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I decided to learn more about quality improvement (QI) after burning myself out as a busy family physician.
I was working with patients with complex needs. I wasn’t feeling like I was giving the kind of care I wanted to give. Like a lot of my colleagues, I was working from a perspective of extreme scarcity. I felt like I was in competition for resources with other teams within my system. My education as a physician didn’t give me the information and skills I needed to improve. I felt disempowered.
I had been working on an improvement project that I was fumbling through. My hospital takes care of many patients who live on the margins and carry with them layers of complex trauma. Staying on a hospital ward can be especially anxiety-provoking for them. I was fixated on an idea to text patients to provide them with orientation and emotional support, but it didn’t have enough alignment within my organization. The direct care staff didn’t understand what I was doing. I couldn’t get any momentum going.
I realized that I was trying to engage teams who were burnt out just like I was. We couldn’t see a future where things were different.
One of my mentors, Curt Smecher, had gone through IHI’s Improvement Advisor program. He told me about the IHI Improvement Coach program. He suggested that the course would be a good opportunity to learn how to lead the development of a QI culture in my community.
"I Don’t Fix Problems"
Learning how to run effective meetings might sound mundane, but consider how many hours a week many of us spend in meetings. How many of them are productive? How many of them make progress or clarify issues? How many unite people to address a common purpose? Even if you don’t have to attend many meetings, think about how those that are poorly run waste your time. And who has time to waste?
The coaching course taught me how to make every meeting a high-value meeting, so I don’t miss opportunities to engage people in improvement. I learned how to design meeting agendas that facilitate interpersonal connection and build trust within the team. I learned how to make sure that I evoke and elicit the wisdom from every person at the table. I learned how to work toward engagement and meaningful buy-in for a change idea. I learned that, as an improvement coach, I don’t fix problems; I help create the environment to empower teams to fix a problem.
Practical Tools and Techniques
The basic agenda I used to have for meetings was to review the minutes of the last meeting and then get down to business. My thinking was, “We only have 90 minutes. We’re going to do this and all of you are going to agree and then we’re going to move forward.”
Now, my meeting agendas include ways to build psychological safety. One way to build psychological safety is to use participative techniques to make sure people feel heard, like using multivoting. After a group has listed different change ideas on big pieces of paper on the wall, I give every participant five colored dots. Each person places their dots next to the ideas they like. They can distribute their voting dots evenly or vote more than once for their favorite idea. This allows a team to prioritize and rank order key change ideas without excluding others. It’s a very democratic way to do this kind of accelerated decision making.
Just as your meeting agenda and decision-making process can create a more empowering environment for an improvement team, so can the tools you use to facilitate meetings and conversations. My favorite tools are known as liberating structures. You can use them to generate ideas while you’re in the process of building the team, getting engagement, and building relationships.
My favorite liberating structure is adapted from an activity called the TRIZ. You start the discussion by asking the group an unexpected question: “What are the things we can do to make sure this project fails?” This question catches people off-guard, but in a good way.
In my current project, for example, we’re working on addressing the opioid crisis by encouraging family physicians to prescribe opioid agonist therapy medications to prevent withdrawal and reduce cravings for riskier opioid drugs. These are physicians who are hesitant about prescribing opioids and unsure of how to care for patients with complex issues.
We use the TRIZ to kick off the brainstorming process. “How can we fail at taking care of people with challenges with substance use?” This question prompts lively discussion that leads the group to develop multiple change ideas. For example, in the “fail” category, a team member suggested, “We ensure that all family doctors harbor intense negative stigma towards any one struggling with opioid use disorder.” This led our team to develop a ground-breaking trauma-informed practice learning experience that we’ve delivered to family doctors over 30 times locally and on the provincial level in British Columbia. It’s a multi-pronged approach to making medical clinics feel safer and more welcoming to those who suffer from psychological trauma.
Why We Do What We Do
When I encountered resistance before, I would tell myself, “I’ve got to push harder. I’ve got to work more hours.” Now, I have a much more strategic approach to the barriers that I face. Using quality improvement science combined with coaching skills, I’m able to rally teams together to work toward aims that matter to patients. At the end of the day, every person on the team got into this work to help patients and we need to do it together. The days of the singular hero are gone. Health care quality improvement is a team sport.
It’s an amazing feeling to watch people you coach make progress. There’s nothing else like seeing the sparkle in their eyes when they say things like, “My team is engaged now. Last month, we were stuck, but now we have these great ideas. I see passion within the nurses, pharmacists, and doctors. We’re getting somewhere.”
I came to quality improvement suffering from burnout. Understanding the science of quality improvement helps improvers like me find joy in work and stay well.
Lawrence Yang, MD, is a family doctor in Surrey, British Columbia at Fraser Health, a health authority in British Columbia, Canada.
You may also be interested in:
The Improvement Coach Professional Development Program
5 Practical Strategies for Managing Successful Improvement Projects