Improvement is a team sport
There was a buzz in the air as the six teams participating in the INSPIRED Scale Collaborative gathered March 7 and 8 in Ottawa for an interactive workshop. Fresh off launching the expansion of INSPIRED, the workshop focused on giving participants the knowledge and tools they need to equitably reach more providers, sites and COPD patients in their transition from hospital to home.
An opening panel on patients and families as essential partners in driving improvement informed the two days. Sue Johnson of Ottawa, who has COPD and has benefitted from the Ottawa Hospital’s COPD outreach program, shared her experience working in partnership with Wendy Laframboise, program lead at the Ottawa Hospital and clinical lead faculty for the collaborative. “The COPD outreach program has really improved my life,” said Sue. “I wanted to take charge of my condition, so I worked with the team to learn strategies to manage my disease.”
Sue Johnson, a patient with COPD, shares her experience with the INSPIRED program.
Sue’s experience demonstrated some of the gaps in coordination for COPD patients; she endured an eight-month wait to see a respirologist after being diagnosed with the disease. “My very first flare up happened as I was waiting for a respirologist. At the time I had little knowledge on the disease,” said Sue. “Every time you have an exacerbation it takes a piece of your lung. So, the sooner you can get the knowledge to make the proper decisions, the better.”
Improvement is a team sport
Over the two days, the importance of teamwork was a recurring theme for the 80 participants – including faculty, stakeholders and team members. Each INSPIRED improvement team brings together members across different organizations in roles such as team leads, executive sponsors, and patient and family partners to name just a few. For many, having the opportunity to network and learn from one another was the most valuable aspect of the workshop.
There was significant patient participation in the workshop and agreement about the crucial role of patients and families in powering improvement. “We need to stop seeing patients as recipients of care and start seeing them as full members of the team,” said Dr. Brendan Carr, President and CEO of William Osler Health System. As Sue Johnson elaborated, “I was a business person and I had a lot to offer in my career – that’s not going to end. I value being here today and being able to learn and contribute; it’s part of my quality of life.”
By embedding patients and caregivers in their improvement teams, the adopters are building on the example of Dr. Graeme Rocker and his colleagues who founded the INSPIRED COPD Outreach program™. “INSPIRED is all about building relationships between providers and patients where one didn’t exist before,” explained Dr. Rocker.
The workshop also welcomed staff from partner organizations – including Canada Health Infoway (Infoway), the Canadian Institute for Health Information (CIHI) and the Canadian Thoracic Society (CTS) – who are delivering content and supporting teams.
It’s all about relationships.
According to Lynn Edwards, Senior Director of Primary Health Care Family Practice and Chronic Disease, at the Nova Scotia Health Authority, because teams are social entities, achieving better team performance rests on building relationships. “It’s about our relationships,” said Ms. Edwards. “We can have all the plans, but if we don’t have the fundamental, connections, working relationships and trust we likely won’t succeed.”
Building relationships with physicians is crucial. For Dr. Michael Gardam, Chief of Staff of Humber River Hospital and a veteran of hand hygiene campaigns, the reasons are rooted in the science of complexity. Spreading and scaling INSPIRED is a complex problem. With simple problems such as baking a cake or medical equipment sterilization, you can follow a recipe that has been standardized because all the variables are known. With more complex scenarios like firing a rocket or surgery, it will take more expertise and there are more moving parts, but it’s still possible to eliminate contradictions, and to standardize, and specify paths and policies. But spreading INSPIRED is more like raising children: there is little role for formulae; there is no guarantee of repeat success; expertise helps, but is not sufficient; relationships are key; you cannot separate the parts; there are unknown variables; and each child (or INSPIRED site and team) is unique.
How do you figure out a complex problem?
- Act and learn at same time
- Work with paradoxes
- Go slow to go fast
- Build generative relationships – source novel solutions by getting people into a room
- Nibble away at the problem
- Determine minimum specifications or simple rules — what are the things that are critical and can’t be altered and what can flex?
- Build on what grows
“We’re not building a wheel, we’re building something complex and people may need to build it with you.” said Dr. Gardam. “You need to engage at each step. We want them to feel ownership and investment, not just buy in.”
Dr. Gardam’s simple tips for engaging doctors:
- Engage early and with people who want to talk to you. Get to others later, likely through their peers.
- Travelling slide decks rarely engage.
- Doctors are illogical as everybody else.
- Build relationships.
- Invite unusual suspects to the discussion – cast the net widely.
- ‘Champions’ rarely go by job title.
- We all have different motivators, don’t assume they’re the same as yours. Moral indignation doesn’t work.
- Try engaging differently (using techniques such as TRIZ).
Don’t scale the program, scale the impact.
The six teams have already reached more than 2000 people with their INSPIRED-like programs and plan to reach up to 2300 more over the next year through their scale efforts. Scaling consists of expanding the reach of a program or model to all the providers, sites and patients who could benefit in a defined jurisdiction. But scaling innovation isn’t as simple as plugging and playing: expanding across the delivery system requires partnerships and greater integration, creating an enabling environment that addresses policy considerations and system attributes.
And scale isn’t just about adding more, it can also involve strategic subtraction: what can you do less of to reach a bigger range of people? “Don’t ask how you’re going to scale the program,” said Dr. Onil Bhattacharyya, INSPIRED faculty and Harkness fellow. “Ask how you’re going to scale the impact.”
Dr. Onil Bhattacharyya, INSPIRED faculty and Harkness fellow, shares his thoughts on scaling INSPIRED.
Data is an important piece of the scale and improvement puzzle, enabling teams to recognize when an approach is (or isn’t) working and pivot if needed. Participants acknowledged there are currently some gaps as they look to scale their COPD programs - a lack of cross-sectoral data, too many manual processes, and lags from the time the data is collected to when it’s available for decision-support. One strategy suggested by Dr. Bhattacharyya is to find ways to gather early metrics, through surveys and other methods, acknowledging that it may not be perfect.
Recognizing the importance of data, CFHI is partnering with CIHI to support teams in evaluating the impact of their scale efforts. Staff from CIHI were at the workshop to discuss standardized data definitions across all teams. CIHI’s expert support will help teams continue to build capacity and processes to ensure data and reporting are a part of their standard operating procedures for INSPIRED as well as any other quality improvement work that they undertake.
We’re not building a better caterpillar.
The importance of the work being undertaken through the INSPIRED scale collaborative wasn’t lost on workshop participants. Maria Judd, Vice President of Programs at CFHI, reflected on the impact already achieved by the six teams, saying: “Our results show that we can redesign care with, and for, people with chronic conditions to better meet their needs in the community.”
“The fundamentals of this program are the fundamentals of what we need to do to improve healthcare in this country,” added Dr. Carr. “You’re creating a methodology that we’re going to lever for congestive heart failure, diabetes, mental health and more.”
Putting the scope of this health system metamorphosis into perspective, Ms. Judd drew inspiration from the natural world: “A butterfly is a transformation, not a better caterpillar.”
Cathy Simpson, spiritual care practitioner and co-founder of the INSPIRED COPD Outreach Program™ summed up best the importance of workshops like these. “It’s so strange that you have to come to Ottawa to really get to know your team,” said Ms. Simpson. “It’s humbling to sit in Ottawa and see the expansion across the country and think of how many people’s lives we’ve touched.”
Teams participating in the INSPIRED Scale Collaborative share their ideas and experiences with one another.