Healthcare Quarterly, 15(1) February 2012: 6-7.doi:10.12927/hcq.2012.22775


Asking the Unaskable – Thinking the Unthinkable

Hugh MacLeod and Steven Lewis

Posing questions and critically examining the current state of affairs across the spectrum are essential to large-scale quality improvement. The questions we are about to pose are not intended to be gratuitously provocative; they must be addressed to get an accurate assessment of where the system is gridlocked, which interests are aligned or misaligned with a quality agenda and what measures must be taken to move forward. Moreover, the great majority of the questions will come as no surprise to those experienced with the system's dynamics and frustrated by the inability to act.

If we want to accelerate change and improve performance on a larger scale, we have to do things differently. We means the principal actors in the system – governments, regulatory agencies, organizations, boards and senior managers, professional groups etc. All have either legal or moral authority to demand and promote quality care; some have both. Collectively, we have the power to make healthcare accountable for quality and to implement policies and practices that are fully aligned with a quality agenda.

A major obstacle to progress is the failure to ask ourselves the wicked questions that will lead to a deep exploration of assumptions we make. Without exploring our assumptions, we will continue to be hostage to our indifference to failure and be unable to reach our improvement potential. Exposing these assumptions can be both uncomfortable and a relief. It is uncomfortable because the conclusions we draw and the beliefs we adopt based on our assumptions often seem to be "the truth" – obvious, acceptable and defensible. They guide us to do and say "the right things." By engaging people in dialogue, wicked questions invite exploration into inconsistencies in thought that have held us back from achieving our purpose, and can be used to promote a search for local solutions to organizational challenges.

This opinion piece poses questions to the main protagonists.

The Role of All Health System Players

  1. Do we play it safe by setting easily attainable goals? If so, why? Do we treat vision and mission as noble ideas that we ignore in our everyday actions? If so, why?
  2. Do we bury or spin bad news to avoid internal and external transparencies that could provide a compelling case for change, and suppress truth in the organization? If so, why? Do we congratulate ourselves based on short-term results achieved at the expense of long-term sustainability? If so, why?
  3. Do we ask ourselves this key question: What behaviour have I tolerated in myself or others that conflicts with my commitment to patient safety and quality of care?

The Role of Governments

  1. To what extent do legislation, high-level policy documents, accountability frameworks and funding mechanisms incorporate quality targets and expectations? Has government signalled that quality is a core value and aspiration? Are these expectations enshrined in effective legislation, regulation and policy?
  2. Once quality-enhancing tools and techniques have demonstrated their value, is there a strategy to ensure their spread throughout the system within as short a time period as possible?
  3. Have governments communicated to regulatory, licensure and accreditation authorities the importance of making quality a core expectation and requirement?

The Role of Accreditation, Regulatory and Licensing Bodies

  1. How robust are the quality requirements and practices? Are there meaningful sanctions and remedies in the event of substandard quality performance?
  2. Do licensing and accreditation bodies require practice audits, feedback and responses at the individual and unit levels in healthcare organizations?
  3. Do professional licensing bodies incorporate quality principles, tools and techniques as part of their core knowledge requirements? Do licensing bodies require continuing education on quality enhancement practices as a condition of continued or renewed licensure?

The Role of Organizational Governance

  1. Do boards make it clear that the adoption of quality improvement practices is a core expectation? Do they drive improvement beyond the requirements of government and external accreditation, regulatory and licensing bodies? Is quality a core element of boards' own continuing education and professional development agenda?
  2. How do boards articulate their quality goals and expectations? How do they communicate their commitments to their organization? What information do boards request and receive on quality performance and issues? What do they do with this information?
  3. To what extent are board resource allocation priorities and decisions focused on improving quality?

Health Science Education Programs

  1. Do health science education programs require that practicum and apprenticeship sites be committed to a quality improvement agenda and model behaviours consistent with a quality culture?
  2. Do health science education programs emphasize inter-professional collaborative practice and teach quality theory and practice from the perspective of teamwork and inter-dependency?
  3. Do health science education programs ensure that students acquire information technology skills and view the analysis of clinical data as fundamental to their professional development?

Health Services Executives and Managers

  1. When quality incidents occur, are there formal processes for turning them into learning opportunities? Does the organization walk the talk of a non-blaming culture that seeks lessons for improvement from quality incidents rather than perpetrators to punish?
  2. Do organizational leaders invest adequate resources to support quality improvement? Does the culture signal that improvement is a core organizational value and an integral part of front-line work?
  3. Are there processes in place to identify and address unjustifiable variations in practice? Are clinical peers jointly accountable for overall performance within their control? Are all clinical occupations equally valued and integrated into the quality improvement culture? Do measurement, evaluation and feedback systems focus on team performance and processes?

Professional Cultures and Values

  1. What is the hierarchy of values among professionals? Does quality trump other professional values such as autonomy and group loyalty? How is clinical autonomy defined, and is it consistent with a systems view of quality and accountability?
  2. Are professionals concerned about broader unit or organizational performance? Do they view variations in practice as inherent danger signs? Are they willing to adopt proven practices and standards in service of better performance?
  3. Do professionals perceive advanced health information gathering and analysis as core elements of their identity? Do they advocate for an information-rich environment and embrace performance measurement as a prerequisite to improvement?

In Closing

Every element of what we set out has been uttered a thousand times in cafeteria conversations and behind-the-back lamentations. Care is not about the role of health system players: government; accreditation, regulatory and licensing bodies; governance; education programs; health services executives and managers; healthcare providers … To quote Don Berwick, "Care is interaction among our assets and between assets and patients. To perfect care, we must perfect interactions" (2002: 51–52). Let's begin the open, honest and probing conversation. To paraphrase Pogo, we have seen the root cause, and it is us.

About the Author

Hugh MacLeod is the president and CEO of the Canadian Patient Safety Institute.

Steven Lewis is the president of Access Consulting based in Saskatoon, SK.


Berwick, D.M. 2002. Escape the Fire: Lessons for the Future of Healthcare. New York: The Commonwealth Fund.



Michelle Purdon wrote:

Posted 2012/07/05 at 06:23 PM EDT

Very welcome "wicked" questions, you two. Many thanks for such a clear piece of thinking and speaking. I particularly like #3 in your first set and plan to use it soon at an all leaders forum in our health system in BC.


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