Offering the latest news in health care quality and safety, the ISQua blog also features guest posts from the best and brightest in the industry.

By Hugh MacLeod Thursday. Nov 21, 2019


In my second blog post on 10 September 2019, I talked about three quality and patient safety improvement leadership truths; reflection fuels, people matter, and relationships make the difference.


Today I talk about what leaders can do with the three leadership truths to sustain quality and patient safety improvement. Many healthcare organizations find that identifying changes is relatively easy.


By far the biggest challenge, however, is sustaining improvement efforts over time.


One of the reasons is that we fail to strike a balance between two competing interests: involving people in the process versus getting results quickly.


If we are focused on achieving results too quickly, it likely means the improvement program is driven top-down, which can result in a “forced march” that marginalizes the involvement of people. By contrast, a “long march”, with large-scale change and diverse contributions, can lack structure and focus, and result in diminishing support when people fail to see improvement results.


Another challenge is the fact that healthcare organizations must continue to deliver high-quality care to every patient while simultaneously innovating the way care is delivered.  Furthermore, complex organization structure and accountability models can create a culture of “managing by consensus” where even small decisions require discussion and approval from committees.  These factors result in a tendency toward small “rapid improvement events” as opposed to broad-scale system transformation.  As capacity, access and wait time pressures mount, more emphasis is placed on these incremental changes.  In other words, any gains made tend to stop short of having a step-change impact in key outcomes and fail to address the broader human and cultural issues.


The most successful healthcare organizations get the balance right by securing the  three inter-connected pillars of sustainable quality and patient safety improvement:


1. Efficient and effective operating system

2. Supportive management infrastructure

3. Deep-rooted learning Organization


Efficient and Effective Operating System

This is the nuts and bolts of the organization’s processes. During a transformational journey, the operating system is commonly improved by applying “improvement” techniques. Areas of focus include: reducing variation in processes; eliminating non-value-added activities; ensuring information, and materials are in the right place at the right time; improving equipment availability; reorganizing workplaces and activities; and basing staffing on demand patterns.


Supportive Management Infrastructure

This comprises the formal mechanisms put in place to support and encourage the desired elements of the transformation. Areas of focus include: putting the right people in the right jobs to drive change; clearly defining key metrics and accountability; cascading performance dialogue; clearly defining roles; frequently measuring and widely sharing operational metrics; and improving visual management.


Deep-Rooted Learning Organization

This forms the cultural fabric of the organization. Areas of focus include: creating mindsets that support superior delivery of patient care; engaging and listening to patients and family members; building capabilities to improve the system; engaging the front line in problem-solving; clearly defining performance expectations; being willing to improve operations; and sharing knowledge of the patient experience.

Looking back at my experiences with quality and patient safety improvement at local, regional, provincial and national levels, there are six common success factors.


1. Demonstrate involvement of senior leadership: The senior team must be aligned on the scope and objectives of the quality and patient safety improvement project, and a senior leader must play an active leadership role throughout the project. For today’s employee audience, rhetoric without action quickly disintegrates into empty slogans and propaganda. What you do in the hallways is more powerful than what you say in the meeting room.


2. Shift from power to people relationships: Misattribution, misinformation, and misinterpretation can be clarified when individuals talk directly to each other. An organization not only changes with different people, it changes with the same people when you converse about different topics by shifting from the power relationships to people relationships.  If staff don’t trust leadership, don’t share the vision, don’t buy into the reason for the change, and are not included in the planning, there will be no successful transformation regardless of how brilliant the strategy.


3. Involve the physicians and clinical and front-line staff: Organizations don’t change—people do or they don’t. Improvement gets rocky not because of strategy but because the human dimension was not appreciated. It is extremely important to get the physicians, clinical and front-line staff onboard early and establish cross-functional working teams; full-time project leaders are also required.


4. Focus on sustainability measures from the beginning: Incorporate performance management, skill-building, and cultural change elements into the work-plan from the start. Accountability, transparency, and comparative reporting are very potent weapons in the service of truth, and in the face of resistance, whether from special interests, journalistic expose, isolated complaints, or even nostalgia.


5. Communicate, communicate, communicate: Ensure everyone knows what is going on before and during the project and stick with it even when times get tough or change fatigue sets in. Keep evidence at the forefront. Generate useful and actionable information and refine it to produce good, measurable indicators. Create and publish narratives while waiting for the evidence to materialize; do not leave a vacant space of “no information” open.


6. Be aware of the traps of too much too early: While the management of quality and patient safety improvement requires organizational form and capacity, too much structural reform, or acting too early, can allow bureaucratic instincts to calcify or freeze-frame the ongoing quality and patient safety reform. Trying to manage large-scale quality and patient safety improvement with the same strategies used for incremental change is dangerous. Past change success may be your greatest obstacle.


Large-scale quality and patient safety improvement change usually triggers emotional reactions: denial, negativity, choice, tentative acceptance, and commitment. Leadership can either facilitate this emotional process or ignore it at the peril of the improvement effort. My biggest learning was recognizing that quality and patient safety improvement is only as strong as it’s weakest human relationship link.


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Hugh MacLeod retired as CEO of the Canadian Patient Safety Institute (CPSI) in 2015. Currently, he is an Adjunct Professor, University of British Columbia, School of Population and Public Health


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