If you want to go far, go together

A little extra can go a long way.

This is the philosophy that guides the Canadian Foundation for Healthcare Improvement’s flagship Executive Training Program (EXTRA). By building leadership and organizational capacity, EXTRA opens a door to change and transformation in the status quo of a stagnate Canadian health system.

This month, CFHI spoke to Shoba Ranganathan – Chief Quality and Patient Safety Officer, Canadian Armed Forces (CAF) and one-quarter of the CAF team from EXTRA’s cohort 12 – about their improvement journey.

EXTRA and the Canadian Armed Forces Team Photo

How it started

The Canadian Armed Forces team’s improvement project was born out of a need to make their Periodic Health Assessment (PHA) more clinically meaningful and improve the overall health of their patient population. 

“As a military organization, we have to ensure that our patients, the members of the Canadian Armed Forces, are fit for operational purposes such as deployments and exercises,” said Ranganathan. The PHA assesses operational fitness once every five years until the age of 40 and then once every two years after that for all CAF members.

Feedback from CAF staff and patients showed that the current PHA process did not adequately address its four core mandates: health promotion, assessment of occupational exposures, operational readiness and diagnosis of ongoing medical issues.

“Furthermore, it was identified that certain aspects of the PHA are not evidence-based nor does the PHA lend itself to the development of good performance measures,” said Ranganathan.

The CAF team’s improvement project will take an evidence-based approach to develop a new health assessment that addresses the policy requirements while concurrently developing performance measures to illustrate this fact.


Ranganathan explained that the CAF specifically chose the EXTRA program to help them develop their improvement project because of the format.

“The delivery of EXTRA is unlike most other quality improvement projects. The interactive blended-learning model and expert Canadian faculty the program offers is an experience second to none.”

For Ranganathan, becoming part of a pan Canadian community of leaders dedicated to improvement was also very important. EXTRA provides a focus on leadership as well as quality improvement that is allowing her team to build much needed capacity within the CAF.

It’s all about teamwork

The CAF team is made up of two physicians and two administrators from three locations across the country. Although the team aren’t physically in close proximity, they have been using virtual means for collaboration and discussion. Each member brings a different strength to the team and they are continuously learning form each other as the project progresses.

Ranganathan emphasized the importance of having physicians as part of the team.

“Clinical leadership in improvement activities is essential. Improvements happen when clinicians play an integral part in shaping clinical services because they gain a sense of accountability in achieving a shared purpose to deliver high quality care.”

Without clinician involvement, decisions on how to improve or what to change are made without their expertise or experiences. According to Ranganathan, quality improvement efforts need to fully engage those that are closest to the processes – the ones that deliver the care.

The improvement journey

The CAF team – which has been a part of EXTRA’s cohort 12 since April this year –  are currently midway through the curriculum, having completed the first and second modules consisting of E-learning and webinars as well as an eight-day residency session in Montreal, QC.

“We have scoped and defined the aim of the improvement project, identified the key measures that will help us know if we’ve achieved our aim, and we are beginning to plan our small tests of changes.”

For Ranganathan and her team, the EXTRA residency session in Montreal was invaluable. The face-to-face interactions with peers, colleagues, and faculty combined with the ability to take a hands-on approach to improvement and take part in an extremely positive learning environment allowed them to advance their project, knowledge and capacity to the next level.

A little bit EXTRA

EXTRA’s hands-on approach allowed the CAF team to take a step back and better understand the problem they were trying to address in order to develop a more comprehensive improvement project.

A major component to the EXTRA program is working alongside coaching staff and faculty, which Ranganathan said is one of the most beneficial aspects.

“Improvement initiatives can be daunting, so having expert coaches and faculty help us along the way is invaluable. As one of the faculty had mentioned in their presentation during the Montreal residency session: if you want to go fast, go alone. If you want to go far, go together.”

The CAF team was able to benefit from bilingual aspect of the program as well, by having the ability to get different perspectives on issues, processes and tools. EXTRA’s diverse nature of participants and their experiences make it unique.

Among the many tools and insights the CAF team has been exposed to during EXTRA, the Driver Diagram has been the most helpful.

“Being able to clearly express the theory or logic behind why you are pursuing an improvement initiative and how you intend to do so is important. Often we rush to implement solutions without even defining the problem.”

The Driver Diagram allowed them to start with a defined process that aligns the initiative with the larger goals of the organization. It’s been so useful in fact, that Ranganthan hopes to use it throughout the CAF organization to better define their strategic goals.

As the program’s finish line moves into sight, there is now a great interest in seeing the results of EXTRA’s structured program on the CAF’s initiative within the Canadian Forces Health Services.

“With the expected success, we hope that this will be the way the organization progresses with change initiatives and potentially could be a model for other organizations with the Canadian Armed Forces and Department of National Defence.” 

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