Building Improvement Into the DNA of Healthcare Systems

Why This Episode Matters

Quality improvement in healthcare is still too often treated as a series of isolated projects—well-intentioned, time-limited, and disconnected from daily operations. Despite decades of progress, this approach struggles to sustain change, reach every patient, or address equity at scale. This episode explores why that gap persists and what it takes to move from episodic improvement to system-level capability. It’s especially relevant for clinical leaders, quality executives, and educators trying to build improvement that actually lasts.

The Arc of the Conversation

This conversation traces Dr. Brian Wong’s journey from early exposure to system-level problem solving to his current role building quality improvement capacity across institutions. Rather than focusing on tools or frameworks, the discussion centers on how improvement becomes durable—through structure, relationships, education, and operational integration. What makes this episode different is its emphasis on how systems learn, not just how projects succeed.

Key Ideas Explored

• Why project-based QI has a ceiling: Small, local projects can teach skills, but rarely sustain impact or scale across populations.
• Improvement without operations doesn’t last: QI efforts fail when they sit outside day-to-day workflows and resourcing.
• Structure shapes outcomes: Structural change creates the conditions for new behaviors and results to emerge.
• Equity requires system design: Improvement efforts can unintentionally exclude patients unless equity is embedded from the start.
• Education as a force multiplier: Building improvement capacity through training is foundational.

Takeaways for Quality Leaders

• If improvement feels fragmented, ask whether your system is optimized for projects rather than learning.
• Notice where QI work depends on individual heroics instead of organizational support.
• Reflect on whether equity is treated as a separate initiative or built into how improvement is done.
• Consider how much protected time and infrastructure exist for people to improve the system they work in.
• Ask whether your organization is building capability or repeatedly relearning the same lessons.
• Pay attention to how improvement work is aligned (or misaligned) with operational priorities.

Publications & Frameworks Explicitly Mentioned

These are named in the transcript and are often things listeners may want to look up:

• SQUIRE Guidelines (Standards for QUality Improvement Reporting Excellence)
• Equity-focused QI scholarship
  • “Equity in action: a scoping review and meta-framework for embed

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Transcript

Why Projects Miss Patients

SPEAKER_01 0:00

I think if we're being very honest with ourselves, a lot of quality improvement still excludes a lot of patients and still fails to benefit a population of patients. But once you embed the improvement work into operations, then it does have the potential to impact every patient that walks through the door. It has the potential to be resourced and supported by the day-to-day functioning of the organization.

Early Career And Med Rec Origins

SPEAKER_00 0:33

Welcome to Leading Quality, the podcast spotlighting the people moving healthcare forward from the front lines to the C-suite. I'm your host, Jason Meadows. Quality improvement in healthcare is often taught and experienced through individual projects, small, focused efforts to make care better. And those projects matter. But over time, many leaders start asking a deeper question. How do we design systems where improvement isn't episodic but continuous? I wanted today's guest on the podcast because he spent a career living inside that question. Not just studying it, but building the structures, relationships, and capabilities that allow improvement to take hold in real clinical environments. Dr. Brian Wong is a general internist at Sunnybrook Health Sciences Center in Toronto and the director of the Center for Quality Improvement and Patient Safety at the University of Toronto. His work spans frontline care, education, research, and system partnerships, from training hundreds of clinicians in quality improvement to advancing equity and improvement science to stewarding the international Squire Guidelines. In this conversation, we talk about how early exposure to system-level problem solving shaped Brian's career, what he's learned about integrating quality improvement into operations, and why structure and relationships matter as much as methods, especially in moments of crisis. Dr. Brian Wong, welcome to the show.

SPEAKER_01 2:16

Thanks for having me. I'm excited.

SPEAKER_00 2:17

Yeah, thank you. I've been really looking forward to this conversation, getting to speak with you again. It's been a few years since we've spoken. You've worked at the intersection of frontline clinical care, quality improvement, and education for a long time. And I want to know how you first got pulled into this work.

SPEAKER_01 2:36

I did my clinical training here in Toronto as a medical student and then eventually a resident at the University of Toronto. And so when you are a resident here, you tend to rotate around different hospitals. And so I spent a year, my second year at Sunnybrook. And then I subsequently became the chief resident here in 2006. And for the longest time, I really thought that I was going to go into the area of medical education in a more traditional sense. I was interested in teaching students, teaching residents, uh clinical medicine. I had thought that maybe I would one day become a program director and maybe, you know, be involved in helping to organize a training program in internal medicine. And then I had this experience where one of the faculty members at Sunnybrook was working on this new initiative that was really pretty uh forward-thinking as it related to medication safety. And I don't think I knew that at the time, but I remember distinctly being at rounds and they were presenting on this idea. They had done some research and had very recently published a paper that showed that there were these unintended medication discrepancies at the time of admission to hospital. And so, of course, now we all know that to be uh the driver or the underpinning rationale for why we need medication reconciliation. But back then in 2004, 2005, it was really not recognized that that was even, it had never been quantified. And some what the colleagues, it was actually the colleagues that or supervisors at Sunnybrook, they're now colleagues, but back then they were my supervisors, who had done the research to establish that there were actually a large percentage of patients who were experiencing these unintended medication discrepancies at the time of admission to hospital, and that a subset of those actually had important clinical consequences. And what was really neat was I went to rounds that day, and the individual who was leading that research had was giving rounds, but it was a very different type of rounds than I had attended before because the content, the talking was very brief. And then what he really wanted was our feedback on a new tool he was developing. And this tool was a sheet that would go into the paper chart that would document as best as we could what the patient was taking at home prior to coming to hospital, and indicating next to the medication what our intended plan was, whether we were intending to continue it, to stop it, to adjust it. And essentially, I think we were, as residents, part of the first discussions around Med Rec and a tool to do best possible medication history, you know, at the very outset. And I'm sure there were other hospitals working on similar types of initiatives at the time. I learned later on that that work that was done informed practices globally around medication reconciliation, which is really kind of like a neat thing that I learned afterwards. But in the moment, I was just like blown away by this idea that we were actually contributing to making the system better for patients in the moment. And I still remember that one of us said there's no box for the allergy documentation on this form. And so the next week they came back and they actually showed us a new version. The form had actually been updated with our feedback. And I was like immediately I thought, and like this is kind of an area I was very intrigued by. And so when I became chief resident, I decided that I wanted to make my scholarly focus around trying to improve some aspect of resident experience related to paging communication. And so that was the project that I took on. And at the time we only had numeric pagers, and I wanted to do a pilot to introduce alphanumeric paging to provide the residents with more information when they were being paged so that they could triage their time to call back. So I won't go into all that detail, but that's sort of how I became interested in quality improvement. I think it was because there was someone who was doing interesting work that I wanted to emulate and they were a really positive role model. And so I saw also the power of um exposing learners to these concepts early as a way to direct them towards pursuing this in their future careers.

SPEAKER_00 7:14

I can I can put myself in the minds of our audience right now who have probably a lot of experience with MedRec, you know, electronically and how how big a part of the conversation that is. And as I'm hearing this, I mean, it must be so cool now to reflect back on I was there when, right? As you say, may not have been the only place in the world doing it, but was certainly some of the earliest seeds of this concept. Was it framed explicitly as as QI? And at what point did did that, did the concepts start to be kind of more explicit for you? And and uh, you know, this became more the flywheel started going, as it were.

Training For Authentic QI Expertise

SPEAKER_01 7:54

Yeah, so I don't think at the time, because at the time there really wasn't this idea that we should even be talking about quality or quality improvement in our residency training. You have to think this is 2004. So, you know, if you were in the US, the ACGME would have just included you know, introduced practice-based learning and improvement and systems-based practice, or sorry, yeah, and systems-based practice, you know, core competencies in 2002. The Royal College CANMES requirements were were nowhere near having introduced those requirements. Those were introduced in 2015. And so it wasn't framed explicitly as quality improvement or patient safety. It was really just about trying to provide the best care possible, but doing it at a system level. But you could immediately sort of recognize this was something different, you know, as a learner. And I would say that though that experience of having been around people thinking about these problems in a different way and trying to solve them in a different way really piqued my interest. And so when I finished my residency, uh, this was in 2007, I actually took a six-month break and took some time off when my first son was born. And then uh coming back to uh work, I was faced with a decision that many early career folks are faced with when they finish residency: is what are you gonna do with your career? And uh if you want to pursue an academic career, what's gonna be your sort of academic niche? And uh I had had that experience implementing an alphanumeric paging system. I'd actually evaluated the impact on you know, sort of resident satisfaction, on interruptions. It was really just a descriptive, you know, study. It wasn't a quality improvement study per se. And so I thought, well, um, I really like teaching in education, but maybe rather than teaching about hyponatremia and heart failure and diabetes, maybe what I'll do is I'll teach about quality and safety. Because by then it started to, you know, become a thing. And uh so I met with the chief of medicine at my site, and I met with the chair as one does to try to, you know, let folks know that you have an interest in an academic job. And the chair at the time uh connected me with uh who now has become a very close friend and mentor, Kave Shajania. So many of your listeners will know Kaveh as being the editor emeritus of the BMJ Quality Safety Journal and really like a thought leader in the field. And so he happened to be uh they were they were recruiting him to come to Toronto. And so as part of his recruitment tour, he was asked to meet with different people, and I'm sure it wasn't his like top choice to meet with me, but I was fit into his you know recruitment schedule as I guess someone who uh had an interest in quality and safety and would he be willing to meet. And I still remember sitting down with him and saying that I was very interested in quality and safety and I wanted to teach others about it. And he asked me a very pointed question, which I think is you know, I and he he doesn't mind me telling the story, I don't think, but he asked me, so then tell me what's your experience with quality and safety? What have you learned about it? What's your training been in that area? And I talked about my project that I'd done as a chief resident, and you know, I think he what he said was, no, but really, like what expertise do you hold in this field to be able to teach others? You know, if I had to be honest with myself and honest with him, I didn't have a lot of expertise. I had a lot of lived experience doing a project, but I hadn't learned the theory, I hadn't learned any of the concepts, and I hadn't applied any of them. And so his advice to me was if you're gonna be, if you're gonna teach about this area, you need to become, you need to develop some expertise and content knowledge around quality and safety. And so that's what I did for the better part of two and a half years. He took me on as a postdoctoral fellow in quality and safety. I actually became the first postdoctoral fellow at the Center for Quality Improvement in Patient Safety, where I'm now the director. And I trained up. Now there weren't master's degrees back then, or there were, if there were a couple, but you had to move away, and I wasn't prepared to do that. And so I did uh a I cobbled together a few different training experiences and surrounded myself with really smart people who would supervise me through a couple projects. And I really learned, I tried to learn about quality and safety in a very deep way. And um, it was really the best thing, best advice I ever got because it allowed me then to have some authenticity around the teaching that I was doing in this area.

SPEAKER_00 12:50

It sounds like this was a major inflection point in your career. Were you, while being a fellow, you were doing more projects, kind of gaining, you know, gaining the academic experience and bridging that with the lived experience? And what did those projects look like?

Three Foundational Fellowship Projects

SPEAKER_01 13:07

Yeah, so I had three projects that I did during that postdoctoral fellowship. So the first was related to paging errors. So I built on my paging work, and so we had um identified that one out of every seven pages sent to a physician in the hospital was actually sent in error, sent at the wrong time, sent to the wrong person. And because we had the text message information related to those pages, we actually were able to adjudicate the criticality of those pages and determine that I can't remember the exact number, but it was something like 40 or 50 percent or something like that of the pages were uh of an urgent nature, or 30%, some meaningful number, let's say. And so my one of my projects was actually uh implementing a like very, very garden variety PDSA, like you know, QI project using all the QI methods to reduce that from one in seven to one in twenty over the course of nine months. So I really felt like I cut my teeth with that project, and we eventually published uh the findings. The second project was that I had an interest in developing a curriculum in quality and safety. And so, as part of that curriculum development process, I was we were taught that you needed to do a literature review to know what was already known about the topic. And Kave, you know, rightly pointed out if you're gonna do that review, why not do it in a slightly more rigorous way and and and and do it as a systematic review? So then my second project was a systematic review, and I learned systematic review methodology, and that's methodology that I still carry forward to this day. In fact, I had a meeting today about a systematic review we're planning on a new topic. So that was really helpful. And then the third project was actually related to computerized order entry systems, and they were just starting to be implemented in Canada, and I was interested in knowing how it affected the educational experience and the learning around uh prescribing. And so uh for that project, I learned how to use qualitative methods. So it was a lot of it was an interview-based study. So, you know, it was a combination of um uh exploring different aspects of quality and safety, but also learning different methodologies. And so I came out of the postdoc having learned some qualitative methods, uh, systematic review methods, and also like actual bread and butter QI methods. And then I learned how to write a paper or two, and I also learned how to write a grant, which was very helpful as well.

SPEAKER_00 15:48

It sounds like you got a really rich footing in in both the academic and the practical camps, which I think is is an area that maybe QI more broadly struggles with. There's some people who err much more on the research side and much more on the practical side. Fast forwarding a little bit, you've since written that sometimes QI as a series of projects maybe isn't enough to move things forward. I wonder if there's a moment where you started to realize that that QI as a series of projects wasn't enough.

Limits Of Project-Only Improvement

Pivot During COVID And LTC Support

SPEAKER_01 16:22

Uh it's hard to know if there was a moment. It feels a little bit like there was a gradual evolution of that understanding. And and just to be clear, I'm not sure that there aren't circumstances where sort of smaller microsystem projects aren't helpful or beneficial. There are many circumstances where I do think that they're still incredibly valuable, right? If you're a you know a provider or a clinician and you're working in your own practice, you might want to still do small-scale projects because that's the scope within which you work. I think for people learning to do improvement work for the first time, you know, taking on a tangible, small-sized project is really helpful for learning purposes, right? So I don't want to say that it's not useful. It's just that there's, I think, uh a ceiling effect to what can be achieved from an impact perspective. And I do think that one of the things, the several things that sort of smaller scale projects suffer from are one, they don't integrate well sometimes, right? So sometimes you have a whole bunch of small-scale projects happening in the clinical environment, and it can create a lot of noise and chaos, right? For you know, so if you happen to be a clinician or a nurse or a provider working in those environments and you have multiple projects going on, but they're all on different topics, that can feel very disjointed. And I think we all know that this is a time when uh clinicians and providers are are feeling quite kind of overwhelmed by workload. And so, you know, we have to be very careful about how we introduce change. Um, the second, though, is that when we think about QI as a series of time-limited projects, you're sort of building in structurally a lot uh challenges around sustaining the change, right? So probably the experience that I think back to now that's been most transformative around this air this thinking has been when we were faced with this dilemma uh when I had taken over as the director for the Center for Quality Improvement and Patient Safety. And two months in, so I took over in January and of 2020. And so, of course, two months in, we all know uh what happened in March of 2020 globally. And we were faced, I was faced with this dilemma. I was just about to start strategic planning. I actually planned a sabbatical to do some leadership training, you know, and of course the COVID 19 pandemic hit. And um we were faced with this challenge around trying to figure out how an academic unit could contribute to supporting the health system's needs. Because, you know, when you think about it, we're a publicly funded entity, and so at a time when it was truly all hands on deck, what was our role going to be? And uh so we made a decision to halt all routine operations. Of course, for us, it wasn't like at the scale of what entire health systems needed to do. You know, we weren't shutting down surgeries, but we were saying, you know what, we're gonna have to put a halt to all our training programs, we're gonna have to put a halt to some of our research that we were doing. And we were gonna take everyone that we had under our team's umbrella and said, okay, where can we direct our energy to try to make a difference, to try to make a contribution, to do whatever we could. So we had to make some choices around how we were gonna support those efforts. And one of the areas where we decided to invest a lot of time and energy was to try to support. Lend support uh in the area of long-term care. You'd say, well, that seems like an odd area for a general internist to sort of, you know, start to get involved. And it was. I knew very little about the long-term care sector. I knew very little about what it was to provide care in the long-term care sector. But we learned very quickly. When I look back to 2020, some of the most professionally rewarding work that I guess I did beyond direct patient care on our COVID unit, which you know, uh I, along with many others, did for about 12 to 18 months, was developing those relationships with long-term care providers to develop this new care program to try to support long-term care physicians, nurses, and other staff to be able to care for long-term care residents in place by bringing more resources into the long-term care homes, uh, whether it was medical expertise, whether it was access to on-site lab work. We even, you know, partnered with on-site diagnostic imaging. And we really created this opportunity for the long-term care providers to reach a general internist any time of day to be able to get uh some advice with the hope that we would be able to treat long-term care residents in their homes rather than have them come to the hospital. And at the time, you know, in addition to the long-standing downsides of hospital transfer, you know, frail uh increased uh delirium rates, uh, increased exposure to hospital-related harms, there were the additional pandemic-related concerns around the need to quarantine upon returning to the home. There were even some instances where people were being transferred, and then due to public health, you know, sort of regulations, they couldn't be transferred back to the home for periods of time. Like it was a very disruptive and uh and yet we knew that there was a huge amount of life lost in long-term care home, which was, I when I think about when we think look back, real very tragic, tragic and difficult outcome that we, I think, in many ways hope that we could have avoided. So it was a very complicated and a difficult time, but we were trying to do what we could. And what I learned through that experience was that um as much as process improvement's helpful, structural change is even more powerful. Creating structural change and putting in place new structures, changing old structures, and through that work, relationship building was just so important. And that in some ways, making those structural changes um creates the environment and creates the circumstances for um new outcomes to emerge. That was really the experience that we had, I guess.

SPEAKER_00 23:08

And one thing I wanted to make sure I understood clearly there was this halting of regular activities, mobilizing your resources for other projects. Are you talking specifically about the Center for Quality Improvement and Patient Safety? That's that's what we're talking about. Yeah. So I mean, I think that that uh is a great segue into just giving the audience a little bit more background about CQPs or the Center for Quality Improvement and Patient Safety. And and now that had history for uh I think a while before before you became involved, and then now you occupy that that director role. What can you kind of tell us about that? And then I'd love to get more into the work that you you do with with CQPs.

Inside CQIPS: Mission And Model

SPEAKER_01 23:51

Yeah, so uh maybe I I'll I'll just talk briefly about the history, which was it was established in 2009. It's what's called an extra departmental unit in at the University of Toronto. So the University of Toronto has a way of designating different units and departments, and so we're not um a formal clinical department like the department of medicine or surgery, right? We're X outside of those departments. So it's called extra departmental. And these units are established to address sort of an unmet need as it relates to um delivery of health care, the training of you know future physicians and health professionals. And so this center in 2009 was established in recognition of this sort of unmet need around quality and safety in healthcare. And interestingly, actually, in the in the beginning, it was actually called the Center for Patient Safety. So, actually, the what spurred the establishment of the center was actually a um a move around patient safety. And I think if for folks who are Canadian uh listeners on the podcast, because I know you have listeners all over, you know, the Canadian Patient Safety Institute was quite prominent at that time and still is, but they've kind of evolved into Healthcare Excellence Canada. But at the time it was Canadian Patient Safety Institute, and there was a lot of energy around, you know, even in the US, you know, to air as human and the thousand or the million lives uh campaign. A lot of that was sort of safety focused. And so I think the center was initially started as a center for patient safety, and then in 2013 it was expanded to really be a center for quality improvement of patient safety. Um and it was around that time I joined as a as the associate director. So I've been associate director at the center since 2013, and then I took on the director role in 2020. Um, and so uh we have um as uh our mission really uh to accelerate uh the work of people and organizations that are passionate about enhancing quality and patient safety. Um and we do that through a few different major areas of work. So um what I would say has been our foundation for many years has been education and training. So we uh provide education and training at multiple different levels, including uh at the certificate level. And we at for a while we contributed to um a graduate program as well. But I would say that the the kind of flagship uh training has been really around certificate level training for health professionals. And I think we are almost at 700 graduates from those programs, uh, and they work in you know healthcare organizations across Canada and uh and outside actually of Canada as well. We have a research arm. Uh so we do research in the area of quality and safety, and we have a few thematic areas related to uh equity and uh health system resilience. And as part of our research activities now, we've also taken on the oversight of the Squire International Writing Guidelines for Quality Improvement. And so this took place in 2023. And uh and I think what that's allowed us to do is um situate the SCORE guidelines within the University of Toronto uh and the Center for Quality Improvement and Patient Safety. And it's allowed us actually to have the uh opportunity to really influence how the field of quality improvement and patient safety is shaped with respect to practice. And so uh we are actually undertaking a revision to Squire so that a 3.0 version will likely be released in the next 12 months. We have a community building arm. So one thing that we realized is that there's a community of folks working in quality and safety all over now. Most hospitals, uh, most even outpatient settings will have quality, you know, quality improvement leads, medical directors, directors, you know, specialists. And so these individuals uh really often would benefit from having a community, a sense of community. And so we've been doing a lot of work that way. Uh, and then we have an arm related to what we call health system partnerships. And so some of the work that I mentioned earlier around long-term care, but we've been doing some work with Choosing Wisely Canada around unnecessary lab testing. We have a partnership right now with a number of groups working with Ontario Health to reduce delirium in hospitals. We have a partnership with Canadian Blood Services to uh improve organ donation referrals. So we have these involvements with different organizations to really try to support uh the implementation of change at scale. And as part of that health system partnership work, we've also started to work with healthcare organizations to do capacity building and consulting. So we actually will work with individual hospitals and health systems and train teams and provide coaching to them around their improvement work. You know, we're uh still a relatively small shop. We're eight or nine full-time, depending on how you count, uh, full-time staff members. And we have about 10 or 12 uh stipend-ended roles in different capacities, whether they're associate directors, research leads, and so on and so forth. We have a fellowship program. So we have some fellows every year that spend time with us. Um, and increasingly we've started having some students work with us as well. So um, yeah, so that's sort of the the in in broad strokes what we do, and happy to kind of go into more detail where you think your listeners would be interested.

SPEAKER_00 29:52

Yeah, I mean, that's uh that's a a big portfolio for uh for eight or nine people and taking on the as they tell me all the time.

SPEAKER_01 30:01

Yeah, we uh and uh yes, it the our team is phenomenal, really. And we always have to be careful we don't take on more than we can manage, but at the same time, there's so we're we're so blessed with opportunities to engage that sometimes it's hard to say no. For sure.

SPEAKER_00 30:18

And I'm wondering as I hear this, so I think a lot of listeners will be familiar with having like a quality department or or some kind of of center around quality improvement and patient safety in in hospitals as that's also becoming more common in in the US and and uh to some extent in Canada. But I'm uh you know I'm curious how much CQIP's kind of the work and the mandate is focused on Sunnybrook, where you're kind of located, versus how much is uh spreading the learning and the research more broadly, as you've said, with the students coming into the certificate program from all over.

Partnerships Across Four Hospitals

SPEAKER_01 30:57

Yeah, so actually I should have thank you for reminding me. So I should mention that centers like ours are uh funded through a partnership between the university and at least one of the affiliated hospitals. And so we're very fortunate that so while I work clinically at Sunnybrook, and I'm taking this podcast from Sunnybrook, my office at Sunnybrook, the CQIPS is actually a partnership between the Tamerty Faculty of Medicine and four affiliated hospitals. So we have uh Sunnybrook. So for your listeners that are aren't familiar, it's sort of a tertiary, quaternary care hospital that has a big cancer program, a big uh cardiac program, trauma. So that's one of our partners. We have sick kids, so the largest uh children's hospital in Canada, probably, but definitely Toronto. We have um Women's College Hospital, which is actually an ambulatory care hospital, and then just uh a few months ago, Michael Guerin Hospital, which is a community-affiliated hospital with a strong focus on equity and community-based care. So, what's been really fantastic about these partnerships is that each partner organization brings uh a unique perspective and expertise around healthcare, quality improvement, and delivery. And so our mandate is not actually to advance the goals and the priorities of our partners' hospitals per se. Uh, it's really to uh advance um our central mission, as I mentioned, around accelerating the work that people and organizations are doing in quality and safety across uh the Toronto affiliated hospitals. Uh, but we do that with support and in partnership with our partner organization. So each of our partner organizations, there's an associate director situated within that hospital that forms part of our leadership team. And we work very closely with other members of the organization to uh lead the work that we're doing. So while we are we don't have a direct mandate, we certainly are afforded lots of opportunities to collaborate with teams at our partner organizations.

SPEAKER_00 33:30

That's great. You have a lot of uh talented people to draw from. The the talent pool is is large.

SPEAKER_01 33:36

It's amazing. And the the generosity with which they're willing to contribute their time and expertise is not lost upon us at our center. You know, in many ways, for a center of our size and our our sort of resourcing to be able to have a large impact, in many ways, you have to draw on partnerships. It's like critical that we form partnerships with others and align ourselves with others who have a similar mandate or aligned uh strategic focus and to bring resources together to be able to uh enact change. I think we've been very fortunate uh in having the opportunity to partner broadly.

Education As A System Lever

SPEAKER_00 34:31

So you mentioned early in the conversation that education was where you saw yourself landing and and what a path it's been since then. But since that is so still so central to the work of CQIPs, and you've commented on almost having 700 graduates at this point, you know, how does this uh inform the the the current work? What is the the impact that you see with with the education now and moving forward and kind of what's most crucial to the the uh the success of the education side of things?

Baking Equity Into Training And Operations

SPEAKER_01 35:02

I have to admit, you know, when I had done, I had there was a period of time of five or six years where I was spending so much time around teaching in education and trying to work with others on setting standards, you know, for training, developing faculty, you know, development programs, that I was a bit worried that I wouldn't actually know how to do the improvement work, you know, that you could teach it, but you couldn't do it anymore. And there was a little worry that I had. And so I still feel like I can do the work. Uh, and I think that work, the the initiative around long-term care and a few other initiatives we've done recently have helped me to feel that I haven't fully lost that uh though that skill set. But what I would say is that we still see teaching and education as being core to our mandate. I do think sometimes teaching and education gets a bit of a bad rap in quality and safety. You probably have heard others say things like education is the weakest uh intervention or the weakest lever, or and it's a misapplication of the hierarchy of effectiveness, and I think it's a misunderstanding of the power of education when done well. You know, education is foundational to the work that we do, and I've seen the the power of training and and enabling people to be change agents um through education, uh, and I can point to so many different examples where that's been, I think, a very effective strategy for system change. And so I think we have an opportunity as we continue to train people to make sure we evolve what we teach to match where the field is going. And so one of the major things that we've done at Sequips in all of our training programs is embed a thread of equity throughout our training content. I think we always had a single session on equity. You know, you'd have a one afternoon was dedicated or a 90-minute session on equity, and we really try to embed the equity principles throughout the training so it's not an add-on, but really part of baked as someone said, is it you know, is it baked in? And we'd really try to bake it into what we're teaching people, and trying to understand what are the sort of approaches that are effective and studying it and trying to disseminate those learnings, right? Um, so that's one thing. The second is of course, um what I'm learning now is as you said, I've been trying to codify what it is that differentiates microsystem small-scale QI projects from some of that larger system change, that larger structural change. I've come to realize is that actually we really need to have the quality improvement work that's happening aligned and integrated with operations. That if and and maybe I was just really late to the game and coming to that realization, Jason, you'll have to be like honest with me to say like everyone knew this already, and Brian, why didn't you know? But it really kind of struck me that actually um embedding and integrating quality improvement work within the operations of the health system is really probably the way that we need to be moving if we want the change to be impactful. Right? Like so many quality improvement programs will be able to demonstrate uh improvement on a small scale for a uh a time-limited period. And then it's never clear whether that gets sustained, and often it's not. Or if it's not sustained, it's still not quite as restricted as research, let's say, where you're only enrolling patients that meet certain criteria. But I think if we're being very honest with ourselves, a lot of quality improvement still excludes a lot of patients and still fails to benefit a population of patients, right? But once you embed the improvement work into operations, then it does have the potential to impact every patient that walks through the door. It has the potential to be resourced and supported by the day-to-day functioning of the organization. So our most recent version of our one of our certificate programs, we actually now have three pillars that we're trying to embed. One is quality improvement excellence, so so excellence around quality improvement science, academic excellence, so the knowledge around how to disseminate your work, how to you know apply a rigorous scholarly approach, and then operational excellence. All with a thread of equity you interwoven throughout. So that's really how we've been thinking about our training now.

SPEAKER_00 40:07

Yeah, I I like and I wanted to lean into that through line that I'm hearing you say there about accomplishing equity more effectively by making sure that it's part of the operational DNA. Yeah. Since you have these relationships with the hospitals you mentioned, is that something that you you're helping in an advisory role or in a kind of direct role to coach hospitals on or try to integrate this operationalization of equity?

SPEAKER_01 40:39

Trying. I mean, I think that, you know, um, so we're trying to do it in a few ways. So one, if you were, if I put on my kind of nerdy research academic hat, well, we did a we did what lots of researchers do. We published a scoping review, but I actually think it's very helpful. We did us for publish a scoping review around how equity can be uh integrated into quality improvement work, and we developed a framework for this. And we're really trying to help organizations sort of learn and understand how to apply that framework to their local settings. So one of the things we have planned for the next year is to develop a toolkit around that work, right? And trying to use that framework uh as an underpinning sort of concept in our training programs. But more concretely, uh maybe I'll point to in you know work that's been happening at several of the hospitals in relation to professional interpretation uh for patients whose preferred language is not English. And I think that we have tried to identify quality improvement targets that are very equity focused and shine a light on these issues, work with organizations to recognize the importance of these uh as quality improvement targets. And again, it's not that people didn't see professional interpretation as an important service to provide, but using quality improvement as a way to increase the use of those services is uh is a strategy that we've been trying to encourage uh several hospitals to adopt. And I'm happy to say that I know of at least two or three major hospitals that have now actually more than doubled the use of their professional interpretation in the last 12 to 18 months by really applying bread and butter quality improvement approaches.

SQUIRE 3.0 And Equity Expectations

SPEAKER_00 42:33

Yeah, huge area and and probably underexamined. I wanted to say out loud a couple titles of publications here, just so I can then I'll be able to include them in the show notes more easily. But I think some of the ones you're referring to here are Equity and Action, a scoping review, and MetaFramework. Yep. That was BM BMJ uh quality and safety in 2025, and then taking action on inequities uh structural paradigm for quality and safety, also from BMJ Quality and Safety in 2024. So just since I've said them out loud, now they're in the transcript and I can uh put them in the show notes. Yeah, because I do want to link to that work, that's important. So now, I mean, the equity is woven into everything that you do, the education, the research side of things. And this has been, you know, a growing area of interest, maybe even before, but certainly since the IHI expanded its uh aim from the triple aim to the quadruple and then ultimately to the the current quintuple aim. Uh does this touch in any way the the work that you guys are doing with stewarding the squire guidelines and and bringing those, uh the new version 3.0 to the to the forefront?

SPEAKER_01 43:42

Uh absolutely. Uh absolutely. I am not to give too much away, but uh I think uh you could expect if you were to look at 2.0, um it's notably absent in terms of reference to equity-based approaches. And uh certainly we see that as uh an important uh addition to the next guidelines. I think how those get uh concepts get integrated in a way that reviewers will find useful uh in terms of uh uh adjudicating and assessing research. The one thing that I think many people also recognize is that the Squire guidelines are often used for teaching and project planning. Uh and so our hope is that this will also hopefully nudge the field both at the dissemination stage, but also at the project planning and execution stage. Um and I think one of the other areas that we have identified as as an area that we need to do more around that's very related to equity, is around you know, patient partnership and engagement. And I would say that that's an area where we've done some, you know, partnership and engagement, but really feel like we could do a lot more. And so I think for us, that's one of the major areas of growth that we're gonna be exploring in the next couple of years.

SPEAKER_00 45:06

Another example of of baking it in, right? If it's a if it's a framework that you're expected to apply when you submit to journals, then then that makes it all the more natural to uh you know to include and to see everything through that lens. So I mean CQIPS is is an exceptionally effective model and it sounds like you guys are doing just incredible work that I'm glad we're able to highlight today. And as we kind of think, I guess move our focus a little bit towards the future. If other institutions who aren't currently, who don't currently have a center like yours wanted to replicate the model of C Cribs, what would you advise them to do? And maybe what challenges or pitfalls would you warn them about?

Building Centers And Avoiding Pitfalls

SPEAKER_01 45:49

That's a great question. I I mean I I think it's really important to be very clear around what value would a new center bring to a particular uh institution. And in particular, this is a university-based institution. And so it has to be very clear from the university's perspective how the a center like this will help to achieve its mandate around better care and better health. And I think the I think the um University of Toronto has seen has been able to articulate that that link very clearly. But it's important for I think the leadership at the university level to be able to see that and and and believe in that. And and we've been very, very fortunate that in my time, there have been two different deans of medicine that have been in the leadership uh position. There was a third uh dean of medicine who was uh in in that position when the center was initiated, and all three have been extraordinarily personally in you know invested in kind of supporting the work that we do and very familiar with the work that we do. Uh, and I think that's just like so so important. I do think you need at least a small group of people that want to come together and work collectively towards something bigger and that want to start to form a community and build capacity. And I think the the question becomes okay, so what's the value add on the university side? I think you have to articulate that. And then what's the value add on the health system side? So, what is it a center like this brings that the health systems couldn't achieve on their own, right? And I think you'd have to interview our CEO and maybe some of the other folks around what they think that we bring. But I suppose on a very concrete level, if you were just to get started, one of the major things that universities do is they train people. We go to universities, you know, universities exist often as one of their core mandates to provide an education to the next generation, right? And so universities are very well suited to doing that. And so if you have a need to build capacity, and I think you and I both will recognize that despite the fact the field has evolved and grown and matured, there's a lot of turnover, there's a lot of need to train new people. And I still think that the number of people with quality and safety training, really advanced quality and safety training, is still far. I mean, I've invested interest in saying this, but I still think it falls far short from what we need.

SPEAKER_00 48:39

I guess that's kind of the genesis of my question. And I'm curious if there's ever been a conversation or if you guys have ever kind of thought about packaging, you know, the ideas and the framework that is CQIPs as a way to help people catalyze more CQIPs like organizations uh elsewhere. And again, they they do exist certainly, but I'm curious if that's been part of your discussions.

SPEAKER_01 49:04

It hasn't been a strategic focus, but we're certainly we certainly engage with other centers like ours and have partnered with them. We've partnered with one in Canada and a couple in the US, you know. But we have never seen it as our mandate to try and replicate a center like ours at other universities, I don't think.

unknown 49:28

Yeah.

SPEAKER_01 49:29

But certainly if other universities were interested, as they have been and want to reach out and discuss and share ideas, uh, we're definitely open to that. Because I think there is value that a center like ours could bring to other settings.

SPEAKER_00 49:44

Yeah. And they'd be better off for it. And you guys have enough on your plate, so I shouldn't heap more onto the agenda. From your vantage points, how has the the field of quality improvement uh matured over the last decade? And where do you think it's still falling short?

How QI Matured And What’s Next

SPEAKER_01 50:02

So I think that with the emergence of electronic health records, there's a lot more data now than there was 10 years ago. You know, the ability to access and analyze data and make sense from data, I think is very different than if I were to look 10 years ago. And I do think that the field is is more data-driven because we can be. I have seen a notable difference in the number of people who've been trained and who see quality improvement as their core work or part of their core work. That's different than 10 years ago. In our university, I haven't mentioned this yet, but several departments have actually made quality improvement a formal academic track. So in my home department, in the department of medicine, where I'm a faculty member, there are almost they they created alongside education and teaching and research a formal track for quality and innovation. And there are a hundred faculty members now in that track, right? That happened in the last 10 years. You know, 10 years ago, there was one 12 years ago, let's say. So I think you know, we've and there are more journals publishing on this topic, right? Not just dedicated QI journals, but clinical journals now publishing on this. There are more conferences that have a quality track in them. And it was interesting. I've seen the field evolve where we needed to hitch ourselves to a rising star to get attention, to new and emerging areas, feeling they they need to hitch themselves to quality and safety to get noticed, right? So that's a big change, right? I've I've I've seen that happen in in my lifetime. But I think that we have a lot of work to do around making sure that our quality improvement efforts uh benefit everyone, not just some, that they don't uh inadvertently widen disparities. Uh, I think we could do better to partner with patients and communities around our quality improvement work. I think there's gonna be a huge unknown around where AI fits in with all of this. You know, I was coaching a team earlier today, and um they needed to develop a driver diagram around a quality improvement uh initiative. Uh, I won't say what it was, but I'll just say it is was a problem that many had tried to tackle before. And with just some careful prompting, you know, a large language model was able to produce a very serviceable first draft of a driver diagram based on what was known in the literature with references, right? And so I actually think that the practice of quality improvement and the interventions that we might try to implement, it's all I we have to I don't know where the that field is going, but I'm I I I'm both excited and intrigued, but a little also trepidatious about where things are headed when it comes to AI. But I think it's it's really gonna be the next frontier that we're gonna need to figure out for QI.

SPEAKER_00 53:31

Yeah, I mean, one of the certainly in in my work and I'm sure in yours, one of the big limiting factors uh structurally is just the the human effort, uh, the human kind of being co-located in the same room to have a discussion or many discussions over many months, and the potential to accelerate that in a careful, safe way uh using new technologies like LLMs, as you're mentioning, seems like an exciting area if we do it well. If someone wanted to take one small step in the next few months towards building improvement infrastructure rather than just launching another new project, what would you recommend that they do? Like a leader or uh Yeah, uh yeah, uh let's let's keep it too. Someone who has uh a role of some authority, you know, I think you're you're alluding to the the sustainability of of change and how you know how structurally that needs to be integrated. And I'm curious how you would think about that. If someone's starting to have these thoughts, wanting to build more QI infrastructure, they have the project IDIS already, you know, seeing too many projects in too many divergent directions, as you mentioned. How would you think about starting to build improvement infrastructure?

Practical First Steps For Infrastructure

SPEAKER_01 54:52

Well, I mean, at the end of the day, I think you do need people that have the knowledge and skills around how to do improvement work. And I think structurally, there needs to be we need to structure our workplaces and our work days so that there's room to do that work. You know, right now I think that when I am looking after patients, it really feels like there's no room to breathe. And so I have the luxury of being able to have some of my time dedicated to doing academic work because I work at a at a university, you know, and I have an academic position. But many people don't. And so it's a matter of trying to figure out so, you know, how do we structure our days? How do we structure our work? How do we build workflows? How do we even think about how we document and organize our dot, you know, our our uh health records so that we can draw insights around the care that we're delivering and be able to react to those insights or you know, through data to be able to sort of to start to contribute to change. And and I think that if you are not familiar with the concepts, if not been exposed to the concepts, then you you may not naturally think that uh about all the opportunities there are for improvement. But like you said, if you've been bitten by the bug or you've taken a course or you started, you've been involved in a successful project, you know, you almost move from being, you know, I'm doing quality improvement on Tuesdays to I'm just gonna try to approach the work that I do with a quality improvement mindset. And maybe that's where we'd like to see things go at some point, right? And so how do you build that quality improvement culture and mindset in into the work that we're doing? And I do think that it starts with training people, but also valuing it as work that's just as important as everything else that we do when we're looking after people, right?

SPEAKER_00 57:01

Yeah. Not having enough room to breathe when you're when you're doing the clinical work and having that that space carved out is so important. I uh you know, I hear that the vivid framing of that. I think it's something that I can relate to and others can when doing clinical work. As we close out our conversation today, what makes you feel hopeful about healthcare and the direction that we're going?

SPEAKER_01 57:25

Yeah, I mean, I think uh it's an important question, I think, given kind of some of the challenging times we've experienced recently. But I think what makes me hopeful is that when I have the opportunity to engage with the next generation of people working in healthcare and be a part of some of the work that they're doing in quality improvement, it really energizes me, you know, to see that people want to take the time to dedicate some of their energy towards making the system better for patients. That makes me hopeful. We've been through a lot and we've bounced back in many ways. That makes me hopeful. And I think generally speaking, I tend to try to be as optimistic as I can because I just think that like education, optimism on its own isn't gonna do, isn't it isn't gonna be enough, but it's a really important foundation for for doing improvement work. And so I do think that having that sense of optimism can really fuel the work we do every day in quality improvement.

SPEAKER_00 58:33

It's a perfect place to to round out the conversation. I I want to thank you so much for for joining me. If listeners wanted to follow your work or connect with you, how would they best do that?

SPEAKER_01 58:44

Oh, good question. Um, so I can uh so we have uh with through the center, we have uh an email address, we have a website, uh which I can provide you and your listeners. I'm also on LinkedIn-ish. Uh you know, I'm not great at it, but I do uh, you know, I do engage a little bit on LinkedIn from a social media perspective. And yeah, I would love to connect with your listeners uh however they might find helpful. Um as I'm as I know your listeners are the ones that are doing the the difficult work to make our system better.

SPEAKER_00 59:21

Well, we'll we'll link to the uh your your LinkedIn um profile and the and the CQIPs website with your permission. And uh again, really appreciate you kind of opening this door to the amazing work that you are doing, you know, before, during, and after the pandemic through CQIPs and research, education, and pursuing equity and stewarding the Squire guidelines on top of it, uh, which we'll look forward to. Thank you so much for the conversation today. I really enjoyed it.

SPEAKER_01 59:50

Oh, thanks for giving me the opportunity to share some of uh my own journey and the work we've been doing at Sequips with your listeners. I really appreciate it.

SPEAKER_00 1:00:01

Thanks so much for listening to today's episode of Leading Quality. If you enjoyed the show, please take a moment to like, subscribe, and share it with someone who might find it useful. You can find all our episodes at leadingquality.buzzsprout.com or in your favorite podcast app. The show was written and hosted by me, Jason Meadows, edited by Milan Milosavievich, and produced by Thrive Healthcare Improvement. See you next time.