The Rule of Three

Improving Quality and Safety in an Overburdened Healthcare System

Monday, February 4, 2019 – Philip De Souza and Michelle Holden

For Dr. Kevin Smith, President and CEO of the University Health Network (UHN), good things come in threes – the rule of three in fact. During a recent Breakfast with the Chiefs hosted by Longwoods Notes, Dr. Smith referred to “the three” as an organization’s main priorities – having more can sometimes challenge focus and direction.

Even Dr. Smith’s presentation that morning followed the rule of three. His focus was on patient engagement, staff engagement, and system-level engagement as integral to improving quality and safety in an overburdened healthcare system.

As a partner of Longwoods and the January 23 event, HIROC is no stranger to the act of engagement. HIROC works with healthcare organizations across Canada to advance safety and risk management.

Patient Engagement

“Patients are the best measure of quality,” said Dr. Smith who believes that when patients are engaged in quality assurance, we have better outcomes. One method of engaging patients that Dr. Smith stands behind is the patient portal. During the talk he cited a New England Journal of Medicine report which named portals one of the most effective engagement tools.

One concern that we have with portals, understands Dr. Smith, is that patients may misinterpret their results before having a conversation with their healthcare provider. But Dr. Smith says a simple phone call with the provider is all that we need to quell this concern, “They [the patients] call, ask questions, and get clarity.”

Another engagement tactic is having patients at the table. Once they take a seat, he says, “Invite patients to every committee… invite patients to hiring panels.” At UHN, 150 carefully selected patient partners sit at the table – “It’s immeasurable feedback,” said Dr. Smith.

But essential, in Dr. Smith’s view, is hardwiring engagement to every healthcare delivery process. He feels success can be realized through time investment by the healthcare team. This is about interconnectedness and ensuring that patients are ready to adopt new processes. There must also be openness to change at the provider level.

Staff Engagement

“What are some of the things we might take off of our plates for a while?” Dr. Smith says we should be asking questions like this to staff to maintain a focus on the important objectives. It all comes back to “the three” – are we having too many meetings, does every step in the process have a purpose. If there are things that are taking time away from the three core goals, we need to move them out of the way.

Burnout is a very real issue facing healthcare providers. Dr. Smith cited an example from France where at one point in time there was at least one physician suicide per week. “We know healthcare providers are at high risk,” he said; “our individual bandwidth is frayed.” One way to address the quality of work, says Dr. Smith, is by focusing on a culture of wellness and asking staff what they need.

That brings us to another component of engagement – leaders need to listen to their people. At UHN the Public Affairs and Communications team have set up online forums with real-time question periods for staff to address their concerns and ask questions. While Dr. Smith says he may not always have the answers, he values knowing what staff are thinking – it holds him accountable.

System-Level Engagemet

On one hand, system-level engagement is about asking if everything we’re doing is adding value. If it isn’t, “Let’s fail fast,” said Dr. Smith. Because it isn’t always an option for health administrators to fail, this has to start with governance. Boards need to be asking leadership to identify the pain points – the areas an organization can do better – and then work together to solve these problems. As a partner for good governance, in 2018 HIROC launched 21 Questions: Guidance for Healthcare Boards on What They Should Ask Senior Leaders About Risk.

The fail fast methodology also extends to partnerships – revisiting long-time partnerships to see if the investment they require in time outweighs the benefits. “The road to hell is littered with memoranda of understanding,” joked Dr. Smith.

Another component of system-level engagement is looking at areas of the system which are outside of healthcare. Dr. Smith discussed the link between health and wealth, referring to poverty as one of the least appreciated system problems.

The development of a more integrated approach to health and social services is something we’re seeing bubble up today through initiatives like social prescribing. While this is still in early stages in Canada, moving forward, says Dr. Smith, will require a change in the health profession curriculum. We need to teach providers how to make those community connections. “Look beyond the conventional hospital visit and patient journey,” said Dr. Smith.

Throughout his talk, Dr. Smith made the invaluable link between patients, staff and the system. “Healthcare is a team sport, but even in a team sport there’s a lot of white space between the players,” said Dr. Smith while standing below an image of a soccer field scattered with lone players. To play on the same team and reduce that white space, he says we have a lot of work to do.

“A relentless focus on the three,” said Dr. Smith while bringing the talk full circle for the large audience. He left the audience with an important challenge – “What are the three things you’ll address and what will you do to keep a line of sight on these three even with the many moving objectives and priorities constantly swirling around you?”

Philip De Souza is HIROC’s Manager, Communications and Marketing. Michelle Holden is Communications and Marketing Specialist.