September 25, 2025 • 45 mins
As Stephen Covey once wrote, "Change happens at the speed of trust." This simple yet profound insight applied by this week's guest, Dr. Curt Smecher captures the essence of how British Columbia's Physician Quality Improvement program transformed healthcare from the ground up. Affectionately known as "Papa QI," Smecher shares the remarkable journey of creating a physician-led improvement movement that has trained over 1,600 clinicians across the province.
What makes this story exceptional isn't just the scale, but the approach. Rather than following the conventional wisdom of starting with executive buy-in, PQI began with frontline physicians and built upward. This counterintuitive strategy created a powerful foundation of clinical expertise while gradually earning administrative support through demonstrated results. The program's governance structure – with physicians, administrators, patients, and Doctors of BC as equal partners – represents a radical departure from healthcare's typical hierarchies.
Perhaps most revolutionary was the early decision to include patients as full participants in all aspects of the program. When questioned about involving patients in budgeting discussions, Smecher's response was telling: "Most of our patients know more about budgeting than our doctors do." This authentic partnership approach has been central to PQI's success and sustainability over its decade-long existence.
The program's impact extends beyond clinical improvements. Physicians trained through PQI demonstrate 40% higher engagement levels compared to their peers, suggesting that meaningful involvement in improvement work serves as a powerful antidote to burnout. Protected funding ensures resources remain dedicated to improvement rather than being diverted to immediate clinical pressures – a recognition that investing in system improvement requires dedicated space and time.
Looking ahead, Smecher describes PQI's evolution from building capacity to effectively utilizing that capacity, with the ultimate vision of "whole system quality" that addresses upstream factors rather than playing healthcare whack-a-mole. For anyone seeking to create lasting healthcare transformation, this conversation offers invaluable insights into building improvement capability that outlasts any single leader or initiative.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
My entry into quality improvement was all self-taught
.
When we started the program, werecognized that we didn't have
the skill sets within thedoctors.
I'm focused on training andcreating capacity.
We've done, I think, anoutstanding job of creating
capacity and now we're trying tomake the transition from
creating capacity to actuallyusing the capacity that we've
(00:23):
created.
Speaker 2 (00:27):
Welcome to Leading Quality, the podcast
spotlighting the people movinghealthcare forward from the
front lines to the C-suite.
I'm your host, jason Meadows.
Today's guest is Dr KurtSmetcher, a retired
(00:53):
anesthesiologist and one of theoriginal architects of physician
quality improvement in BritishColumbia, also known as PQI.
If you've ever tried to move QIfrom a slide deck into
day-to-day practice, you know ittakes more than enthusiasm.
Slide deck into day-to-daypractice, you know it takes more
than enthusiasm.
Kurt helped design a programthat gave physicians practical
training and protected time touse it, so improvement work
wasn't just something squeezedin after hours.
(01:16):
What I appreciate about Kurt isthe way he leads without fanfare
Clear governance, so good ideasdon't stall.
Shared ownership instead oftop-down edicts and a steady
focus on outcomes that matter atthe bedside.
His colleagues affectionatelycall him Papa QI, but the real
story is a decade of careful,repeatable moves that allowed a
(01:40):
small pilot to grow across theprovince.
I wanted him on the showbecause his approach is both
humble and high impact.
We're going to trace the earlydays of PQI, the decisions that
helped it scale and theleadership habits any
organization can borrow, whetheryou're starting on one ward or
trying to shift an entire healthsystem.
(02:01):
Kurt, welcome to the show,thank you, and before we get too
deep into it, welcome to theshow.
Thank you and before we get toodeep into it, do you mind if I
call you Kurt for thisconversation?
Speaker 1 (02:09):
Oh, please go ahead, very good.
Speaker 2 (02:11):
So you've done a lot in quality improvement in
British Columbia.
I'm curious to know how you gotstarted, both in terms of your
backstory as an anesthesiologistand what sparked your interest
from clinical work into qualityimprovement.
Speaker 1 (02:27):
So I was a late entry into medicine.
I've had a number of careers inthe past, including marine
biologist, computer scientist.
I did doctor's research.
My interest in qualityimprovement started back in
about 1980, while I was still inindustry, and that's about the
(02:50):
time that Deming came to noticein North America.
Through that period I was doingmy work in IT and applied some
of those principles.
When I switched over intomedicine in 1992, and it was my
first day in medical school myattention was somewhat divergent
(03:11):
.
But once I went through medicalschool, went through residency
and got a firm footing inmedicine, then I naturally
turned back towards qualityimprovement, and the timing
seemed to be right.
The appetite was there and so,as with all good leaders, I
(03:33):
jumped in front of the crowd.
Speaker 2 (03:36):
That's great, and so paint the scene for me a little
bit more in terms of where youstarted with quality improvement
clinically.
Where you started with qualityimprovement clinically, was
there a first project or wasthere a particular mentor in the
quality space in healthcarethat got you involved in this?
Speaker 1 (03:54):
My entry into quality improvement back in 1980 and
throughout that period was allself-taught.
Most of us at that point wereself-taught.
When I tried to apply it inmedicine, I went back and I got
my training from IHI.
I was part of wave 30 of theirimprovement advisor cohort and
(04:17):
then I stayed on with them tohelp teach a couple of waves
just to consolidate my knowledge.
To help teach a couple of wavesjust to consolidate my
knowledge.
So my mentors at that pointwere most of the principals
(04:38):
involved in quality improvementat IHI and I still keep up to
date with them and very muchappreciate their input and
leadership leadership.
Once we got back to working inCanada, doctors of BC here had
an interest in having physiciansengaged in improving the system
.
They didn't have a lot ofknowledge around quality
improvement or exactly what itwas that would make this
(05:02):
successful, exactly what it wasthat would make this successful,
and so to a large extent, I wasin the right place at the right
time, 2014,.
Dr Jan Korner presented someinformation about having a
physician compact that I kind oftook him to task for just
because I felt there was a powerimbalance there, and suggested
(05:25):
that the common ground betweenthe administration and the
physicians was actually qualityimprovement.
If you wanted to engage, youwanted to work together, work on
that common ground, because weall wanted the system to
function better, our workplaceto be better, our patients to
improve faster.
(05:45):
Later in that spring John kindof tapped me on the corner and
it was kind of a put up or shutup type of proposal and so I
took over the Ecosystem QualityImprovement Program in Fraser,
which was the first in BC, byabout a year and a half in BC by
(06:08):
about a year and a half, and soyou used quality improvement as
kind of this common ground tounite people who were in Doctors
of BC as well as people inprovincial politics, or was it
mainly Doctors of BC?
It was a combination the qualityimprovement program the funding
for it came out of the 2014physician master agreement, so
that was an agreement betweenthe Ministry of Health and the
(06:30):
doctors and it provided fundingfor quality improvement.
So we had the doctors at BC onboard, we had the Ministry of
Health on board and then atFraser, I spent quite a bit of
time working with the currentCEO and VP of medicine to get
(06:51):
them on board, because one ofthe things that would run us
into trouble pretty quick is anysense that we were undermining
what they were doing, or runningrogue, or we're trying to get
aligned, we're trying to geteveryone running the same
direction, but there's a lot ofsuspicion on both sides about
what our intent is.
So there's a lot of upfrontwork that I did in order to make
(07:14):
sure that everyone was clearwhat we were doing, why we were
doing it, a little bit about howwe were doing it, because I
wasn't really clear at the timeexactly what this was going to
look like.
And then, using thoserelationships that I developed
throughout 2014, we hadpermission from the health
authority, the proposal wentthrough Doctors of BC and we
(07:43):
initiated the first cohort,probably appropriately April 1st
2015.
Speaker 2 (07:45):
As you're thinking back to that first cohort, we're
about 11 years out from thatnow.
Were there important lessonsthat you learned in doing that?
Can you walk me through, maybe,what the lessons were and just
how that cohort went?
Speaker 1 (07:58):
Well, the first lesson.
It was a tremendous amount ofwork For that first cohort.
I did the teaching, I bookedthe rooms, ordered lunch, did
everything.
It was a lot of work, but itwas also very, very rewarding.
The first cohort we had 12people.
They were from pretty much allaspects of medicine and one of
(08:24):
the things I told them is thatyou know, 10 years from now or
whenever you look back on todayand say I was there when, and
guess what?
They really were there when.
For us, a lot of those peopleare still involved.
They're still actively teachingor leading programs throughout
the province.
The lessons there was a lot ofwork, but it's worth it.
(08:46):
You build your leadership fromwithin and my success, you know,
as I measure my success, it'sthe success of the people that
I've empowered to do this work,that I've taught and have now
become leaders, not only inquality improvement in BC but
within the medicaladministration as well, because
(09:09):
we have a lot of people who havemade that transition.
You know we used to joke aboutwell, it wasn't so much a joke,
but moving over to the dark side, now there's a lot more
understanding of the differentpoints of view, the different
constraints that everyone runsunder and how to work together,
(09:31):
and so that's been a huge partof the process for us.
Speaker 2 (09:37):
You mentioned that you had 12 participants, all
physicians, because this is aphysician-driven and physician
training program.
I'm trying to imagine are thesepeople you were just knocking
on doors and saying, do you wantto get trained in QI?
Or are these people who wereexpected to do quality
improvement already and this wasan outlet?
Speaker 1 (10:02):
How did this cohort of the people who were
originally there, how did theycome into it?
The first cohort was probablythe most difficult to recruit
into because nobody knew what itwas about.
We put the word out through anychannel that I had available,
so mostly through theadministrative, departmental
channels, we ended up with the12 people.
The first question that we hadwas it comes through Doctors of
(10:25):
BC, but it comes through theSpecialist Services Committee.
You know that's where thefunding comes from.
So were we going to acceptfamily doctors?
Yes, and so the answer to thatwas yeah, why wouldn't we?
And so we did include familydoctors in that first cohort and
(10:46):
then after that it reallywasn't a problem.
The program after the first yearreally sold itself.
We developed a lot of word ofmouth referrals.
You know we were seen to be avery rigorous program, but also
(11:07):
a program that gave you a way todeal with the frustrations of
your day-to-day work, a way toget in there and legitimately
deal with.
You know what we're now callingthe pebble in your shoe.
Deal with you know what we'renow calling the pebble in your
shoe, but also to you know, as Itry and sell it to the
administrators to deal with someof those problems that we have
(11:27):
in the system that are lowending fruit, that are the day
to day inefficiencies in processor cost inefficiencies, or or
patient care that you know on onthe ground you see it every day
, but from the 30,000 foot levelyou would never see it, and so,
(11:49):
having that bottom up drive andthe reputation that was rapidly
being built, it really wasn'tvery difficult to recruit.
Speaker 2 (12:01):
And you mentioned this interplay between Doctors
of BC and the SpecialistServices Committee and I
understand that's also how thefunding comes to be.
I'm curious if you can sharefor people who might not be
familiar with BC or even arelistening from outside of Canada
kind of what those two groupsare, how this interplay has
worked so well and maybe evenyou know ballpark, what kind of
(12:23):
funding this program isreceiving today compared to when
it started.
Speaker 1 (12:27):
The organization that we're working under is I think
it's probably unique in Canadaso we have Doctors of BC, which
is our medical association, andthen, kind of off to the side,
we have an organization that's apartnership between the medical
association and the provincialgovernment, which are called the
(12:49):
Joint Clinical Committees, sothe JCCs.
Under the JCCs it's split intofamily practice specialists,
shared care, which is kind of atransition between the two and
rural.
So we have the four differentgroups represented there.
(13:10):
Each of them has their ownfunding and each of them is
governed through a joint set ofcommittees that is half Doctors
of the BC and half Ministrypeople, so that we keep that
coordinated and so that keeps usall aware of what's going on
(13:34):
and aligned and legitimizes thework that we're trying to do.
Oh, and you mentioned budget.
The budget that we have issomewhere between $10 million
and $18 million over the yearsfor every year.
But remember, it's a provincialprogram, so $100,000 doesn't go
(13:55):
very far.
So we run $10 million to $18million in the budget.
Speaker 2 (14:02):
Certainly no small feat in the context of finding
that spare you know, the sparechange to, you know within a
provincial healthcare budget tobe able to deliver something
like this.
And I can imagine there mighthave been some skepticism
initially, as you said, as youkind of alluded to before, on
what it is you were doing andwhat the ROI might be.
Speaker 1 (14:21):
We still have those issues because when we started
the program we recognized thatwe didn't have the skill set
within the doctor.
So I had the technical skillset that I brought back from IHI
and the ability to teach it,but within the province there
really wasn't anyone that wastrained in quality improvement,
(14:44):
so to take on qualityimprovement projects was going
to be a problem.
So the beginning of the programwe focused on training and
focused on creating capacity andwe've done, I think, an
outstanding job of creatingcapacity and now we're trying to
(15:05):
make the transition fromcreating capacity to actually
using the capacity that we'vecreated.
Part of our problem again we'requite unique in this is that
most QI programs are top-down,and you'll hear it said very
often that if you want to starta QI program, the first thing
(15:27):
you have to do is you have toget the CEO or the
administrators in line and thentake it down to the shop floor.
We did exactly the opposite.
We felt that the positions wereready, but the administrators
were not.
We created the program in theopposite direction.
(15:49):
We created it from the bottomup.
It gave us the ability to dothe training, it gave us the
ability to make local change andI think we had some really good
successes in that.
But when the scope of changethat you're able to make is
limited to the scope of singlephysicians, you don't see those
(16:13):
really big system levelimprovements that you really
want level improvements that youreally want.
So now what we're trying to dois we're trying to make that
transition so that we have abalance between the bottom up
the low hanging fruit and thetop down for the higher system
impact.
And I think if we can get thatbalance going, then we really
(16:36):
have something to show please.
Speaker 2 (16:39):
Yeah, we really have something to show, please.
Yeah, and it sounds likesomething that started really as
an initial seed with this firstcohort back in 2014.
That has now grown into aprovince-wide movement and I
certainly I meet people, a lotof people at the IHI, and
certainly the Canadian cohort isheavily represented by British
Columbians, and certainly theCanadian cohort is heavily
(17:01):
represented by BritishColumbians.
What kind of key governancedecisions do you think were
pivotal in getting from thatlocal pilot to a province-wide
program?
And then I can also imaginethat this had a kind of a
grassroots energy, as you'retalking about this coming from
the bottom up, and I'm curiousif it has been a struggle to
maintain the grassroots energyas it's gotten bigger.
Speaker 1 (17:23):
Yeah, I think grassroots energy is still there
.
But the governance structurethat we've set up, I think, is
really important.
So, to be honest, I reallydidn't expect the program to
survive as well as it has.
So some of the structure isguerrilla structure.
If you create a monolithicgovernance structure, it's easy
(17:48):
to attack and destroy.
If you create a distributedgovernance structure, then if
one arm of that runs intotrouble or gets cut off for
whatever reason, the programitself can still exist.
So we created a governancestructure that was focused in
(18:08):
six different areas for the sixdifferent health authorities.
Five of the health authoritiesare geographic and one of them
is province-wide, looking afterthings like cancer agency and
that type of thing.
So each of those has their ownsteering committee.
Now the governance structurewithin steering committees is
(18:28):
important too, because thehealth authorities, as most of
our health administrativesystems are, is extremely
hierarchical, and what we builtis we built a very
entrepreneurial system withinthis hierarchy.
We built a system of four equalpartners within the hierarchy
(18:53):
and there's a bit of a cultureclash when you do that and
there's a bit of a culture clashwhen you do that.
So our four partners was theadministrators, the doctors, the
patients and doctors at BC,mostly to make sure that the
(19:15):
intent across the six differenthealth authorities is maintained
and that there's someconsistency between them and
that there's some consistencybetween them.
So having that structure meantthat we could have good
representation of all thestakeholders without worrying
about who had the balance of thevoting power or who was the
boss of who.
We were all equal participantsat that level and it also made
(19:39):
sense from the point of viewthat if the health authority
really didn't want to dosomething, it would be foolish
for us to try and push it.
Similarly, if the doctorsreally didn't want to do
something, it would be foolishto push it.
So that consensusdecision-making structure that
we put in place has reallyserved us very well, and the
(20:02):
culture clash has only reallyhappened a couple of times and
the recovery from it's beenfairly easy.
It's just people kind of getinto their at-work modes and
doctors give orders, notsuggestions, and administrators
they not suggestions andadministrators.
(20:22):
They run a hierarchy, and sowhen you get everyone together
and everyone has to work asequals, it doesn't always flow
naturally, but over the 10, 11years we've done this it's
really become ingrained andwe've recently had a situation
(20:43):
where everyone kind of gottogether and fought to maintain
it, because we had an incidentaround budgeting that people
weren't consulted and that hasbecome such an ingrained part of
our culture that people justweren't having it and we got
back to consulting all parties.
(21:05):
So it's not just a cultural I'msorry it's not just a technical
quality improvement program.
It's a very big culture changethat we've put in place as well.
Speaker 2 (21:18):
And it sounds like the structure right, the way
that you've organized thesesteering committees, the way
that this is an intentionalcollaboration between doctors of
BC and the specialist steeringcommittee, all of these kind of
meta aspects, all thesestructural aspects are perhaps
as important as the trainingitself, as the projects
(21:39):
themselves.
Speaker 1 (21:40):
Yeah, very much so.
It's the cultural aspect, butalso the patients, right?
So back 11 years ago, when weput this in place, the idea of
bringing patients intostructures like this was
questioned.
People didn't understand whyyou would do that.
We're doctors, we know what thepatients need, or we're
(22:04):
administrators, we'll tell themwhat they need.
We brought patients in as fullpartners.
So one of my first patientpartners joked that the first
day she met me, I handed her astack of textbooks and told her
to get to work because she was afull partner.
We've had conversations aboutwhy would you have patients
(22:25):
involved in the budgeting of theprogram.
Well, that's the same question.
Why would you have doctorsinvolved?
Most of our patients know moreabout budgeting than our doctors
do.
So in all aspects of theprogram the patients are full
partners and that's reallyimportant to the culture of what
we've built and it's expandedright.
(22:48):
Once you get these things inplace and people see them work,
they want to push them out toother areas.
Speaker 2 (22:55):
Yeah, and so I'm hearing this theme of reducing
hierarchies and doing so veryintentionally, and I am
imagining, as this program isgrowing, you have more
physicians getting trained.
Each of those physicians worksin their own context, whether
it's their own family clinic,whether it's a hospital, whether
(23:15):
it's some kind of grouppractice, and those structures
themselves have hierarchieswhere physicians are often seen
as being at the top of some ofthose structures or certainly in
a bigger role of authority.
Was there work that had tohappen for this to work also at
that local level, so thatphysicians were aware of perhaps
(23:37):
being inclusive orintentionally reducing
hierarchies within their ownproject teams?
Speaker 1 (23:43):
Yeah.
So we've been very clear rightfrom the start that you know
quality improvement is a teamsport, that you know you can't
do it by yourself.
You need to have thosedifferent perspectives.
Every team has a leader andoften that leader will be a
physician not always but if aphysician is not a leader, the
physician will be involved inthe leadership in some way.
You know, when we started therewere a few tenets that we
(24:09):
adhered to.
One is that physicians do wantto make a difference, they do
want to make the system workbetter.
That the physicians will engagebut only from a position of
strength.
If they don't know how thisworks or what's happening or
whatever, they will findsomething else to do with their
time where they feel it cancontribute more.
(24:29):
So they needed to have thatposition of strength that the
quality improvement is a teamsport and that everyone had to
be involved, and not involvedjust in doing the work, but
involved in all aspects of it.
I have a couple of t-shirts Icall my medical administration
(24:51):
t-shirts.
One of them says the floggingswill continue until morale
improves and another one saysteamwork a whole bunch of people
doing what I say.
So we try and make sure thatpeople understand that teamwork
involves respecting others'knowledge, their perspectives
(25:12):
and working together more inthat flat structure.
And I think that comes acrossnot so much because of what we
say but because of how wedemonstrate it.
And creating those steeringcommittees of four equal
partners, I think, is a reallygood demonstration of that.
And then we apply it indifferent aspects of what we do
(25:37):
as well, where the teaching isteaching by example, especially
for a lot of the cultural stuffstuff, yeah, and you alluded to
this a bit earlier.
Speaker 2 (25:53):
But this idea of building capability and then
from there, leveraging thecapability that you've built at
scale.
So training is certainly onething.
It's quite another to haveprotected time after the
training is over or to leverageyour skills in new ways, perhaps
form new collaborations thatexist outside of the program,
but maybe with other graduatesof the program.
(26:15):
How are you thinking about thisleveraging of this huge cohort
of 1600 physicians who have beentrained under PQI?
Speaker 1 (26:24):
A number of things that we've learned over the
years.
So one of those is that, youknow, as we bring people through
the system and the physiciansand the administrators start to
work together, they developtrust and understanding, and
that extends far beyond justtheir learning project project.
(26:52):
They make those relationshipsand that trust builds and it
grows as they bring other peoplein, either on the administrator
side or on the physician side.
The other thing that we andthat was expected, that wasn't a
surprise.
What was a surprise was thatwhat we bring in with our
funding is we bring in protectedfunds.
So the health authorities theyare so strapped for cash to get
(27:14):
the clinical work done that anymoney that could possibly be
diverted into clinical worktends to be diverted into
clinical work, and so any moneythat would have come to them for
quality improvement likelywouldn't have lasted very long
just because of thoseoperational pressures.
So one of the things that webring to the table is protected
(27:39):
funding for them, because it'sour money and if it's not used
for quality improvement theydon't get it, and that's always
been understood.
It's never been a problem.
But having those protectedfunds and having this protected
workforce is important becausewe pay.
You know we don't pay as wellas clinical work does, but we
(28:03):
pay enough to take the bite outof it.
And so we provide the workforce, we provide funding for the
projects and it keeps us that'sour carrot, I guess is it keeps
us in the program and workingwith each other and it helps
bridge over any rough periods inthe relationships, which are
(28:26):
very few and far between but itkeeps us at the table.
Speaker 2 (28:32):
I read a research report that was looking at the
impact of PQI and this is, Ithink, about three, four years
ago that this was put out andone of the things that caught my
eye was they commentedspecifically on how PQI has
impacted the quadruple aim asdefined by the IHI, and within
(28:53):
that they comment on improvedphysician experience, which we
know is one of these four aims.
And in an era where moralinjury and burnout seems to be
one of the highest, the mosttalked about priorities and the
most urgent priorities in ourhealthcare workforce, how do you
(29:15):
think PQI has impactedphysician well-being and perhaps
rippling even further to otherswho have participated through
these projects?
Speaker 1 (29:26):
One of the things that we did a number of years
ago.
Well, quite a few years ago,doctors at BC started to do an
engagement survey of allphysicians in the province.
So for PQI, we took some of thequestions that they'd been using
and gave them to our cohortsand the difference between
(29:47):
physicians as a whole and ourphysicians our physicians were
about 40% more engaged, or 40%more engaged than the physicians
as a whole.
So it gave them, you know,feelings that they, they were
making a difference, that theyhad, say in their own destiny,
and they, they had some autonomywithin the system.
(30:08):
They knew who, who to talk toand and how to, how to approach
these issues rather than justbeing a victim.
And so that has had a hugeeffect and we see, we see it all
the time.
It also means that they're notafraid to to speak up, and then
when they speak up, they speakup with some knowledge of their
(30:31):
audience.
And we all know that if you'redoing a presentation, the first
thing you need to consider isyour audience and what's
important to them.
So now when they make anypresentations, even if it's just
an elevator pitch, they knowwho they're talking to and
what's important to them and howto phrase it.
Speaker 2 (30:53):
Yeah, I'm hearing as you're saying this.
I'm hearing some of thesethemes that I've also
encountered, for example,through the IHI's joy and work
framework, where you're givingpeople more choice and autonomy
over the work that they do,you're giving them the ability
to to actually influence how thework goes, and that that can be
, you know, a big boost to howyou know, how they feel, their
(31:14):
kind of, their outlook for, forhow this work is going to go for
them one of the um.
Speaker 1 (31:20):
One of the things that that comes up fairly often
is is the join, work and joy.
Joy in work was always um, itwas always one of the goals, I
think, of the triple aim, but itwas a derivative and then it
worked its way into from tripleaim to the quadruple aim and, uh
(31:42):
, there was some resistance toit because there was a feeling
that it was self-serving andthat if you you push too hard on
it, especially in politicalcircles, it just comes across
self-serving.
But it's always been there asas a derivative.
So when we talk about the moralinjury, we talk about, you know
(32:02):
, the autonomy, the, the abilityto affect your environment as
being a big part of joint work.
But that's a, that's all partof the tripling.
So so, yes, that fourth point,there they, the joy in work is
important and, uh, recruitment,retention, productivity within
(32:24):
the workplace, all of all ofthat is part of joy and work,
but it's largely derivative fromthe others.
I think there are some thingsthat are specifically addressing
joy and work, but the bulk ofthe effect we see is in making
(32:44):
the workplace better, inproviding better service and all
of the reasons that we got intomedicine, you know.
Being able to enhance and focuson that is, I think, the
biggest part of joint work.
Speaker 2 (33:00):
Looking kind of forward into the future of the
PQI.
I've heard that PQI alumnialways ask what's next.
I'm curious what you think isnext for PQI.
I've heard that PQI alumnialways ask what's next.
I'm curious what you think isnext for PQI.
Speaker 1 (33:13):
Two things the first thing is we need to make this
transition between creatingcapacity and using capacity, and
we're in the throes of thatright now.
So part of that isrestructuring so that we are
structured around a projectcycle as opposed to a classroom
(33:37):
cycle.
That's actually a fairly majortransition in structure.
So going to a project cyclemeans that September through
June doesn't cut it anymore,that the end result is a
finished project, not agraduation, that the choice of
(33:58):
projects that we do needs to bemore based on the value of the
project now rather than theenthusiasm of the student.
So we're making that transition.
The other thing that's coming upis whole system quality, and
it's starting to gain tractioninternationally.
(34:21):
But within the province we'retrying to socialize the idea
very strongly so that qualityimprovement is just one aspect
of it.
So if you go back to Duran'strilogy, you have quality
planning, which everyone thinksthey do but they don't do.
(34:43):
We have quality improvement andDuran called it quality control
.
I prefer to call it qualitymonitor, and we need to get
those three put in place.
So the way that I see thathappening, first of all, we've
got a pretty good handle onquality improvement and a lot of
the measurement we do in ourprojects could easily filter
(35:06):
into more of a dashboard type ofquality monitoring system and
then, if you add to that somepurposeful building of that
quality monitoring system,that's a fairly easy transition.
The quality planning that canhappen in stages, the the
(35:30):
elephant in the room for a lotof this is always um, just the
system, uh, system flow.
And how do we?
How do we?
How do we make the system workbetter, patient, patient flow in
particular.
What we often end up doing yeah, I characterize as a game of
whack-a-mole.
(35:52):
Um, we, today the hot button is,uh, time specialist consult in
the emerge, so you whack thatmole and out pops something else
.
There's no beds to move theminto, so you uh whack that one
probably whack that one everyday right now and then something
(36:14):
else pops up and it's access toradiology or whatever it is.
There's always something therethat's a bottleneck.
So, looking at system planningin terms of where are the real
bottlenecks to the overall flowwithin the system, where are you
going to get the biggest bangfor the buck?
I guess in solving problems andnot just shift the cues around,
(36:39):
shift the bottlenecks from onething to another, and so that's
something that we're activelytalking about it's going to be a
much larger task to actuallyget it working within the
province.
That's more of a 10-year planfor us, I think.
Speaker 2 (36:57):
Yeah, it sounds like the ideas are all there and it
will take a little while topercolate and to solidify a lot
of the partnerships there.
Speaker 1 (37:06):
Yeah, the partnerships is a big thing
because when you work at thatlevel in the system, you've got
to have those partnerships.
If I'm just worried about the,you know the flow through
radiology in one hospital.
You know that's within thescope of one or two physicians
to work on.
But if I'm looking at the flowof the entire healthcare system
in the province, I've got tohave buy-in on all levels in
(37:30):
order to be able to address that.
A lot of relationship building.
Speaker 2 (37:34):
If another province called tomorrow with zero extra
dollars, what's the first movethat you'd tell them to make and
what pitfalls would you warnthem about?
Speaker 1 (37:45):
Well, the first thing that I would say is that this
is not rubber stamps.
What works in one place doesnot necessarily work in the
other.
This has been extremelyentrepreneurial, so you have to
recognize the opportunity andhave an organization in place
that can pivot quickly enough totake advantage of it.
(38:05):
So when we see an opportunityto help solve a problem, we need
to be able to bring resourcesto bear very quickly in order to
do that and help develop thesense of what our worth is.
If it takes us three, four yearsto pivot, we're kind of like
(38:26):
the healthcare system as a whole, where you're trying to steer a
tanker right, it doesn't pivotvery quickly.
Where, for us, if we have theability to take up and work on a
hot project right now and makeit work and demonstrate our
value, that's how you get tobuild up, you bootstrap.
(38:48):
The other thing is there's thesaying that change happens at
the speed of trust, and there'sa lot of truth to that.
The thing is, how do you buildthat trust?
And you build that trust byworking together and, over time,
understanding better how eachother works, what their
priorities are, how to worktogether better, and that's how
(39:10):
you build that trust.
So it's the same theme of beingentrepreneurial, you know,
looking for the opportunitiesand being able to address the
opportunities very quickly.
Speaker 2 (39:25):
I have to say I love me a good QI quote, and I
haven't heard that one yet.
Change happens at the speed oftrust.
I feel like that so perfectlyencapsulates a feeling that I
have felt.
I think that a lot of peoplewho are in this QI world in
healthcare and probably QI worldmore broadly, have experienced
(39:46):
you in this community, havebecome affectionately known as
Papa QI.
I am so curious as to how thatnickname came to be.
And now, after more than adecade of doing PQI, what
continues to get you excitedabout this work?
Speaker 1 (40:15):
about this work.
Nick came up as an allusion toPapa Haydn, a musician, and Papa
Haydn was a musician in his ownright, but he was also the
mentor to a whole generation ofoutstanding musicians and I got
the nickname because that's therole that I play.
I said earlier that I measuremy success not in what I do, but
(40:36):
in what I enable others to do.
That's the heightenedcomparison.
And why Papa QI?
Not just because I have a bigpoint beard.
Speaker 2 (40:46):
Fair enough, as we kind of close out our
conversation today, if we had aconversation again in 2030, so
five years from now what do youhope PQI is?
What do you hope PQI is doing?
Speaker 1 (41:01):
I never really expected it to last this long.
It's outlasted.
What I thought the you knowwhat I call the corporate immune
system would allow, and now youknow we've made enough cultural
change that I think there's areasonable chance of it actually
lasting that as long as you'resaying.
What I've seen is we'veinfiltrated a lot of the system
(41:25):
with QI thinking, and that ishuge.
So we're seeing people who arestarting to think in terms of
solving problems with scientificmethod, which is what QI is, of
formulating a statement ofproblem, a name statement, in a
way that can be solved and canbe measured, and working from
(41:50):
data, and we're seeing thatthroughout the system.
Now, as our very many graduateswork their way into higher
positions in the system, what Ihope to see is a stronger
integration between people wetrain and the organization as a
(42:10):
whole.
It's a sharing of power that isvery uncomfortable, I think,
for the hierarchies, and what Ihope to see is I hope to see
that a little more accepted andalso the planning for the system
to be a little more shared.
So right now, what I'm pushingfor is every year we have
(42:35):
mandate letters that come fromthe premier to the ministries.
The ministries you know, such ashealth, create mandate letters
for the health authorities andthen the administrators within
the health authorities have tooperationalize it, those mandate
letters.
There's never anything therethat we would disagree with.
(42:55):
There's kind of broad sweepingmotherhood statements.
Where I think we could be of alot of value initially is in
operationalizing those mandateletters, because the people who
are told this is what you'regoing to do this year, they
don't have that knowledge of howthings work on the floor.
(43:18):
And so to get the doctorsinvolved in that, to get the
other stakeholders involved inthat in more of a QI process, to
operationalize those mandates,I think has a lot of potential
to enhance those relationships,to make the yearly work more
(43:40):
feasible and to start to buildtowards more of a quality
planning type of structure.
Speaker 2 (43:48):
Yeah, it sounds like going further upstream to affect
things at a broader systemslevel.
Speaker 1 (43:55):
Always yes.
Speaker 2 (43:56):
Yeah, yeah, I love that.
I mean, I think that's a greatplace to end our conversation
today, Dr Kurt Smetcher.
Kurt, I really appreciate youtaking the time.
I don't know if you're much ofa social media guy.
I usually allow people to saywhere they can find you or find
more about you.
Is that just tapping you on theshoulder at IHI?
Or where could people find outmore about you and about PQI?
Speaker 1 (44:20):
Yeah, I'm not much of a social media guy, but I am
very happy to talk to peoplevery generally.
So send me an email, give me acall, tap me on the shoulder at
IHI.
I will be at IHI in Anaheim forthe first time this year, a
little closer to home for us.
So please, you know, come havecoffee, we can talk.
Speaker 2 (44:45):
Very good, well again .
Thank you so much, kurt.
I really do appreciate theconversation and you telling us
more about your own journey andabout PQI.
So thanks for joining me onLeading Quality today.
Like subscribe and share itwith someone who might find it
(45:11):
useful.
You can find all our episodesat leadingqualitybuzzsproutcom
or in your favorite podcast app.
The show was written and hostedby me, jason Meadows, edited by
Milan Miloš Savljević andproduced by Thrive Healthcare
Improvement.
See you next time.
My entry into quality improvement was all self-taught
.
When we started the program, werecognized that we didn't have
the skill sets within thedoctors.
I'm focused on training andcreating capacity.
We've done, I think, anoutstanding job of creating
capacity and now we're trying tomake the transition from
creating capacity to actuallyusing the capacity that we've
(00:23):
created.
Speaker 2 (00:27):
Welcome to Leading Quality, the podcast
spotlighting the people movinghealthcare forward from the
front lines to the C-suite.
I'm your host, jason Meadows.
Today's guest is Dr KurtSmetcher, a retired
(00:53):
anesthesiologist and one of theoriginal architects of physician
quality improvement in BritishColumbia, also known as PQI.
If you've ever tried to move QIfrom a slide deck into
day-to-day practice, you know ittakes more than enthusiasm.
Slide deck into day-to-daypractice, you know it takes more
than enthusiasm.
Kurt helped design a programthat gave physicians practical
training and protected time touse it, so improvement work
wasn't just something squeezedin after hours.
(01:16):
What I appreciate about Kurt isthe way he leads without fanfare
Clear governance, so good ideasdon't stall.
Shared ownership instead oftop-down edicts and a steady
focus on outcomes that matter atthe bedside.
His colleagues affectionatelycall him Papa QI, but the real
story is a decade of careful,repeatable moves that allowed a
(01:40):
small pilot to grow across theprovince.
I wanted him on the showbecause his approach is both
humble and high impact.
We're going to trace the earlydays of PQI, the decisions that
helped it scale and theleadership habits any
organization can borrow, whetheryou're starting on one ward or
trying to shift an entire healthsystem.
(02:01):
Kurt, welcome to the show,thank you, and before we get too
deep into it, welcome to theshow.
Thank you and before we get toodeep into it, do you mind if I
call you Kurt for thisconversation?
Speaker 1 (02:09):
Oh, please go ahead, very good.
Speaker 2 (02:11):
So you've done a lot in quality improvement in
British Columbia.
I'm curious to know how you gotstarted, both in terms of your
backstory as an anesthesiologistand what sparked your interest
from clinical work into qualityimprovement.
Speaker 1 (02:27):
So I was a late entry into medicine.
I've had a number of careers inthe past, including marine
biologist, computer scientist.
I did doctor's research.
My interest in qualityimprovement started back in
about 1980, while I was still inindustry, and that's about the
(02:50):
time that Deming came to noticein North America.
Through that period I was doingmy work in IT and applied some
of those principles.
When I switched over intomedicine in 1992, and it was my
first day in medical school myattention was somewhat divergent
(03:11):
.
But once I went through medicalschool, went through residency
and got a firm footing inmedicine, then I naturally
turned back towards qualityimprovement, and the timing
seemed to be right.
The appetite was there and so,as with all good leaders, I
(03:33):
jumped in front of the crowd.
Speaker 2 (03:36):
That's great, and so paint the scene for me a little
bit more in terms of where youstarted with quality improvement
clinically.
Where you started with qualityimprovement clinically, was
there a first project or wasthere a particular mentor in the
quality space in healthcarethat got you involved in this?
Speaker 1 (03:54):
My entry into quality improvement back in 1980 and
throughout that period was allself-taught.
Most of us at that point wereself-taught.
When I tried to apply it inmedicine, I went back and I got
my training from IHI.
I was part of wave 30 of theirimprovement advisor cohort and
(04:17):
then I stayed on with them tohelp teach a couple of waves
just to consolidate my knowledge.
To help teach a couple of wavesjust to consolidate my
knowledge.
So my mentors at that pointwere most of the principals
(04:38):
involved in quality improvementat IHI and I still keep up to
date with them and very muchappreciate their input and
leadership leadership.
Once we got back to working inCanada, doctors of BC here had
an interest in having physiciansengaged in improving the system
.
They didn't have a lot ofknowledge around quality
improvement or exactly what itwas that would make this
(05:02):
successful, exactly what it wasthat would make this successful,
and so to a large extent, I wasin the right place at the right
time, 2014,.
Dr Jan Korner presented someinformation about having a
physician compact that I kind oftook him to task for just
because I felt there was a powerimbalance there, and suggested
(05:25):
that the common ground betweenthe administration and the
physicians was actually qualityimprovement.
If you wanted to engage, youwanted to work together, work on
that common ground, because weall wanted the system to
function better, our workplaceto be better, our patients to
improve faster.
(05:45):
Later in that spring John kindof tapped me on the corner and
it was kind of a put up or shutup type of proposal and so I
took over the Ecosystem QualityImprovement Program in Fraser,
which was the first in BC, byabout a year and a half in BC by
(06:08):
about a year and a half, and soyou used quality improvement as
kind of this common ground tounite people who were in Doctors
of BC as well as people inprovincial politics, or was it
mainly Doctors of BC?
It was a combination the qualityimprovement program the funding
for it came out of the 2014physician master agreement, so
that was an agreement betweenthe Ministry of Health and the
(06:30):
doctors and it provided fundingfor quality improvement.
So we had the doctors at BC onboard, we had the Ministry of
Health on board and then atFraser, I spent quite a bit of
time working with the currentCEO and VP of medicine to get
(06:51):
them on board, because one ofthe things that would run us
into trouble pretty quick is anysense that we were undermining
what they were doing, or runningrogue, or we're trying to get
aligned, we're trying to geteveryone running the same
direction, but there's a lot ofsuspicion on both sides about
what our intent is.
So there's a lot of upfrontwork that I did in order to make
(07:14):
sure that everyone was clearwhat we were doing, why we were
doing it, a little bit about howwe were doing it, because I
wasn't really clear at the timeexactly what this was going to
look like.
And then, using thoserelationships that I developed
throughout 2014, we hadpermission from the health
authority, the proposal wentthrough Doctors of BC and we
(07:43):
initiated the first cohort,probably appropriately April 1st
2015.
Speaker 2 (07:45):
As you're thinking back to that first cohort, we're
about 11 years out from thatnow.
Were there important lessonsthat you learned in doing that?
Can you walk me through, maybe,what the lessons were and just
how that cohort went?
Speaker 1 (07:58):
Well, the first lesson.
It was a tremendous amount ofwork For that first cohort.
I did the teaching, I bookedthe rooms, ordered lunch, did
everything.
It was a lot of work, but itwas also very, very rewarding.
The first cohort we had 12people.
They were from pretty much allaspects of medicine and one of
(08:24):
the things I told them is thatyou know, 10 years from now or
whenever you look back on todayand say I was there when, and
guess what?
They really were there when.
For us, a lot of those peopleare still involved.
They're still actively teachingor leading programs throughout
the province.
The lessons there was a lot ofwork, but it's worth it.
(08:46):
You build your leadership fromwithin and my success, you know,
as I measure my success, it'sthe success of the people that
I've empowered to do this work,that I've taught and have now
become leaders, not only inquality improvement in BC but
within the medicaladministration as well, because
(09:09):
we have a lot of people who havemade that transition.
You know we used to joke aboutwell, it wasn't so much a joke,
but moving over to the dark side, now there's a lot more
understanding of the differentpoints of view, the different
constraints that everyone runsunder and how to work together,
(09:31):
and so that's been a huge partof the process for us.
Speaker 2 (09:37):
You mentioned that you had 12 participants, all
physicians, because this is aphysician-driven and physician
training program.
I'm trying to imagine are thesepeople you were just knocking
on doors and saying, do you wantto get trained in QI?
Or are these people who wereexpected to do quality
improvement already and this wasan outlet?
Speaker 1 (10:02):
How did this cohort of the people who were
originally there, how did theycome into it?
The first cohort was probablythe most difficult to recruit
into because nobody knew what itwas about.
We put the word out through anychannel that I had available,
so mostly through theadministrative, departmental
channels, we ended up with the12 people.
The first question that we hadwas it comes through Doctors of
(10:25):
BC, but it comes through theSpecialist Services Committee.
You know that's where thefunding comes from.
So were we going to acceptfamily doctors?
Yes, and so the answer to thatwas yeah, why wouldn't we?
And so we did include familydoctors in that first cohort and
(10:46):
then after that it reallywasn't a problem.
The program after the first yearreally sold itself.
We developed a lot of word ofmouth referrals.
You know we were seen to be avery rigorous program, but also
(11:07):
a program that gave you a way todeal with the frustrations of
your day-to-day work, a way toget in there and legitimately
deal with.
You know what we're now callingthe pebble in your shoe.
Deal with you know what we'renow calling the pebble in your
shoe, but also to you know, as Itry and sell it to the
administrators to deal with someof those problems that we have
(11:27):
in the system that are lowending fruit, that are the day
to day inefficiencies in processor cost inefficiencies, or or
patient care that you know on onthe ground you see it every day
, but from the 30,000 foot levelyou would never see it, and so,
(11:49):
having that bottom up drive andthe reputation that was rapidly
being built, it really wasn'tvery difficult to recruit.
Speaker 2 (12:01):
And you mentioned this interplay between Doctors
of BC and the SpecialistServices Committee and I
understand that's also how thefunding comes to be.
I'm curious if you can sharefor people who might not be
familiar with BC or even arelistening from outside of Canada
kind of what those two groupsare, how this interplay has
worked so well and maybe evenyou know ballpark, what kind of
(12:23):
funding this program isreceiving today compared to when
it started.
Speaker 1 (12:27):
The organization that we're working under is I think
it's probably unique in Canadaso we have Doctors of BC, which
is our medical association, andthen, kind of off to the side,
we have an organization that's apartnership between the medical
association and the provincialgovernment, which are called the
(12:49):
Joint Clinical Committees, sothe JCCs.
Under the JCCs it's split intofamily practice specialists,
shared care, which is kind of atransition between the two and
rural.
So we have the four differentgroups represented there.
(13:10):
Each of them has their ownfunding and each of them is
governed through a joint set ofcommittees that is half Doctors
of the BC and half Ministrypeople, so that we keep that
coordinated and so that keeps usall aware of what's going on
(13:34):
and aligned and legitimizes thework that we're trying to do.
Oh, and you mentioned budget.
The budget that we have issomewhere between $10 million
and $18 million over the yearsfor every year.
But remember, it's a provincialprogram, so $100,000 doesn't go
(13:55):
very far.
So we run $10 million to $18million in the budget.
Speaker 2 (14:02):
Certainly no small feat in the context of finding
that spare you know, the sparechange to, you know within a
provincial healthcare budget tobe able to deliver something
like this.
And I can imagine there mighthave been some skepticism
initially, as you said, as youkind of alluded to before, on
what it is you were doing andwhat the ROI might be.
Speaker 1 (14:21):
We still have those issues because when we started
the program we recognized thatwe didn't have the skill set
within the doctor.
So I had the technical skillset that I brought back from IHI
and the ability to teach it,but within the province there
really wasn't anyone that wastrained in quality improvement,
(14:44):
so to take on qualityimprovement projects was going
to be a problem.
So the beginning of the programwe focused on training and
focused on creating capacity andwe've done, I think, an
outstanding job of creatingcapacity and now we're trying to
(15:05):
make the transition fromcreating capacity to actually
using the capacity that we'vecreated.
Part of our problem again we'requite unique in this is that
most QI programs are top-down,and you'll hear it said very
often that if you want to starta QI program, the first thing
(15:27):
you have to do is you have toget the CEO or the
administrators in line and thentake it down to the shop floor.
We did exactly the opposite.
We felt that the positions wereready, but the administrators
were not.
We created the program in theopposite direction.
(15:49):
We created it from the bottomup.
It gave us the ability to dothe training, it gave us the
ability to make local change andI think we had some really good
successes in that.
But when the scope of changethat you're able to make is
limited to the scope of singlephysicians, you don't see those
(16:13):
really big system levelimprovements that you really
want level improvements that youreally want.
So now what we're trying to dois we're trying to make that
transition so that we have abalance between the bottom up
the low hanging fruit and thetop down for the higher system
impact.
And I think if we can get thatbalance going, then we really
(16:36):
have something to show please.
Speaker 2 (16:39):
Yeah, we really have something to show, please.
Yeah, and it sounds likesomething that started really as
an initial seed with this firstcohort back in 2014.
That has now grown into aprovince-wide movement and I
certainly I meet people, a lotof people at the IHI, and
certainly the Canadian cohort isheavily represented by British
Columbians, and certainly theCanadian cohort is heavily
(17:01):
represented by BritishColumbians.
What kind of key governancedecisions do you think were
pivotal in getting from thatlocal pilot to a province-wide
program?
And then I can also imaginethat this had a kind of a
grassroots energy, as you'retalking about this coming from
the bottom up, and I'm curiousif it has been a struggle to
maintain the grassroots energyas it's gotten bigger.
Speaker 1 (17:23):
Yeah, I think grassroots energy is still there
.
But the governance structurethat we've set up, I think, is
really important.
So, to be honest, I reallydidn't expect the program to
survive as well as it has.
So some of the structure isguerrilla structure.
If you create a monolithicgovernance structure, it's easy
(17:48):
to attack and destroy.
If you create a distributedgovernance structure, then if
one arm of that runs intotrouble or gets cut off for
whatever reason, the programitself can still exist.
So we created a governancestructure that was focused in
(18:08):
six different areas for the sixdifferent health authorities.
Five of the health authoritiesare geographic and one of them
is province-wide, looking afterthings like cancer agency and
that type of thing.
So each of those has their ownsteering committee.
Now the governance structurewithin steering committees is
(18:28):
important too, because thehealth authorities, as most of
our health administrativesystems are, is extremely
hierarchical, and what we builtis we built a very
entrepreneurial system withinthis hierarchy.
We built a system of four equalpartners within the hierarchy
(18:53):
and there's a bit of a cultureclash when you do that and
there's a bit of a culture clashwhen you do that.
So our four partners was theadministrators, the doctors, the
patients and doctors at BC,mostly to make sure that the
(19:15):
intent across the six differenthealth authorities is maintained
and that there's someconsistency between them and
that there's some consistencybetween them.
So having that structure meantthat we could have good
representation of all thestakeholders without worrying
about who had the balance of thevoting power or who was the
boss of who.
We were all equal participantsat that level and it also made
(19:39):
sense from the point of viewthat if the health authority
really didn't want to dosomething, it would be foolish
for us to try and push it.
Similarly, if the doctorsreally didn't want to do
something, it would be foolishto push it.
So that consensusdecision-making structure that
we put in place has reallyserved us very well, and the
(20:02):
culture clash has only reallyhappened a couple of times and
the recovery from it's beenfairly easy.
It's just people kind of getinto their at-work modes and
doctors give orders, notsuggestions, and administrators
they not suggestions andadministrators.
(20:22):
They run a hierarchy, and sowhen you get everyone together
and everyone has to work asequals, it doesn't always flow
naturally, but over the 10, 11years we've done this it's
really become ingrained andwe've recently had a situation
(20:43):
where everyone kind of gottogether and fought to maintain
it, because we had an incidentaround budgeting that people
weren't consulted and that hasbecome such an ingrained part of
our culture that people justweren't having it and we got
back to consulting all parties.
(21:05):
So it's not just a cultural I'msorry it's not just a technical
quality improvement program.
It's a very big culture changethat we've put in place as well.
Speaker 2 (21:18):
And it sounds like the structure right, the way
that you've organized thesesteering committees, the way
that this is an intentionalcollaboration between doctors of
BC and the specialist steeringcommittee, all of these kind of
meta aspects, all thesestructural aspects are perhaps
as important as the trainingitself, as the projects
(21:39):
themselves.
Speaker 1 (21:40):
Yeah, very much so.
It's the cultural aspect, butalso the patients, right?
So back 11 years ago, when weput this in place, the idea of
bringing patients intostructures like this was
questioned.
People didn't understand whyyou would do that.
We're doctors, we know what thepatients need, or we're
(22:04):
administrators, we'll tell themwhat they need.
We brought patients in as fullpartners.
So one of my first patientpartners joked that the first
day she met me, I handed her astack of textbooks and told her
to get to work because she was afull partner.
We've had conversations aboutwhy would you have patients
(22:25):
involved in the budgeting of theprogram.
Well, that's the same question.
Why would you have doctorsinvolved?
Most of our patients know moreabout budgeting than our doctors
do.
So in all aspects of theprogram the patients are full
partners and that's reallyimportant to the culture of what
we've built and it's expandedright.
(22:48):
Once you get these things inplace and people see them work,
they want to push them out toother areas.
Speaker 2 (22:55):
Yeah, and so I'm hearing this theme of reducing
hierarchies and doing so veryintentionally, and I am
imagining, as this program isgrowing, you have more
physicians getting trained.
Each of those physicians worksin their own context, whether
it's their own family clinic,whether it's a hospital, whether
(23:15):
it's some kind of grouppractice, and those structures
themselves have hierarchieswhere physicians are often seen
as being at the top of some ofthose structures or certainly in
a bigger role of authority.
Was there work that had tohappen for this to work also at
that local level, so thatphysicians were aware of perhaps
(23:37):
being inclusive orintentionally reducing
hierarchies within their ownproject teams?
Speaker 1 (23:43):
Yeah.
So we've been very clear rightfrom the start that you know
quality improvement is a teamsport, that you know you can't
do it by yourself.
You need to have thosedifferent perspectives.
Every team has a leader andoften that leader will be a
physician not always but if aphysician is not a leader, the
physician will be involved inthe leadership in some way.
You know, when we started therewere a few tenets that we
(24:09):
adhered to.
One is that physicians do wantto make a difference, they do
want to make the system workbetter.
That the physicians will engagebut only from a position of
strength.
If they don't know how thisworks or what's happening or
whatever, they will findsomething else to do with their
time where they feel it cancontribute more.
(24:29):
So they needed to have thatposition of strength that the
quality improvement is a teamsport and that everyone had to
be involved, and not involvedjust in doing the work, but
involved in all aspects of it.
I have a couple of t-shirts Icall my medical administration
(24:51):
t-shirts.
One of them says the floggingswill continue until morale
improves and another one saysteamwork a whole bunch of people
doing what I say.
So we try and make sure thatpeople understand that teamwork
involves respecting others'knowledge, their perspectives
(25:12):
and working together more inthat flat structure.
And I think that comes acrossnot so much because of what we
say but because of how wedemonstrate it.
And creating those steeringcommittees of four equal
partners, I think, is a reallygood demonstration of that.
And then we apply it indifferent aspects of what we do
(25:37):
as well, where the teaching isteaching by example, especially
for a lot of the cultural stuffstuff, yeah, and you alluded to
this a bit earlier.
Speaker 2 (25:53):
But this idea of building capability and then
from there, leveraging thecapability that you've built at
scale.
So training is certainly onething.
It's quite another to haveprotected time after the
training is over or to leverageyour skills in new ways, perhaps
form new collaborations thatexist outside of the program,
but maybe with other graduatesof the program.
(26:15):
How are you thinking about thisleveraging of this huge cohort
of 1600 physicians who have beentrained under PQI?
Speaker 1 (26:24):
A number of things that we've learned over the
years.
So one of those is that, youknow, as we bring people through
the system and the physiciansand the administrators start to
work together, they developtrust and understanding, and
that extends far beyond justtheir learning project project.
(26:52):
They make those relationshipsand that trust builds and it
grows as they bring other peoplein, either on the administrator
side or on the physician side.
The other thing that we andthat was expected, that wasn't a
surprise.
What was a surprise was thatwhat we bring in with our
funding is we bring in protectedfunds.
So the health authorities theyare so strapped for cash to get
(27:14):
the clinical work done that anymoney that could possibly be
diverted into clinical worktends to be diverted into
clinical work, and so any moneythat would have come to them for
quality improvement likelywouldn't have lasted very long
just because of thoseoperational pressures.
So one of the things that webring to the table is protected
(27:39):
funding for them, because it'sour money and if it's not used
for quality improvement theydon't get it, and that's always
been understood.
It's never been a problem.
But having those protectedfunds and having this protected
workforce is important becausewe pay.
You know we don't pay as wellas clinical work does, but we
(28:03):
pay enough to take the bite outof it.
And so we provide the workforce, we provide funding for the
projects and it keeps us that'sour carrot, I guess is it keeps
us in the program and workingwith each other and it helps
bridge over any rough periods inthe relationships, which are
(28:26):
very few and far between but itkeeps us at the table.
Speaker 2 (28:32):
I read a research report that was looking at the
impact of PQI and this is, Ithink, about three, four years
ago that this was put out andone of the things that caught my
eye was they commentedspecifically on how PQI has
impacted the quadruple aim asdefined by the IHI, and within
(28:53):
that they comment on improvedphysician experience, which we
know is one of these four aims.
And in an era where moralinjury and burnout seems to be
one of the highest, the mosttalked about priorities and the
most urgent priorities in ourhealthcare workforce, how do you
(29:15):
think PQI has impactedphysician well-being and perhaps
rippling even further to otherswho have participated through
these projects?
Speaker 1 (29:26):
One of the things that we did a number of years
ago.
Well, quite a few years ago,doctors at BC started to do an
engagement survey of allphysicians in the province.
So for PQI, we took some of thequestions that they'd been using
and gave them to our cohortsand the difference between
(29:47):
physicians as a whole and ourphysicians our physicians were
about 40% more engaged, or 40%more engaged than the physicians
as a whole.
So it gave them, you know,feelings that they, they were
making a difference, that theyhad, say in their own destiny,
and they, they had some autonomywithin the system.
(30:08):
They knew who, who to talk toand and how to, how to approach
these issues rather than justbeing a victim.
And so that has had a hugeeffect and we see, we see it all
the time.
It also means that they're notafraid to to speak up, and then
when they speak up, they speakup with some knowledge of their
(30:31):
audience.
And we all know that if you'redoing a presentation, the first
thing you need to consider isyour audience and what's
important to them.
So now when they make anypresentations, even if it's just
an elevator pitch, they knowwho they're talking to and
what's important to them and howto phrase it.
Speaker 2 (30:53):
Yeah, I'm hearing as you're saying this.
I'm hearing some of thesethemes that I've also
encountered, for example,through the IHI's joy and work
framework, where you're givingpeople more choice and autonomy
over the work that they do,you're giving them the ability
to to actually influence how thework goes, and that that can be
, you know, a big boost to howyou know, how they feel, their
(31:14):
kind of, their outlook for, forhow this work is going to go for
them one of the um.
Speaker 1 (31:20):
One of the things that that comes up fairly often
is is the join, work and joy.
Joy in work was always um, itwas always one of the goals, I
think, of the triple aim, but itwas a derivative and then it
worked its way into from tripleaim to the quadruple aim and, uh
(31:42):
, there was some resistance toit because there was a feeling
that it was self-serving andthat if you you push too hard on
it, especially in politicalcircles, it just comes across
self-serving.
But it's always been there asas a derivative.
So when we talk about the moralinjury, we talk about, you know
(32:02):
, the autonomy, the, the abilityto affect your environment as
being a big part of joint work.
But that's a, that's all partof the tripling.
So so, yes, that fourth point,there they, the joy in work is
important and, uh, recruitment,retention, productivity within
(32:24):
the workplace, all of all ofthat is part of joy and work,
but it's largely derivative fromthe others.
I think there are some thingsthat are specifically addressing
joy and work, but the bulk ofthe effect we see is in making
(32:44):
the workplace better, inproviding better service and all
of the reasons that we got intomedicine, you know.
Being able to enhance and focuson that is, I think, the
biggest part of joint work.
Speaker 2 (33:00):
Looking kind of forward into the future of the
PQI.
I've heard that PQI alumnialways ask what's next.
I'm curious what you think isnext for PQI.
I've heard that PQI alumnialways ask what's next.
I'm curious what you think isnext for PQI.
Speaker 1 (33:13):
Two things the first thing is we need to make this
transition between creatingcapacity and using capacity, and
we're in the throes of thatright now.
So part of that isrestructuring so that we are
structured around a projectcycle as opposed to a classroom
(33:37):
cycle.
That's actually a fairly majortransition in structure.
So going to a project cyclemeans that September through
June doesn't cut it anymore,that the end result is a
finished project, not agraduation, that the choice of
(33:58):
projects that we do needs to bemore based on the value of the
project now rather than theenthusiasm of the student.
So we're making that transition.
The other thing that's coming upis whole system quality, and
it's starting to gain tractioninternationally.
(34:21):
But within the province we'retrying to socialize the idea
very strongly so that qualityimprovement is just one aspect
of it.
So if you go back to Duran'strilogy, you have quality
planning, which everyone thinksthey do but they don't do.
(34:43):
We have quality improvement andDuran called it quality control
.
I prefer to call it qualitymonitor, and we need to get
those three put in place.
So the way that I see thathappening, first of all, we've
got a pretty good handle onquality improvement and a lot of
the measurement we do in ourprojects could easily filter
(35:06):
into more of a dashboard type ofquality monitoring system and
then, if you add to that somepurposeful building of that
quality monitoring system,that's a fairly easy transition.
The quality planning that canhappen in stages, the the
(35:30):
elephant in the room for a lotof this is always um, just the
system, uh, system flow.
And how do we?
How do we?
How do we make the system workbetter, patient, patient flow in
particular.
What we often end up doing yeah, I characterize as a game of
whack-a-mole.
(35:52):
Um, we, today the hot button is,uh, time specialist consult in
the emerge, so you whack thatmole and out pops something else
.
There's no beds to move theminto, so you uh whack that one
probably whack that one everyday right now and then something
(36:14):
else pops up and it's access toradiology or whatever it is.
There's always something therethat's a bottleneck.
So, looking at system planningin terms of where are the real
bottlenecks to the overall flowwithin the system, where are you
going to get the biggest bangfor the buck?
I guess in solving problems andnot just shift the cues around,
(36:39):
shift the bottlenecks from onething to another, and so that's
something that we're activelytalking about it's going to be a
much larger task to actuallyget it working within the
province.
That's more of a 10-year planfor us, I think.
Speaker 2 (36:57):
Yeah, it sounds like the ideas are all there and it
will take a little while topercolate and to solidify a lot
of the partnerships there.
Speaker 1 (37:06):
Yeah, the partnerships is a big thing
because when you work at thatlevel in the system, you've got
to have those partnerships.
If I'm just worried about the,you know the flow through
radiology in one hospital.
You know that's within thescope of one or two physicians
to work on.
But if I'm looking at the flowof the entire healthcare system
in the province, I've got tohave buy-in on all levels in
(37:30):
order to be able to address that.
A lot of relationship building.
Speaker 2 (37:34):
If another province called tomorrow with zero extra
dollars, what's the first movethat you'd tell them to make and
what pitfalls would you warnthem about?
Speaker 1 (37:45):
Well, the first thing that I would say is that this
is not rubber stamps.
What works in one place doesnot necessarily work in the
other.
This has been extremelyentrepreneurial, so you have to
recognize the opportunity andhave an organization in place
that can pivot quickly enough totake advantage of it.
(38:05):
So when we see an opportunityto help solve a problem, we need
to be able to bring resourcesto bear very quickly in order to
do that and help develop thesense of what our worth is.
If it takes us three, four yearsto pivot, we're kind of like
(38:26):
the healthcare system as a whole, where you're trying to steer a
tanker right, it doesn't pivotvery quickly.
Where, for us, if we have theability to take up and work on a
hot project right now and makeit work and demonstrate our
value, that's how you get tobuild up, you bootstrap.
(38:48):
The other thing is there's thesaying that change happens at
the speed of trust, and there'sa lot of truth to that.
The thing is, how do you buildthat trust?
And you build that trust byworking together and, over time,
understanding better how eachother works, what their
priorities are, how to worktogether better, and that's how
(39:10):
you build that trust.
So it's the same theme of beingentrepreneurial, you know,
looking for the opportunitiesand being able to address the
opportunities very quickly.
Speaker 2 (39:25):
I have to say I love me a good QI quote, and I
haven't heard that one yet.
Change happens at the speed oftrust.
I feel like that so perfectlyencapsulates a feeling that I
have felt.
I think that a lot of peoplewho are in this QI world in
healthcare and probably QI worldmore broadly, have experienced
(39:46):
you in this community, havebecome affectionately known as
Papa QI.
I am so curious as to how thatnickname came to be.
And now, after more than adecade of doing PQI, what
continues to get you excitedabout this work?
Speaker 1 (40:15):
about this work.
Nick came up as an allusion toPapa Haydn, a musician, and Papa
Haydn was a musician in his ownright, but he was also the
mentor to a whole generation ofoutstanding musicians and I got
the nickname because that's therole that I play.
I said earlier that I measuremy success not in what I do, but
(40:36):
in what I enable others to do.
That's the heightenedcomparison.
And why Papa QI?
Not just because I have a bigpoint beard.
Speaker 2 (40:46):
Fair enough, as we kind of close out our
conversation today, if we had aconversation again in 2030, so
five years from now what do youhope PQI is?
What do you hope PQI is doing?
Speaker 1 (41:01):
I never really expected it to last this long.
It's outlasted.
What I thought the you knowwhat I call the corporate immune
system would allow, and now youknow we've made enough cultural
change that I think there's areasonable chance of it actually
lasting that as long as you'resaying.
What I've seen is we'veinfiltrated a lot of the system
(41:25):
with QI thinking, and that ishuge.
So we're seeing people who arestarting to think in terms of
solving problems with scientificmethod, which is what QI is, of
formulating a statement ofproblem, a name statement, in a
way that can be solved and canbe measured, and working from
(41:50):
data, and we're seeing thatthroughout the system.
Now, as our very many graduateswork their way into higher
positions in the system, what Ihope to see is a stronger
integration between people wetrain and the organization as a
(42:10):
whole.
It's a sharing of power that isvery uncomfortable, I think,
for the hierarchies, and what Ihope to see is I hope to see
that a little more accepted andalso the planning for the system
to be a little more shared.
So right now, what I'm pushingfor is every year we have
(42:35):
mandate letters that come fromthe premier to the ministries.
The ministries you know, such ashealth, create mandate letters
for the health authorities andthen the administrators within
the health authorities have tooperationalize it, those mandate
letters.
There's never anything therethat we would disagree with.
(42:55):
There's kind of broad sweepingmotherhood statements.
Where I think we could be of alot of value initially is in
operationalizing those mandateletters, because the people who
are told this is what you'regoing to do this year, they
don't have that knowledge of howthings work on the floor.
(43:18):
And so to get the doctorsinvolved in that, to get the
other stakeholders involved inthat in more of a QI process, to
operationalize those mandates,I think has a lot of potential
to enhance those relationships,to make the yearly work more
(43:40):
feasible and to start to buildtowards more of a quality
planning type of structure.
Speaker 2 (43:48):
Yeah, it sounds like going further upstream to affect
things at a broader systemslevel.
Speaker 1 (43:55):
Always yes.
Speaker 2 (43:56):
Yeah, yeah, I love that.
I mean, I think that's a greatplace to end our conversation
today, Dr Kurt Smetcher.
Kurt, I really appreciate youtaking the time.
I don't know if you're much ofa social media guy.
I usually allow people to saywhere they can find you or find
more about you.
Is that just tapping you on theshoulder at IHI?
Or where could people find outmore about you and about PQI?
Speaker 1 (44:20):
Yeah, I'm not much of a social media guy, but I am
very happy to talk to peoplevery generally.
So send me an email, give me acall, tap me on the shoulder at
IHI.
I will be at IHI in Anaheim forthe first time this year, a
little closer to home for us.
So please, you know, come havecoffee, we can talk.
Speaker 2 (44:45):
Very good, well again .
Thank you so much, kurt.
I really do appreciate theconversation and you telling us
more about your own journey andabout PQI.
So thanks for joining me onLeading Quality today.
Like subscribe and share itwith someone who might find it
(45:11):
useful.
You can find all our episodesat leadingqualitybuzzsproutcom
or in your favorite podcast app.
The show was written and hostedby me, jason Meadows, edited by
Milan Miloš Savljević andproduced by Thrive Healthcare
Improvement.
See you next time.
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