Profiles in Improvement: Enrique Ruelas, MD, IHI Senior Fellow

Publication Date: September 2011

Dr. Enrique RuelasEnrique Ruelas, MD, MPA, MHSc, served as Secretary of the General Health Council of Mexico for almost five years, a position that is similar to the US Surgeon General. Previously, he was the Mexican Vice Minister for Innovation and Quality in the Ministry of Health where he oversaw the modernization of Mexico's health care system using supply chain techniques that radically improved service levels and also resulted in significant cost savings. Dr. Ruelas was responsible for the design and implementation of a comprehensive, country-wide quality improvement strategy and he led a prospective analysis on the future of the Mexican health care system. Prior to his government posts, he gained widespread entrepreneurial and academic experience, and he is an expert on health care quality and managing health care systems. He is Vice-President of the National Academy of Medicine, to become President; President of the Latin American Society for Quality in Health Care; Chair of the Latin American Consortium for Innovation, Quality and Safety in Health Care (CLICSS); and Senior Fellow at the Institute for Healthcare Improvement. Previously Dr. Ruelas served as President of the International Society for Quality in Health Care, Founding President of the Mexican Society for Quality in Health Care, President of the Mexican Hospital Association, Program Director of Health for Latin America and the Caribbean at the W.K. Kellogg Foundation, and Dean of the National School of Public Health of Mexico at the National Institute of Public Health. He has published seven books, over 60 articles, holds a number of honorary positions, and has lectured extensively worldwide.

 

Q: What was your path from medicine to quality improvement?

Right after I got my MD, I decided what I really wanted to focus on was the health of populations, not on individuals. So I got my masters of public administration in Mexico and then my masters in health administration in Toronto in 1984. Studying in Canada gave me an interesting perspective: I was really impressed by all the resources available to hospitals there. They were very well equipped and were performing very well. At the same time, the Canadian federal government issued a law saying that within three years all hospitals in Canada would have a quality assurance program (at the time, the buzz word was “assurance”; we didn’t yet speak of “improvement”).

As I watched this, I thought about our situation in Mexico. At the time we were dealing with one of the worst financial crises in our history, so hospitals lacked almost everything; they were really struggling. And my concern was: How come these people in Canada, who have so much available to work with, are concerned about quality… while we in Mexico, who are lacking almost everything — exactly the time when we need a strong focus on quality — are not even talking about it?

So I decided that when I returned to Mexico I was going to work on quality. And I did. I came back in 1984, I started to talk about quality… and nobody knew what I was talking about.

Q: Can you describe your career path from there?

In 1984 I was appointed head of planning at a tertiary care teaching hospital, where my main activity was to implement a quality assurance program. I started by developing quality standards — at the time we didn’t have standards in Mexico. So I gathered nurses, doctors, residents, and administrators to help me do this. The input I got was eye-opening; they had all kinds of complaints: “We don’t have this,” or “Our children are having these problems,” or “We have a problem with that kind of patient.”

This process seemed to open a space for “catharsis.” I started to document what they were telling me, thinking about how we were going to systematize all of these experiences. I was taking these steps toward building a foundation for quality.

Around this time I happened upon a book on “quality circles” in Japan. While I was reading it I thought. “Gosh, it looks like I’m doing something similar, without knowing it.” So I baptized our hospital’s quality assurance initiative “Quality Circles” and imported some of the methodology from this book.

I moved next to the Center for Public Health Research, where I focused on converting my hospital project into an action research project. I had the good fortune to meet for the first time Avedis Donabedian (a public health pioneer, considered the “father of quality in health care”), who was a member of a council of the Center and had travelled to Mexico for a Center conference. He listened to my presentation, “Quality Assurance in a Mexican Hospital,” where I presented my activities and our results. He said to me, “I don’t know what you’re talking about, but this is not quality assurance.”

I had a lot to learn! But actually it turned out that the work we were doing with hospitals in Mexico was the first implementation of the quality circles methodology with doctors and nurses — as opposed to ancillary personnel such as kitchen staff, facilities workers — worldwide.

That’s how I started. And since then I’ve been working on quality improvement all my life.

I then became Dean of the School of Public Health, where I implemented the first formal program of quality improvement in health care in Mexico. I was also invited around this time by the Kellogg Foundation to open a Latin American office based in Mexico. My next position was with the Mexican Health Foundation. When I was hired, the chairman, who was the former minister of health in Mexico, said to me, “I know you’re very interested in quality, but we have our own agenda, so you won’t be able to work on quality here.” And I said “Okay, I understand, but just give me permission to follow up on a commitment I already have: the international ISQua meeting [International Society for Quality in Health Care] is coming to Mexico City in three months — I’m the Chair of the meeting.” Well, I invited him to the meeting, and he attended. And at the end, he said to me, “Listen, you can do whatever you want with quality. This is a very important topic.”

In 2000 I was invited by the incoming president of Mexico and the incoming Minister of Health, Julio Frenk (who is now the dean of the Harvard School of Public Health), to become the Vice Minister of Health. Julio had been a student of Avedis Donabedian — he was very keen on improving quality of care. So he said to me: “You’re going to be the Vice Minister, but you can do whatever you want.” So I titled myself Vice Minister for Quality and Innovation.

I was very fortunate to have this trust and flexibility, because it allowed me to restructure the whole vice ministry and launch what we called the “National Crusade for Quality” campaign, a comprehensive national strategy to improve quality of health care. I choose the name “crusade” because in Spanish crusade means an effort aimed at a very high level — truly ambitious, with the highest of goals and aspirations.

The strategy included many things: we strengthened a system of accreditation, developed codes of ethics for health professionals, and patients’ rights. We set up a series of quality indicators to be measured, and we systematically implemented them with individual organizations, one-by-one, and with groups of facilities. We ended up with 6,000 facilities reporting on about 17 indicators, in both patient satisfaction and technical quality. We also trained 60,000 people in a period of six years on quality improvement tools.

We also went into communities to partner with groups and individuals, through a strategy that I called “citizen endorsement.” We would ask residents who lived near a community’s health care center, for example — even youngsters on the local football team — to join the program and establish their own citizen endorsement group. They would receive some training in using a questionnaire we developed, and then go into the medical units themselves and assess how they were doing. We ended up with about 2,500 groups all over the country working with us — it was a fascinating experience, involving the community in improving quality.

In 2006, I was invited by the new Minister of Health and the new President of Mexico to become the Secretary of the General Health Council, which is equivalent to the Surgeon General. I continued my focus on quality of care. One responsibility of the General Health Council in Mexico is equivalent to The Joint Commission’s role in the US; so I was in charge of accreditation. Another responsibility I had — again closely tied to quality — was oversight of the National Formulary of Drugs and Technology Assessment.

So, that’s my journey, through August 31, 2011.

Q: How did you connect with IHI?

At the end of the 1980s, as I was moving more into the international arena, in part through an article I published on our “quality circles” project in Mexico, I was invited to join the International Society for Quality in Healthcare. I attended their meeting in 1986 in Copenhagen to share my experiences working with hospitals and at the Center for Public Health Research. That’s where I learned about Don Berwick [founder and former President and CEO of IHI].

Shortly after that, I met Don and Paul Batalden [IHI Senior Fellow] at a major foundation meeting, and I was really impressed. Over the years I always stayed in touch, following what IHI was doing. I also attended several Forums in Orlando [IHI National Forum].

 

Q: So what led you to join IHI?

I got a great phone call from Don Berwick in 2008, inviting me to a meeting in Bellagio to analyze how to implement quality improvement in Africa. I was the only one from Latin America invited to that meeting, and I had a chance to explore these issues along with Maureen and Don and the whole team. That was when I began to think seriously of leaving my government position.

Working closely with IHI is a dream for me. I’ve always admired what you’ve done; you have positioned yourself as the leaders of the world of quality improvement in health care. For 11 years, in my government positions, I was focused only on my country; I was not able to devote time to other regions and issues — even though I am President of the Latin American Society for Quality in Health Care. My new role with IHI gives me the opportunity to do this, to refresh my international vision.

Q: What are your plans and goals for your work as IHI Senior Fellow?

Everything started with a meeting in December 2010 in Mexico City, convened by IHI and the Latin American Society for Quality in Health Care, with funding from the Carlos Slim Health Institute. My main concern at the time was that many countries in Latin America had been working for years on quality improvement, accumulating knowledge and experiences — but none of it was shared. The other motivation behind this meeting was IHI’s intention to increase its involvement in Latin America. Both goals coincided: IHI wanting to help in Latin America; and, within Latin America, groups wanting to work together on quality.

For many years, Latin American health professionals have seen IHI as the leader in the world. But for those who do not speak English, it can be hard to approach a US institution; to attend the National Forum, for example. So I am now very enthusiastic because of the approach that IHI is taking toward Latin America — toward the whole world, including developing countries.

I see my role as bringing people together. We created a structure called the CLICSS. I chose this name deliberately: in English, it’s the “Latin American Consortium for Innovation, Quality, and Safety in Health Care” but the Spanish translation is the Consorcio Latinoamericano de Innovación, Calidad y Seguridad en Salud — CLICSS. I wanted that name because my role will be to facilitate clicking:  making clicks between individuals, health care professionals, patients, health care organizations, and potential funders.

So far the members of CLICSS include IHI as the core; and the Latin American Society for Quality in Health Care; URC [University Research Corporation]; the University of Murcia in Spain; and the Avedis Donabedian Foundation, in Spain as well. And we are inviting other organizations.

We designed CLICSS as a set of circles with IHI as the nucleus. Then we will have expert organizations and individuals, such as the Latin American Society for Quality in Health Care and URC. We also want to bring in strategic organizations like, for example, the World Bank, the Inter-American Development Bank, the Pan-American Health Organization, and the Carlos Slim Institute. These are organizations that can provide either financial resources or political resources. The last circle — the main aim — will be health care providers, who will be involved through specific projects.

One of the first things happening through the CLICSS network is to develop 25 IHI Open School Chapters — to start with — in Latin America by December 2011. And the IHI team [with help from volunteers from around the world] is translating Open School courses into Spanish and Portuguese — there are 10 in Spanish already. Another goal is to host a Latin American Forum on Quality Improvement in 2012. Pedro [Delgado, IHI Executive Director] is working really hard in this direction, and I am enthusiastic to work with him on this project. I will also be very focused on helping IHI develop a Quality and Innovation Center (QIC) or Centers in Latin America — a concept I learned of through Maureen [President Emerita and Senior Fellow] in 2010.

There is a lot to do, and I am very excited about the opportunities. As for the specifics: I will still be based in Mexico, but I’ll be working with IHI one week a month, coming to Cambridge or traveling to other countries in Latin America to promote and implement QICs.

Q: How do you think IHI can be instrumental or effective in improving health care quality and experience in Latin America?

I think IHI has three advantages that will help very much to make a difference in Latin America. One is your technical know-how. You have a lot of information, in the US and other countries, on what can be done to improve quality. The second characteristic is credibility and leadership. Even if an organization could get the kind of experience and expertise of IHI, without the kind of credibility and leadership that IHI has, it could not do much.

And the third advantage I would describe as a respectful attitude toward others. We in Latin America are very sensitive to that; we don’t like anybody else to come and say, “You have to do this and this and this.” And the approach of IHI that I’ve seen through the years is a very respectful approach, which means understanding others, being compassionate to others, and learning from others. This is the image of IHI in Latin America — and it’s a valuable asset when you’re trying to bring change.

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