Our fragile system needs embedded quality improvement (QI) 

By Dr. Cole Stanley

We’ve reached a crisis point in primary care in BC. Family physicians are burning out like never before. Clinics are closing, the public uproar is loud and sustained, and politicians can’t afford to look away. Day-sheets are overpacked, inboxes overflowing, and we’re forced to trudge through the same poorly designed systems, with little time or energy to make things better. You may be thinking, “QI? This is the least appropriate time to be asking me to do one more thing!” Well, thank you for getting this far. Bear with me, though, as experience tells me we must embed QI in our daily work. A key tenet of QI is to “steal shamelessly”, and  I’ve done so with the title of this article. W. Edwards Deming’s 1982 book of the same name contains many of the principles of QI that have worked to reinvigorate other industries, and we now need them here if we are to find a way out of this crisis.  

Let’s think about how we got here. Common explanations center on pay disparities within our profession or how previous governments blundered in workforce planning. These may be valid contributing factors, but I suspect the problem runs much deeper. Our current system has the unfortunate feature of being increasingly fragile over time- each day it becomes more prone to breaking. In her 2017 book, Dr Danielle Martin highlights “…by its nature, fee-for-service rewards the volume of interactions rather than their complexity or quality.” Physicians’ panels fill up and care is provided as efficiently as possible. This may run smoothly for a time, but the system and world around us inevitably drifts, and sometimes dramatically shifts (COVID is the obvious recent example). Here’s where the spring of this efficiency trap snaps down on us. We have no capacity to adapt to our new reality, and quickly feel overwhelmed and burnt out. Never mind the fact that our patient panels also gradually age and become more complex over time. Never mind that new practice guidelines, College standards, paperwork, and software literacy requirements are constantly added to our list of expectations. Yes, we should recruit more longitudinal family physicians and correct pay disparities, but the underlying fragility will remain.  

To fix this, we need to build the ability to adapt into our core work. 

Sacrificing wellbeing and life outside of work, we make valiant efforts to adapt and hold this fragile system together. Many evenings are spent charting, with QI work and continuing education done off the side of the desk. We sometimes even earn the distinction of “healthcare hero”. But is this a long-term solution? The absurdity is laid bare when we look to other industries. Who would accept routinely relying on heroic efforts to have the plane we’re flying home on land safely? Everyone loves a good hero story, but it’s time to relegate this to Dr. Strange and the cinematic multiverse. It’s time to shift away from a system that relies on ad hoc efforts that are inconsistent, unsupported, and unsustainable.  

Instead, imagine what it would feel like to have this learning and improvement function built into our work day, where it is supported and valued. We must expect the unexpected and have the capacity and coordinated approach to solve problems as they arise. In short, we need what Nassim Taleb would call an antifragile system – one that is only more capable to thrive in response to stressors (think muscle hypertrophy secondary to the intentional stressor of lifting a weight). 

Now is the time to get QI embedded in our daily work. The QI-capable team has the dedicated time to define what is important to them and their patients. They have the methodology to respond, adapt, and improve. From understanding the problem, to focusing on an aim, testing change ideas, and implementing what works – this team becomes the muscle. The system is protected from breaking, and this includes protecting our physicians from breaking. We know having happy workers leads to delivery of a high-quality product. And this works in reverse – I’m generally a happier physician when I can deliver high quality care, yet our current system pays little heed to this. This changes when we embed QI, where we acknowledge provider experience as central to our efforts. 

Although I dream of a system where it’s “80% do the work, 20% improve the work”, I know it’s impossible and even inadvisable to get there overnight. Here another key tenet of QI comes in – “think big, but start small”. Despite being near burning out, or stretched beyond capacity, I suspect that most physicians can find value in leaning into QI right away. I say this with a hint of bias, as I thank QI work for pulling me back from the brink of burnout, but I’m not alone here. We hear similar tales from our growing contingent of Physician QI (PQI) alumni across the province. I suspect this is because it gives us the chance to replace some of our tedious, boring, or anxiety-provoking work with something of more value, allowing us to reconnect to purpose. It gives us a way to shift more of our work towards that ideal state of flow, where we are challenged, the work is engrossing and we have the necessary skills to be a high performer. In short, when we’re running on fumes, this work can actually start to refill our tanks.  

So, does this feel safe to try for you? It’s a hard decision to take some time away from direct patient care, but a small investment can yield compounding results for your patient panel. At Hope to Health, my team in the Downtown Eastside was able to reduce our percentage of disengaged clients from 45% to 15% using embedded QI. This has been rewarding and motivating for our team, as we know our most marginalized clients are getting better care because of it.  

With new flexible payment models and sessional funding available through the Practice Support Program (PSP) and PQI, I’m confident that you can also get started right away. At HDC, we’d love to help you figure out how. Please contact me at cole.stanley@hdcbc.ca or our HDC team at info@hdcbc.ca to find out more.  

I’ll share more about my QI experiences in coming articles, along with stories from physicians across BC who are joining the movement to embed QI as an important part of our work.