Peter Lachman, left, with representatives from the 18 teams in the QI Programme, the Mozambique Ministry of Health, and Irish Aid.
I have been involved in quality improvement (QI) all my career, though the true start date was in 2005. Though I was an experienced leader and previously served as a deputy medical director, I did not have the formal training to give me the theoretical background and methodologies to complement the managerial work I was doing. Though I was managing high-risk services and there were numerous patient safety incidents, in those days — and it was not that long ago — improvement science and patient safety approaches were not widespread.
It was in 2005 that I became a Health Foundation Quality Improvement Fellow with IHI in the US. The fellowship exposed me to leaders in the field from around the world. I learned a number of lessons which have served me well on my quality journey, including as Deputy Medical Director for Quality at Great Ormond Street Hospital for Children (London, England) and now as CEO of the International Society for Quality in Health Care (ISQua), a member-based, not-for-profit community based in Dublin, Ireland.
I’d like to share six key ideas I’ve learned over the past 15 years while working with people in various parts of the world:
- Have a vision and keep it simple. At Great Ormond Street, we took the Institute of Medicine’s six domains of health care quality and turned them into a vision to which people could relate: No Waste, No Waits, Zero Harm. This was well before the concept of zero harm became popular, and it allowed us to aim high. It was simple, direct, and relevant to children and their families as well as to health care providers.
- Learn by measuring. We need to make it easy to measure where we need change. Start counting, without making it burdensome, and then study the process you are measuring. Too often, we do not have an aim because we don’t know the process. An example of this is the National Acute Stroke Collaborative in Ireland, which has just been completed. By studying the process, identifying the order of steps and areas of possible delays, we were able to redesign stroke care to decrease door to decision time (from arrival at the facility to decision to admit) from over 4 hours to 30 minutes. This redesign varied in each context.
- Use the best approach for your team. People often ask, what is your method? Though I was trained with the Model for Improvement in the US, I believe that it is but one approach to improvement science. Use whichever of the different methodologies — Microsystem, Lean, Six Sigma, Quality Control Circle, etc — works best for the situation. Just keep it simple and remember testing via a process like Plan-Do-Study-Act cycles is central to all.
- Care for the people who care for others. Person-centered care starts with caring for the people who provide care to others. In other words, we need to treat our staff in the same way as we want them to treat their patients to enable them to be person-centered in their own work. “Hello, my name is” and “What matters to me” campaigns will not work if we do not know the names of our staff and what matters to them.
- Respect and empower your team members. In all the projects I have been involved in — and I supervise and advise over 30 projects a year — one needs to respect the current way things are done and build on the dedication of health care providers and the hope people have in their work. Only then will one see results from change. An example of this is the work we have been part of in Mozambique, where the participants chose 20 projects with support from the Ministry of Health. Subsequently a national QI network was developed. The people themselves were a key resource in this work and we respected their efforts to improve and deliver care in the community in the face of constraints. Even when there is limited funding or resources, innovation and change can be found in the people if they have the right knowledge, the ability to build a network, and a voice to share success and challenges, in keeping with ISQua’s core values.
- Remember to learn as much as you teach. It is easy to fall into the trap of coming into a new setting and telling people what to do, especially when coming to a low-income country from an upper-income country. In Mozambique, we started with solutions from earlier work in Australia and adapted them to fit the local context. Later, these adapted solutions were taken from Mozambique to Ireland and the UK for further teaching and intense learning in turn. As an example of these types of exchanges, when teaching the foundations of improvement methods, one needs to begin with previous successes, look at the local context, and then customize and improvise for the current situation.
I started learning some of these leadership lessons in Cape Town, South Africa where I trained early in my career. For this reason, I believe many of the solutions to addressing QI problems in Africa will come from African clinicians sharing ideas and knowledge with each other. ISQua’s 36th International Conference (October 20–23, 2019 in Cape Town in partnership with the Council for Health Service Accreditation of South Africa and Mediclinic International) and the 2020 IHI Africa Forum on Quality and Safety in Healthcare in Johannesburg will offer two opportunities for this kind of exchange with people from around the world.
Dr. Peter Lachman is the CEO of the International Society for Quality in Health Care.