Insight: In Conversation with Ben Chan
With credentials from Princeton, Harvard, Stanford and Toronto, numerous leadership awards, clinical appointments that criss-cross Canada and a growing track record in health system quality and public policy, Dr. Ben Chan is the inaugural chief executive officer (CEO) of Ontario's Health Quality Council (OHQC). No stranger to the complexities and challenges of the Canadian healthcare system, Dr. Chan has participated in most of its niches and corners, giving rise to his thoughts about quality, quality improvement and system performance. He shared his comments with Ken Tremblay just after moving into his new niche at OHQC in November 2007.
HQ: You were the inaugural CEO of Saskatchewan's Health Quality Council. What lessons learned from that experience will shape your leadership and mandate at OHQC?
BC: First, we have to be clear about what we want to accomplish, and that is to drive quality improvement through the entire healthcare system. In the past, quality improvement was a sequence of quality improvement projects. While that has been true, we are at the point where we have to find new ways to ensure that these initiatives connect to strategic and systemic goals.
The most important lesson is the whole concept of alignment. We need to pick topics for quality improvement that align province-wide goals with local priorities and that resonate with providers on the front line. That requires relationship building, dialogue and negotiations. Quality improvement gains for the system are far better if we can achieve that alignment. As well, we're better off working on a small number of areas but going deep - finding high-priority topics that affect the health status of large populations and where there is a large gap between current and desired practices.
There are many ideas for improvement and leading practices that have not been implemented in a systematic fashion. We need a campaign that represents a coordinated strategy from the front line right to the boardroom. In Saskatchewan, chronic disease management was an obvious choice where we could achieve huge gains through systemic approaches. The obvious ones were coronary artery disease and diabetes, but others included depression and arthritis.
HQ: How will health quality councils be able to improve the quality of care in a province where other agencies haven't been as successful? What will be different?
BC: There are a number of areas where health quality councils can be highly influential. One is the notion of facilitating consensus on key improvement priorities and aligning strategies among stakeholders. More importantly, health quality councils need to do this in a way that allows players in the system to take collective ownership of the quality agenda. The health council alone does not own the [entire] quality agenda.
HQ: How do you plan to approach the general public so that the person on the street will benefit from your reports and findings?
BC: Health quality councils in Ontario and Saskatchewan have dual mandates - to report on quality of care to the public and to support quality improvement. Patients and the public need to be engaged in quality improvement processes. Every quality improvement team should have patient input. Rather than picking up a report on gaps in quality, we want the public to think about ways it can contribute to overall system improvement. That could be anything from better management of their own chronic condition to signing up for quality improvement teams with their provider's quality improvement activities.
HQ: How should policy makers utilize the mandate and expertise of health quality councils? What do you see as your advocacy role?
BC: Do I need to answer that one? [laughs] The only reason I hesitate is because it's a question to which there is no clear answer right now. Let me put it this way: in the course of doing quality improvement activities, it is inevitable that one will identify policies at the government, hospital or local level that support or impede the progress of quality improvement. When that happens, the quality councils could potentially play an important role in identifying possible areas for improvement.
HQ: How will you access data and information sources so that the quality council can focus on quality and safety? What data do you intend to leverage?
BC: We have huge gaps in our capacity to measure information about quality. Most of our data is on utilization, which doesn't truly reflect quality. The other challenge is that much of our information comes in too late, often a year or two after the fact, which is inappropriate for quality improvement. Quality councils can play a leading role in identifying the types of information needed for managers and quality improvement teams. With an e-health strategy emerging in Canada, we have to ensure that information technology is seen as a tool supporting quality improvement rather than an end in and of itself.
HQ: What would you hope would be your legacy as the first CEO of OHQC?
BC: To work closely with all the key players in the system and, most importantly, the public. I would like the entire healthcare system to breathe, eat and think quality in everything it does.
HQ: As inaugural CEO, what will be the focus of your first year? What do you hope will be early wins for the council?
BC: We're in the middle of our own strategic planning process. The first part of a new CEO's mandate is to get out there and listen to both people who work in and people who use the healthcare system. I want their comments about the most critical roles that the health quality council can play in supporting quality improvement - that feedback will form the basis of our current strategic planning process.
At the same time, I'll be exploring with potential partners ideas for implementing some of the key elements of a quality-focused system. Those include governing boards focused on quality and a robust measurement system that gives real-time information on quality to quality improvement teams and managers. I would like to see deep skills in quality improvement science embedded throughout the healthcare system and a limited number of high-profile, large-scale quality improvement initiatives tied to broad provincial goals and strategies.
HQ: If quality healthcare outcomes tend to be linked to critical mass or economies of scale, any thoughts about how large and small jurisdictions will compare, e.g., urban versus rural, small versus large provinces, north versus south, etc.?
BC:Let me answer that in a couple of ways. We all know that there are variations in quality of care. But often there is not a consistent pattern between smaller and larger institutions. Certainly there are some procedures that clearly demonstrate a very strong correlation between quality outcomes and higher volumes. In other instances, for example, when it comes to patient or staff satisfaction, smaller places consistently outperform larger institutions.
Yet, there are opportunities to improve for both. Smaller settings can be important testing sites for innovation because they're less complex settings.
HQ: Improving quality in the health system - including its providers, professions, organizations and policy makers - is a daunting task. How do you plan to build the bridges you will need with these many stakeholders?
BC: I'm going to go back to a point that I made earlier. It's extremely important that quality councils build strong working relationships with key providers in the healthcare system. It has to be done in a way that works for the people in the system, those who are served in the system and all who share a strong sense of ownership in the quality improvement agenda. They have to feel that [change] is not being imposed on them but that they internally feel [it] is the right and absolutely essential thing to do. Only then will you truly see a culture change. Only then will you begin to see a culture focused on quality throughout the system.
Secondly, we have to do more than just education. Education and conferences, while important, are not going to drive quality improvement by themselves. We need to set strategic goals and specific targets for improvement throughout this system, goals that everybody in the system can agree upon. Educational events, conferences and training courses need to be hooked to specific targets. We need to have real-time measurement of our targets and tailor our strategies and educational activities that help us meet the targets.
Our Spring 2008 Report of the OHQC will have a special focus on chronic disease management. When we release the report to the public, we want to pitch it in a way that engages the public about what they can do about chronic disease management and quality improvement. Soon, our website will list quality improvement tools and other resources for quality improvement teams. Later, we will include tools for patients, information on how they can be engaged in the quality improvement agenda. Discussions are already under way with different healthcare organizations about how we can work together on quality improvement.
Discussions are also under way about what we can do together to support teams that need coaching and mentoring, and knowledge about quality improvement science; boards of directors about quality measurement; and the design of information systems that will support quality initiatives.
HQ: You have won several leadership and innovation awards. Which one stands out the most for you, and why?
BC:The award that had the most sentimental value for me was the Distinguished Alumnus of the Year Award from my alma mater, Victoria College, University of Toronto. As a student, I became involved in the student government. That experience taught me many lessons about the power of what you can achieve when you work constructively with people.
HQ: Thank you, Dr. Chan, for your time and comments.
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