Saskatchewan's Health Quality Council (HQC) was launched in 2003 with a mandate to not only measure and report on healthcare but also work with a range of partners to improve the province's health system. In late 2007, HQC's board decided it was time for Saskatchewan to reinvent its healthcare system, using the highest-performing systems in the world as its model. And in 2008, HQC launched Accelerating Excellence, a multi-level program to rethink, redesign and renew healthcare.

To help maintain momentum and show other provinces whether high-performing healthcare can be achieved in Canada, HQC is documenting its journey. This fifth article in this series discusses the incremental steps needed to effect and sustain change.

Like instant gratification? Don't look for a job in quality improvement.

"It's hard. It's one of those jobs where you never go home and think, 'I have done everything I could today. My desk is clear,'" admits Felecia Watson, director of quality improvement and strategic planning for Sun Country Health Region in Southeastern Saskatchewan. Instead, Watson finds herself struggling daily to choose among dozens of Sun Country activities that would benefit from a systematic quality improvement exercise. That's because Sun Country, like all the health regions, is taking part in a province-wide effort to create a high-performing health system that's safer and easier to deal with for patients, and more effective and efficient.

Accelerating Excellence, as it's called, is led by Saskatchewan's Health Quality Council (HQC). Modelled after the approaches that have led to successful reinventions of health systems in the United States, Sweden and England, Accelerating Excellence promises to give "people working at all levels in our health system … the knowledge and tools to overhaul our system's current piecemeal collection of disparate parts into a co-ordinated quality-focused system." It's a multi-level effort to rethink and renew healthcare through a variety of programs – including Quality as a Business Strategy for leadership teams, Releasing Time to Care for nurses and the Quality Improvement Consultant program. It blends several approaches to improving quality, notably W. Edwards Deming's theories of management and Lean (based on Toyota's methods for eliminating waste and increasing efficiency).

All the business approaches have at their core the principle that efforts to improve quality can never stop. Fortunately for Watson and others, they also promote some practices to make that a little easier: you must follow a standard structure for every initiative, with a charter to guide you; gather and review data to measure progress and assess changes; make extensive use of flow diagrams, charts and other tools to understand the context and impact of what you're doing; and start small. (Sun Country, for example, is testing a program to detect chronic kidney disease early in just one clinic, though staff plan to spread it throughout the region.)

"There is so much I would like to do, so much information, so many groups having priorities. It's exciting, but it's hard," Watson says in an interview in her office in Weyburn (the region's headquarters). This is her second spell of working in quality improvement; she started in it 15 years ago. She says Deming's theories have changed the work by shifting the focus from individual projects to building leadership for change and encouraging commitment to improving care at every level. "We did great projects, but there was no spread and they often weren't sustained," she explains.

Sustaining improvements and spreading them through the system are keystones of quality improvement. Probably the only more difficult aspect is the principle that problems and their solutions must be identified by teams of people directly involved (rather than a planner removed from day-to-day operations). Dedicated specialists are often needed to guide teams through the processes of improvement science and make it meaningful to people at every level of an organization.

To help create those specialists, HQC began its Quality Improvement Consultant (QIC) Program in 2007. The year-long program (which will be compressed into nine months starting in 2011) promises to teach participants how to define quality problems, understand and use quality improvement tools and methods, help teams with their projects and plan for spread and sustainability. It's a demanding program in which participants work on a quality improvement project from their own organization, while attending four workshops and five "webinars," and regularly connecting with faculty and other participants.

Mark Pettitt, Watson's predecessor in her job, was the first Sun Country staffer to attend QIC school. He jokes about "the curse of Lean," whereby anyone who has studied its methods can't go anywhere – not to a restaurant, not to a store – without seeing wasteful work design everywhere and itching to fix it. Pettitt is now Sun Country's regional chronic disease prevention and management coordinator, working on (among other things) a detection program for early chronic kidney disease. He found using measurement to improve quality the most compelling aspect of QIC; the chronic kidney disease detection program has just started testing patients for vascular disease and many more people are being referred for anti-embolism stockings and other types of continuing care. Measurement, Pettitt says, is showing that "in the past maybe these people weren't getting the help they needed. They were perhaps just living with the pain." Previously, he continues, people were often found to need dialysis even thought they had no previous record of kidney disease. With this new, early-detection approach and proper care, however, they may never need dialysis.

Sun Country also sent Heather Tant, regional director of primary health and rehabilitation, to QIC. She wanted to learn more to help in her role as a sponsor – the person in a quality improvement project who allocates resources and helps overcome barriers. She was particularly anxious to learn more about how to work with teams, but doesn't think QIC's intense training is necessary for everyone.

"Involvement in any QI project helps people develop the skills," she asserts, citing the region's part in a national campaign to increase handwashing to fight hospital-borne infections. The people who worked on that project had to do small tests of innovations, check them with Plan-Do-Study-Act cycles and take process and outcome measures. But staff do need to be clear that the old way of doing business has changed for good, and that continuous quality improvement will be the norm from now on, she continues. "People don't resist the idea improvement is needed … if they don't already know something can be done to improve care, you show them the evidence and they say, 'You're right, let's go.' But then the hard work begins."

Julie Johnson, director of quality improvement for the Regina Qu'Appelle Health Region, says she was "desperate for knowledge" when she started her job in 2005 and took every learning opportunity HQC offered, including the first session of QIC. She and her staff had been working hard with quality improvement teams; but before she went to QIC, they weren't systematic about what they did, and didn't offer guidance on either methodology or sustaining projects. "Honestly, we wouldn't have been able to describe what we did for a living," she recalls in her office in Regina. "We were jacks of all trades."

Now, their roles are much clearer. She reckons about 20% of their effort goes to actual technical improvement and the other 80% is spent providing quality improvement methods to teams leading change. They include understanding the psychology of how change affects people, and why some people are quick to embrace an idea but others aren't. ("There's a lot to be learned from late adopters," she notes.) The job requires negotiating skills, to get teams through tough spots, and supporting front-line workers.

It helps, Johnson says, that quality improvement is quite intuitive, once staff understand the processes they believe are helping patients may actually be putting them at risk, and need to be rethought. Part of her work is therefore aimed at implanting a "nugget of knowledge" that will make Regina Qu'Appelle staff at every level sufficiently aware of quality issues to be uncomfortable when they come across a problem.

But how likely is it that humans – mostly creatures of habit – will adopt a work ethic that demands they question everything they do and regularly change it for the better? Change, after all, can create a lot of work for already-busy people.

That's where focus on the patient helps, according to Bonnie Brossart, chief executive officer (CEO) of HQC. "It is added work," she acknowledges, "but if you approach it from a position of service, it's the most important work you can do." She says quality improvement requires "a constant state of humility," of awareness that we can do better and openness to learning, rather than the default position of assuming the way we do things is the right way.

It also takes constancy – of leadership, at every level, and of time and resources. Time, Brossart says, is a question of priority, but letting quality programs fall victim to funding cuts could just be an easy way out of difficult work.

Developing and maintaining leadership for quality improvement, she admits, is a huge task. In quality improvement, leadership doesn't just refer to senior management; it's a characteristic needed at all levels to create change. Nevertheless, Accelerating Excellence is struggling with concerns that some CEOs are not supportive enough – concerns particularly heard from front-line staff in the Releasing Time to Care program, which actually dictates which senior managers should visit a ward and how often. Maybe they are visiting but not connecting with the staff, Brossart says, or maybe they're afraid of being asked questions they can't answer. She states that CEOs believe they have to be able to answer every question; but in quality improvement, questions may be the best way to open a conversation.

David Fan, who is CEO of Prairie North Health Region, admits he was a bit slow to support the Accelerating Excellence program. A 30-year veteran of healthcare administration, he felt he'd always worked hard to deliver quality healthcare and could not see what he now calls "the imperative to change." But the province made quality improvement programs mandatory, and he learned Lean methods and about Releasing Time to Care. "For me, those were truly powerful … if I could wind back time, I would have done both a long time ago," he admits. Fan has got a dozen Lean projects on the go now, which he calls "a dozen bright lights for change." Prairie North already had architectural drawings for a new emergency room in Lloydminster, but then Fan called for a Lean review. After the Lean study of workflow and use, the plans had to be redone (the ward has not yet been built). Another Lean initiative ended demands for more storage and more carts for linen; once those involved had done a Lean redesign of the laundry, they got rid of 40% of their inventory, and with it the need for more space and more transport.

Now Fan is giving Lean methods their biggest test so far: he's using them to find $5 million in savings he'll need to balance his budget next year. "I could easily have just done a slash and burn," he admits. So far, he and the team have cut 30% from the overtime budget. It's more work than shutting down beds and laying off staff, but it's worth it, he says.

As for Releasing Time to Care, he wishes he'd been able to put it onto every ward where he ever approved additional staff because of work pressures. He's keen on it for another reason too – it's a great way to show all 3,000 Prairie North employees the tremendous benefits of quality improvement.

And they do need to see benefits. "The reality is, if the staff don't understand it, don't embrace it, we can't make a whole lot of progress," he states. "We have to create an environment so that they can understand and embrace the changes."

Fan acts as the facilitator at every Lean initiative, and often hears from employees that no one's ever asked them before how their job could work better. "The old way was, 'I tell you policies and practices; your job is to comply, and my job is to enforce compliance,'" Fan explains. "Now, my job is to say, 'What do you feel is the problem and what are the solutions?' I think that's very meaningful."

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