundaries. Otherwise, even islands of excellence can leave safety, quality, and equity gaps. Coalitions for learning and care integration support meaningful transformation and improvement.

Engaging frontline in improvement culture

The pandemic added incredible strain to people who provide care. At the same time as Canadian Institute for Health Information (CIHI) data show rates of potentially preventable harm to patients rising, there were higher staff absences, more overtime work, and increased use of agency staff to fill gaps. ¹⁵ These trends reinforce the need to engage and support frontline staff and managers as agents for improvement.

Patient safety and the physical and psychological safety of the people who work in healthcare are deeply intertwined. We need frontline actions for safer high-quality care, on a day-to-day or even minute-by-minute basis. Research shows that places with positive safety cultures tend to have less patient harm and higher staff satisfaction. ¹⁶

For instance, regular safety conversations allow staff to work together to prevent problems before they occur. Staff from organizations Healthcare Excellence Canada partnered with to implement regular safety huddles said that they looked forward to them as opportunities to come together to proactively discuss how to make care safer for all those involved. They told us that being involved in safety gives meaning to their work, as well as value day-to-day.

Promoting evidence-informed decision-making

High-performing health systems systematically seek internal and external evidence and actively use what they learn to inform decisions that affect health and healthcare. Many types and sources of evidence have value in this process, as do a range of learning practices that reinforce improvement goals.

For instance, teams from seven provinces and the Department of Defense joined forces in the Connected Medicine collaborative to spread general practitioner/specialist e-consult innovations from Ottawa and Vancouver. They built on evidence from the early adopters and then carefully monitored progress to continue to improve. By the end of the collaborative, in addition to speeding access to specialist advice, more than half of e-consults avoided face-to-face specialist visits and two in five avoided an emergency department visit.^17,18

Tools to advance health system foundations

Many tools are available to support organizations in strengthening the foundations of high performance, including ones to assess:

• • Assets, strengths, and gaps relative to the six levers of high-performing health systems ¹⁹ ;

• • An organization’s capacity for purposeful and meaningful engagement ²⁰ ;

• • Cultural safety competency for individuals and organizations ²¹ ;

• • Readiness, opportunities, and risks from a value-based healthcare lens ²² ;

• • Governance knowledge and tools for excellence in healthcare leadership, patient safety, and quality improvement. ²³

Conclusion

Healthcare transformation happens when there is a deep understanding of the needs of the individuals and communities served, along with collective learning and action at all levels of the health system. To accelerate improvement in health systems at scale, we need to act both on specific, focused improvement goals and on the foundational building blocks of high performance. Using proven approaches to do so can close the gap between what we know works and what we do in practice.

Given the challenges facing health systems today, it is imperative that we harness this possibility to catalyze and deliver the services and outcomes that people like Andy and Susan—along with everyone in Canada—want and deserve.

Ethical approval

Institutional review board approval was not required.

ORCID iD

Jennifer Zelmer https://orcid.org/0000-0002-1556-6686