By Dr. Cole Stanley

The high stakes path to embedded frontline QI and why we need to take it now 

Preface – In true QI style, I’ve decided to test out something new. Unlike a lot of other business articles (of sedating quality), I’ve indulged in a lengthier intro, with hopes that the result is a little less dry and a little more memorable. Doing QI affords a creative license, not “more of the same”. The balancing measure is ~2 extra minutes of reading time up front. Thank you in advance for testing it out with me and getting to the crux and calls to action at the end. 

Large drops of rain slide down the small office corner window over a dark grey background, reflecting glints of hot white from the outdoor security light. It’s not yet 3pm, but low dense clouds and the Earth’s tilt this late November make me feel like this day is already over, or did it even start? The tube lighting buzzes overhead, and in my solitude, I notice a mild pressure in my forehead as I stare at the screen. My typing grinds to a halt and I instinctively swap EMR windows to see two more patients are waiting for me. I am now a full 45 minutes behind. I look down at torn up duplicate prescription pages on the desk, presumably from yet another paper jam, and like a millennial looking for a date I blankly swipe them left, down into the small trash can. I thought I moved that trash can away from the side of the desk. 

Refocusing on my visit note, I’m struck by the incongruence of feeling lonely while I’ve been seeing people all day. Though they just left the exam room moments ago, the details of my last patient visit are hazy. I recall a recent talk on new diabetes guidelines and have a sense that I am doing something wrong, I’m missing something.  I’m alone with no team to help me and no time to figure it out. There’s an active tug-of-war in my head now, with judgemental finger-pointing of external bodies pulling towards providing “adequate care according to guidelines”, facing off against a more human side of not making my next clients wait even longer. A real tension headache it seems. I start to catastrophize. Have I reached a sort of escape velocity where each subsequent client visit sets me back so much further in my schedule that my day will actually never end? 

Tachycardic, I stand quickly and move to the window hoping for reprieve. Something’s odd though. I look out and up, and up on the inner courtyard of this old building and can only see repeating small windows identical to my own. Is that a silhouette in each one, mirroring my pose? Is that me? A thunderous crack and boom startles me as lightning flashes outside from high above. The crack repeats twice, but somehow with a wooden undertone. Then again, but more like a door knocking. My eyes flash open, and I’m startled for a moment, but then settled with a deep sense of relief. as my teammate gently opens the door and asks if I am ready to speak with them about our shared client. Here, I realize, my usually restorative short midday nap has been tainted by a nightmare. 

This never happened, but it is a plausible nightmare in my mind (followed by a dream of having a shameless clinic-based restorative midday nap). For you, it maybe even felt mostly believable. Certainly, many of us sometimes feel that we are but lonely cogwheels in the machine of healthcare, submitting to intense external pressures to solely enact guidelines, policies, procedures, and directions. Others may be thinking I am being a bit melodramatic. I’ll nod my head at you and suggest it’s for dramatic effect. Because we are at a crossroads, and I really do fear that choosing the wrong path could trap us in this nightmare. 

Traditionally in medicine, we really separate the doing of the work from the improving of the work. We often even rely on separate people (i.e. researchers, policymakers, and our Colleges) to tell us what to do, and we need to do continuing medical education outside of normal working hours to independently learn how to do better, or even perform to a minimum standard. I argued in my last article that this is sorely inadequate. With more of us working in teams and the delivery of care growing in complexity, it is magical thinking to assume that we can reliably apply what we’ve learned while away from our team. When we get back to work, the realities of lack of time and complex adaptive systems mean that most of the learning is left unapplied, and soon forgotten. The know-do gap ever widens, where the body of knowledge of what we ought to do grows and puts pressure on us, but we have little ability to adapt what we actually do. With the primary care crisis, a new primary care payment model now available, and talk of implementing learning health systems, I see us at a crossroads– one that could lead us down a dark path to my dystopian cogwheel nightmare. This isn’t predestined though, and we urgently need to forge our alternate path.  

Don’t get me wrong, I am a full supporter of implementing learning health systems (LHS), but I get worried about this proposition when I hear some decision-makers’ ideas about what this looks like. They talk of being able to glean rich complex data from the frontline work. This bountiful harvest is then served up to researchers and decision-makers armed with their “advanced analytics” and new affinity for data science and big data. This, they say, is where the learning happens – away from the frontlines, where they are too busy doing the work anyway. This may make decision-makers feel data-informed and create many high impact papers for researchers, but what does it do for the know-do gap? Knowledge increases, the frontline team has no time to adapt, and so pressure from yet more directives and feelings of inadequate performance only increase. 

How can we avoid this? Dr. Charles (Chuck) Friedman is one of the pioneers on the topic of LHS. In his teaching, he states that the hardest part is the Knowledge to Performance step, where we run into an “implementation gap” (at K2P on The Learning Cycle pictured1). More like an implementation chasm, I say. Dr. Gabor Mate and his son Daniel put it plainly, “One of the most persistent and calamitous failures handicapping our health systems is an ignorance- in the sense of either not knowing or of actual, active ignoring – of what science has already established.”2 It’s important to note here that they aren’t pointing at us as individuals working in the system, but to the ignorance of the system itself. As individuals, we often know there is a better way, but end up with moral distress and burnout when the system won’t budge. To address this, we must embed the ability to learn and adapt (read “do QI”) into our frontline team’s workday. In line with this notion, a recently published LHS guidance document from the UK stresses this vital and necessary component of building improvement capability and capacity in frontline teams. This NHS document serves as an excellent primer for those interested in learning more about LHS, and it includes 16 case examples (including some from primary care). 

The frontline team often knows best in terms of what changes will result in improvement, and have insights not visible to others. It’s time to prioritize learning at the frontline and shift away from the idea that we need to fully rely on backroom intellectuals to tell us what to do. No, I am not saying we need to get rid of researchers or policymakers, nor am I questioning the value and need for what they do. But the impact of their work may be blunted or even net negative if we don’t fix our system soon, where the know-ers are separate from the do-ers. This is why I get quite perturbed when I hear colleagues say that QI is not a part of their job – a surface frustration that stems from my underlying fear of us choosing the wrong path.  

You can imagine my gut reaction last week to seeing a primary care physician-researcher tweet that now is not the right time to do QI. It took a moment of mindfulness to pull me back from over-interpreting the 140 characters devoid of context. After all, she has a point – we can’t force people. QI efforts devoid of intrinsic motivation and initial positive experience are unlikely to be continued and risk leaving busy frontline staff resistant to future QI. A friend and colleague who works at a busy HIV Primary Care Clinic in Toronto has experienced this, where he felt that his mandatory project came at the wrong time, getting in the way of higher priority work (it’s my goal to win him back from the resultant QI skepticism). Another Torontonian, intensivist and IHI fellow Dr Chris Hayes’ warns that we need to make QI highly adoptable for it to work (https://www.highlyadoptableqi.com). His work confirms that making QI mandatory and neglecting teams’ motivations is a recipe for failure.

Indeed, our path ahead is fraught. As a profession, we can fully embrace doing QI and become data-driven at the frontline. If we do not seize this opportunity, we risk giving away the power inherent in data-driven approaches and diminishing our profession. Consider the cautionary tale of the UK experience with pay-for-performance and the Quality and Outcomes framework (QOF): “By following a medicine-by-numbers, pay-for-performance path [determined by government] under the QOF, the [medical] profession cannot lay claim to its own knowledge base and priorities.” Here the data was used with a desire to good, but was missing necessary frontline insight, where they neglected the importance of nuance and context dependence in the decisions we make while treating patients. I’m optimistic that if we start small and harness the growing resources for learning and doing QI in our province, we can become data-driven while learning from the missteps of others.  

Let’s also not skip over the many benefits. Doing QI with your team at the frontline can be some of the most rewarding and reinvigorating work that you find. It can serve as team building and pull you back from burnout, and it’s sometimes just plain fun! This has become a common refrain from our growing contingent of PQI alumni. When you and your team decide on what’s important, have a sense you can do better, and try something new, it’s quite motivating when the data reflects the improvements you’ve made. I’ve started collecting real-life examples to illustrate this point, which we’ll be sharing in our new section “Bright Spots”.  

In the coming months, many of us are planning to change key aspects of how we deliver care. Whether you are switching to the new payment model, shifting towards team-based care, or connecting in primary care networks (PCNs), consider how you can start making QI part of your day. You’ll not only be building in resilience to your own work but will be helping our system as a whole move in the right direction, further away from my nightmare.  

I’ve listed calls to action below that you can share for collective impact.   

What can you do? 

Frontline providers and your teams:

  • Find the small first steps to getting started, engage with PSP  
  • Talk to a PQI alumni 
  • Contact us at HDC for support and guidance 

PQI alumni and other providers with QI experience:

  • Find ways to embed QI in your workday instead of relying on special projects outside of normal working hours  

Government and policy-makers:

  • Promote and fund embedding QI capability and capacity in frontline work 
  • Be leery of strategies that rely on extrinsic motivation, judgement, or quality assurance 

Researchers

  • Promote embedding QI capability and capacity in frontline work as a vital component of learning health systems, one that can lessen the implementation gap and increase the impact of your efforts 
  • Consider how newly created knowledge can be applied and implemented and point frontline teams to resources for accomplishing this

References 

  1. University of Michigan Medical School. (Accessed 2022, November). Our Approach. https://medicine.umich.edu/dept/lhs/explore-learning-health-sciences/our-approach  
  2. Mate, Gabor and Daniel. The Myth of Normal. Penguin, 2022.  
  3. Hardie T, Horton T, Thornton-Lee N, Home J, Pereira P. Developing learning health systems in the UK: Priorities for action. The Health Foundation; 2022 (https://doi.org/10.37829/HF-2022-I06). 
  4. Hayes, Christopher William, and Don Goldmann. “Highly Adoptable Improvement: A Practical Model and Toolkit to Address Adoptability and Sustainability of Quality Improvement Initiatives.” The Joint Commission Journal on Quality and Patient Safety, no. 3, Elsevier BV, Mar. 2018, pp. 155–63. Crossref, doi:10.1016/j.jcjq.2017.09.005. 
  5. Mangin D, Toop L. The Quality and Outcomes Framework: what have you done to yourselves? Br J Gen Pract. 2007 Jun;57(539):435-7.  

Image credit: AI-generated by OpenAI