November 6, 2025 • 36 mins
A door swinging open in the OR. A tiny defect in IV tubing. Both seem trivial—until you realize they expose how fragile our systems really are.
In this episode, Allie Muniak, Executive Director of Health System Improvement at Health Quality BC, shows how human factors turns everyday frustration into lifesaving insight. We follow her path from psychology to system redesign, uncovering how design, teamwork, and curiosity prevent harm long before checklists or policies do.
Allie explains what human factors really means in healthcare—how people, technology, and environments interact under real-world pressure. She shares how normalizing observation as learning (not policing) helped surgical teams transform the safety checklist from a compliance tool into a culture of attention, anticipation, and role clarity.
Then, a gripping case study: ICU nurses reporting spontaneous over-infusions after a new pump rollout. Rather than defaulting to “retrain the user,” a multidisciplinary team dug deeper—partnering with engineers and vendors to discover a hidden tubing defect that led to a global recall of hundreds of millions of sets. It’s a powerful example of how listening to the front line and rejecting blame can reshape safety worldwide.
We close with lessons for every leader: slow down to see work as it’s really done, balance reactive review with proactive learning, and design systems that support clinicians instead of constraining them.
If you care about real root cause analysis and systems that make the right action the easy one, this episode is for you.
🔗 Additional Resources
- Health Quality BC – Learn more about the organization’s work in system improvement and patient safety:
➡️ https://healthqualitybc.ca/ - Allie Muniak – Executive Director, Health System Improvement, HQBC
➡️ LinkedIn: linkedin.com/in/allisonmuniak/?skipRedirect=true
➡️ Health Quality BC: https://healthqualitybc.ca/about-us/meet-our-team/allison-muniak/
📚 Mentioned in This Episode
- The Checklist Manifesto by Atul Gawande — the seminal book behind the global surgical safety checklist movement.
👉 https://www.goodreads.com/book/show/6667514-the-checklist-manifesto - Safety-I and Safety-II Framework (Erik Hollnagel) — foundational ideas for balancing reactive reviews with proactive learning.
👉 https://www.england.nhs.uk/signuptosafety/wp-content/uploads/sites/16/2015/10/safety-1-safety-2-whte-papr.pdf - World Health Organization: Surgical Safety Checklist — global reference tool for surgical teamwork and communication.
👉 https://www.who.int/teams/integrated-health-services/patient-safety/research/safe-surgery
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
SPEAKER_00 (00:00):
I think right now across Canada, we're in an
unprecedented time withchallenges and uncertainty
within healthcare.
I do think that now more thanever, us listening into what is
happening at the point of care,what the experience of patients
is, but also what our clinicalteams are experiencing and how
(00:21):
we can help design the system tohelp them.
SPEAKER_01 (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 Ali Muniac, theExecutive Director of Health
(00:50):
System Improvement at HealthQuality British Columbia.
Ali brings a rare and powerfulmix of psychology, human factors
engineering, and deep healthcarequality experience.
Her work spans from observingsurgical teams in action to
uncovering hidden technicalflaws in medical devices.
She's led major system scalesafety investigations, most
(01:12):
notably discovering a defect ininfusion pump tubing that
triggered a global recall bypartnering clinical,
engineering, and vendor teams todig beyond the usual refrain of
just retraining the frontlinestaff to finding the real root
causes.
At HealthQuality BC, Allie nowleads efforts across primary
(01:34):
care, mental health, long-termcare, and physician
administrative burden.
Bringing those frontline detailsto system leaders.
She's someone who refuses toaccept the usual line in
healthcare that says that's justhow it's done.
And she's passionate aboutbuilding systems that support
clinicians, not constrain them.
Allie, it's a pleasure to haveyou on Leading Quality.
SPEAKER_00 (01:57):
Thanks, Jason.
Thanks for having me.
SPEAKER_01 (02:00):
The pleasure's all mine.
And you and I have known eachother for a little while.
We got to uh do a professionaldevelopment program together a
few years ago.
But I I love to I'd love to divea little more into kind of your
background.
And so can you uh tell us a bitabout your journey, kind of what
drew you from a bachelor'sdegree in psychology and then
(02:21):
human factors engineering andhow that led you into healthcare
quality improvement?
SPEAKER_00 (02:25):
Yeah, absolutely.
I think anyone who I have talkedto about human factors
engineering has a unique journeyand how they've discovered the
science and the area and thediscipline.
And so mine also, I never wentto university thinking I'd be a
specialist in human factors.
Started in the typical pre-medprogram, and uh then fell into a
(02:51):
human factors course in myundergraduate in psychology at
the University of Calgary.
I fell in love with thediscipline and I found it easy
and interesting.
And um, I had an opportunity towork with um some great mentors,
um, Dr.
Jeff Carrot and Dr.
Jan Davies at the University ofCalgary, and slowly shifted my
(03:16):
area of focus into humanfactors.
And so had the opportunity tothen pursue a grad graduate
degree um at the University ofToronto under uh the mentorship
of Dr.
Paul Milgram.
And it was my career just kindof took off from there.
So it was an area that I findthat human factors becomes part
(03:38):
of everything that I do, an areathat I think is super important
for um the healthcare system.
SPEAKER_01 (03:44):
Yeah.
And so I've met other types ofengineers in the healthcare
space who've done through, gonethrough um industrial
engineering, processengineering, that kind of stuff.
And a lot of them went into thatknowing that it was a discipline
they could apply to somethinglike manufacturing, just like
they could to healthcare andotherwise.
Was yours a specific, did itbecome a specific focus towards
(04:07):
healthcare?
Or was there a period therewhere you were thinking you
might do human factors researchin in other disciplines?
SPEAKER_00 (04:14):
So I actually started my human factors journey
in the psychology department.
So I'm not an engineer, but Idid do my graduate work in
engineering.
What I ended up starting in isactually transportation safety.
So working at the University ofCalgary, we had a full car
simulator, and we would be atthat time doing different
(04:37):
research studies on novicedrivers and elderly drivers.
We also did a lot of studiesaround cell phone use in
driving, which was a big thingat that point in time before
legislation was in place and uhwent from there.
So I shifted um when we weredoing transportation safety at
(04:59):
that time, uh, when I was inCalgary, there was also an
opportunity to be exposed tosome areas in healthcare.
And that was my area of passion.
So yeah.
SPEAKER_01 (05:09):
That's great.
So, like a lot of us in thequality improvement world found
uh an interesting way to stumbleinto it.
SPEAKER_00 (05:15):
Yeah, and there was um there was a big um event
within Calgary um around amix-up of potassium chloride and
sodium chloride.
Um, and so at that point intime, um, there was some
opportunity to be involved injust some different types of
reviews and understanding someof the human factors
requirements to medicationmanagement, um, mislabeling and
(05:41):
other different areas aroundinfusion pumps and how they
actually work within healthcareenvironments.
So it felt like I kind of fellinto it, but then very quickly
uh found that it was veryinteresting.
It was very needed inhealthcare.
And there was a big opportunityto really bring that human
factors expertise into workingin partnership with clinicians
(06:05):
on identifying how we can makethe health system safer.
SPEAKER_01 (06:09):
When you first entered where your training
wasn't in kind of an explicithealthcare provision discipline,
what did you think about workingwith clinical people about how
clinical systems were designed?
Do you remember some of thosefirst impressions you had?
SPEAKER_00 (06:28):
Yes, there was a couple.
And when I first started, I hadgreat um advice from Dr.
Jan Davies, who was a practicinganesthesiologist at that time.
And what she said to me was formy career, if I was to work in
healthcare, it would be veryimportant for me to partner and
(06:49):
have strong partnerships withclinical individuals, bringing
my expertise and bringing theirexpertise together.
I think one of the things that Ifound so surprising was just the
conversations around, well, thisis just the way that things are
done.
So the number of interviews ormeetings is like, well, this is
just the way we've always doneit.
(07:10):
So I kind of got this uh driveto really challenge the status
quo and be curious withindividuals around, well, how
can we potentially make thingsbetter for you?
SPEAKER_01 (07:22):
Yeah.
And that that has led you toultimately to your current role
as an executive director withHealth Quality British Columbia.
For listeners who might not befamiliar, uh, what is Health
Quality BC and how does it fitinto a landscape of provincial
care?
Are you providing direct patientcare or is it uh is it something
other than that?
SPEAKER_00 (07:42):
Yeah, so health quality BC, we're arm's length
to the health authorities and tothe Ministry of Health.
And so what our value is, isthat we have um an impartiality
to how we can actually look atthe health system.
So our key purpose is to improvehealth care quality across
British Columbia.
(08:03):
So we're a provincial entity,and we our main driver is to
really bring health systempartners together to accelerate
action on key quality of careissues within the province.
So this could look a whole bunchof different ways.
It's system-wide impact throughthings like reactive or
retrospective types of thingswhere there's like patient
(08:25):
safety concerns, or how we'reactually driving quality
improvement forward throughinnovative thinking,
evidence-informed strategies,and areas where we can really
shift the culture and improveclinical practice.
So the opportunity, why I lovethis organization and um enjoy
(08:47):
working here so much is that itprovides that holistic view of
the system, but we have theopportunity to really work at or
work with individuals from pointof care to leadership and
management to executive, board,and ministry, as well as other
external partners like doctorsat BC and MPBC, et cetera.
SPEAKER_01 (09:09):
How do these projects kind of come through
the door?
Are you embedded in hospitalsworking in some of the same
hospitals all the time and newprojects emerge?
Or how are those prioritiescoming in and how are they set?
SPEAKER_00 (09:23):
So we try to align our priorities with um key
mandate components out of theministry, but also um having our
ear to the ground with ourpartners at the point of care
and within the healthauthorities around what are
emerging areas of concern orconsistent areas that we need to
(09:44):
be um raising the attention ofand that uh need to be
prioritized within operationalprioritization.
SPEAKER_01 (09:52):
Yeah.
Shifting gears a little bit tokind of your present work,
you've talked uh about theimportance of how people
interact with tools, not justthe fact that the tools exist.
And you and I talked a littlebit offline about your work in
surgical safety checklists.
I'm curious what that lookedlike and and how the, you know,
(10:16):
how you use the tool versus justhaving the tool was uh became a
rough concept for you.
SPEAKER_00 (10:22):
So I started actually when I moved to British
Columbia, um, I met uh Dr.
Doug Conquerin at that time.
And um, this was in around 2008,and we had an interest both in
making surgical safety betterand safer.
And so at that point in time,Atul Gwandi's work was uh
(10:47):
emerging around the surgicalsafety checklist and the work
with the World HealthOrganization.
And so it seemed like a naturalarea to uh focus on.
We also did a bunch of workaround bringing some of those
human factors components intothe system as well.
And so looking at things likenon-technical skills and how
(11:08):
teams actually function.
And so, in hindsight, lookingback to it, a lot of the work
was very much about introducinga tool like a checklist and the
implementation of that tool.
But there weren't as manyconversations around the how the
tool is used with complex teamsand how those conversations are
(11:30):
so important to increase thingslike situation awareness,
problem solving, anticipatorytypes of behavior around
anticipating what the potentialrisks are within this space, and
then how a team couldpotentially um respond to um
with like role clarity and howthey would potentially respond
(11:51):
to things that were coming up.
SPEAKER_01 (11:53):
And so when you when you did this work, one thing you
shared with me was that youwatched cases in the OR, I'm
guessing on video, and youlooked at 300 plus cases looking
for important features of howpeople carried out the
checklist.
Tell me about that.
SPEAKER_00 (12:12):
Yeah, so it started with uh, I'll say with Doug's
vision.
And he uh unfortunately he didpass away last year, but I know
he is okay with me sharing this.
But our first conversation thathim and I had was him reviewing
video of a surgical procedure hehad been completing with one of
(12:34):
his fellows.
And there was a conversationaround what the two sets of
hands were doing within thattechnical case.
And he provided feedback to hisfellow uh based upon what he
thought was an improvement onthat one set of hands.
And what he realized was it wasactually his set of hands that
(12:54):
um he should have been providingthe improvement to.
And so what he said to me whenwe started this conversation was
he asked me, would I be willingto come and do some shadow
shifts within the operating roomwith him?
Because what he said is I don'tknow what else I'm missing and
what I'm not seeing from thelarger team.
(13:17):
And so he was one of the firstpeople that I had interacted
with who was very, very awarebut curious about what those
non-technical components, howthey were potentially impacting
his cases in a positive way orpotentially in a way that was uh
potentially decreasing thesafety of the case.
(13:39):
So we started um doingobservations just by looking at
having a third, like kind of afly on the wall type of
approach.
And I know that there's likemuch more technical ways of
doing this, but we wanted toslowly make this and normalize
it for the team members ofbringing in people to observe in
(14:03):
a curious way, as opposed to itbeing a punitive or a technical
type of review.
So we started by actuallylooking at how many times the
doors open and closed in theoperating room, which sounds
kind of simple, but it wasactually fascinating from a
culture perspective around howthe doors open and closed, the
(14:25):
conversations that happened.
Technically, that the HFACsystem probably wasn't keeping
up with the number of times thedoors opened and closed within
the space.
But we did 30 cases looking atthat.
Um, and then what we did wasonce people were comfortable
with um having an observer inthe room, knowing that that
(14:46):
observer was not looking atindividual factors of
performance, but more on thatsystem level opportunity uh for
looking for opportunities forimprovement.
And then we shifted to thingslike the surgical safety
checklist.
So, how are people doingbriefings?
How are they doing timeouts?
How are they mobilizing the teambefore the procedure begins?
(15:10):
And then how are they doing andpreparing that handoff to
perioperative um like recoveryrooms and so and so forth?
SPEAKER_01 (15:19):
And I can imagine, I mean, you've gotten so into the
weeds there in terms of doorsopening and closing, you know,
the eye contact, the uh theusing the uh the checklist and
using it well or using it as a acheckbox, you know, purely as a
as a as a checkbox in your day.
I love diving into theseconversations, and I'm realizing
(15:40):
we haven't taken the time tokind of define what human
factors is for people who mightnot be as initiated.
Can you, you know, given whatyou've just described, can you
tell us how, like, what is humanfactors and how does a human
factors um engineering personthink?
SPEAKER_00 (15:56):
Yeah, so human factors is a large discipline.
And so the high-level definitionthat I like to use is by
Alphonse Schiphanis.
And what he says is it's reallyaround um the human
characteristics of how teams,systems, tasks, jobs,
environments all come together.
And so um, what we want to do isreally understand both the
(16:20):
physical characteristics, butalso the human characteristics
of how a system works.
And so these human abilities,human limitations, and other
human characteristics that arerelevant to design are things
that could be both the physicalinteractions, which we're very
familiar with with things likeergonomics, but it's also the
(16:43):
cognitive component, so howpeople respond, the decision
making, the reaction times, theinformation processing that
people do, and then the teamdynamics on top of it.
And so I think what's uniqueabout human factors is that
there's a variety of differentways to get involved in the
(17:04):
area.
So some people have a straightpsychology background, some have
a straight engineeringbackground, some have gone
through computer scienceprograms, and then there's some
of us who have a mix of two orthree of those different types
of disciplines.
There's also areas like humankinetics and anatomy types of
(17:25):
areas as well.
So I think what's helpful inthis area is that it often
brings a variety of differentexpertise from different areas
together to really understandhow people and technology and
the physical environment andteams all come together.
(17:45):
And so you can focus in on oneor two of the components, or you
can focus in on like a largerarea within that space.
SPEAKER_01 (17:53):
Yeah, I'm reminded as you're talking about uh
essentially what you're talkingabout is is uh systems thinking
and you know, envisioning, youknow, this is something that has
gained a lot of traction, but Ithink depending on where you go
and who you talk to inhealthcare, the idea of systems
thinking as a part of your yourregular work is is maybe a novel
(18:15):
concept.
And I wonder if that's kind ofone of the challenges in
demonstrating value, in gettingin the door for uh like to work
with healthcare people is justto to um you know present
yourself as an expert in systemsand an expert in how the human
and the infrastructural and theother components of a system are
(18:39):
working together and that thatadditional expertise, which I'm
very bought into, but that thatadditional expertise is needed.
SPEAKER_00 (18:46):
Well, and it's something, you know, I've
thought about it often, and um,and when I've talked with other
human factors experts aboutthis, what I find so interesting
is that many of the things thatwe're identifying often feel
like common sense in anenvironment, but when things
aren't working well or whenyou're frustrated, it often
(19:08):
comes across as like a verystrong emotional response.
Like, you know, when you turn onthe wrong element of the stove
and you take that personally, oryou get frustrated, or you mix
up something with like an ETMmachine and the buttons aren't
where you expect it, or ifyou're paying for parking, like
there's all of these thingswithin our physical environments
(19:30):
and our day-to-day environmentsthat we either just accept or we
just assume that there's goingto be some level of frustration
and um challenge.
SPEAKER_01 (19:42):
You were very generous in using those examples
and not the the one that you andI just encountered together,
which was in trying to hitrecord.
I was logged in as a guest to uhto this platform and uh had to
log myself back in as the uh asthe host.
So I feel that frustration.
I felt it just a minute ago.
That's that's great.
With another powerful story fromyour career, uh has to do with
(20:06):
continuous infusion pumps and areally important finding that
you had, which led to a reallybig global impact, even beyond,
I think, where you thought itwould go.
Tell me about that.
SPEAKER_00 (20:17):
Yeah, it's interesting that infusion pumps.
I I started my career withinfusion pumps in the University
of Calgary, where we wereevaluating the different
infusion pumps that couldpotentially um come into the
health system there.
Um, and more on the procurementside and the usability side and
identifying where there waspotentially like safety um
(20:39):
factors that needed to beconsidered.
But I worked for 15 years atVancouver Coastal Health and
loved my experience there.
And one of the things that cameup in um around 2018 was that we
were implementing a new infusionpump into the health authority.
(21:01):
And at that point in time, wealso started to identify uh some
safety concerns withover-infusion events that were
happening.
And they were spontaneousover-infusion events.
And this occurred by an ICUnurse coming to our office and
identifying that this was aconcern and that they were quite
(21:23):
worried about this.
So, one of the things that wasso interesting is that it was a
multidisciplinary team that cametogether where we had uh quality
and safety and human factors, wehad professional practice with
nursing, we had our medicalstaff, um, we have biomedical
engineering, and we also had ourrisk department come together,
(21:46):
as well as the point of careclinicians and identifying what
could potentially be happening.
We also partnered with thevendor who was like super
responsive and wanting to workcollaboratively on trying to
solve this.
Now, the thing that was sointeresting about this was the
initial response was going tothat individual factor.
(22:09):
So it must have been somethingthat the nurse had programmed.
And so the nurses, therecommendation initially from
the vendor was to just requiremore training.
And we know from the hierarchyof effectiveness that training
is one of the least effectivemethods of improvement in a
system.
(22:29):
And I'll be honest, I didn'tthink it was a training issue.
And so knowing that we had ourhighly trained critical care
nurses having problems withloading the tubing seemed like a
bigger system concern and abigger issue with the actual
technology.
So it took us some time and itwas very unsettling because we
(22:53):
didn't actually know what theissue was, but through a variety
of different tests, and actuallyone of the nurses identifying an
overinfusion event, being ableto very quickly take the device
and remove the device from thepatient and keeping the
integrity of the device, we wereable to actually, with our
(23:15):
biomedical engineering partners,identify what the potential
issue was.
Um, and so they did a whole hostof different things that
included actually in partnershipwith the vendor doing uh a micro
CT scan of the tubing set andidentified a huge concentricity
(23:36):
uh issue with the tubing.
And what that means is that ifyou think of something looking
like an equal Cheerio or adonut, there was one wall that
was very thick and one that wasvery thin.
And when you use that with thedevice, it could impact the
occlusion of how the tubing setwould work within the pump.
(24:00):
Now, this was fascinating for meand for the team because it
really showed that it was atechnical issue or a quality
control issue with the tubingset that somebody couldn't
identify with their own eyes.
And so a clinician would beguessing because they wouldn't
be able to actually determine ifthere was an issue with the
(24:22):
tubing.
What ended up happening was thatthe tubing sets were recalled,
the vendor was involved with therecall as well, and globally
hundreds of million tubing setswere recalled.
And so it's one of the um areaslike this was me in partnership
(24:42):
with a variety of differentpeople.
This was the success of this wasbecause we were an
interdisciplinary team.
But um I think this onehighlighted to me that the
importance of listening to yourpoint of care team members.
And when something doesn't feelright, that the first response
(25:02):
shouldn't necessarily be thatsomebody requires more training,
but actually to dig a little bitdeeper into this uh to the issue
to see if we could actuallysolve a larger safety concern.
SPEAKER_01 (25:15):
I think a lot of our audience could relate to a lot
of the the themes that arecoming up in what you're what
you're sharing here.
You know, the the idea that Ithink so many of us who have
gotten into healthcare by anyroute are you know, have gone
through a lot of education.
And there is a stronginclination we all have to say,
(25:36):
first of all, as you as youmentioned, to have the
responsibility rest very heavilywith individuals.
And so if there was a problem,it was at the individual level,
not at the population or systemlevel.
And then to uh to think thateducation will be the answer and
maybe to skip some of thosesteps that we know to do,
looking at root cause analysis,for example, by various
(25:59):
modalities, and instead justsaying, okay, well, let's
retrain them.
Was this team that you'redescribing, were were they, you
know, naturally just able to saylet's push beyond training,
training, training?
Were they all thinking that?
Or was it a r was that one ofthe challenges to success here?
Was actually pushing people tonot think in that limited
(26:20):
training first kind of way?
SPEAKER_00 (26:22):
It was definitely a team who is very systems
focused.
And so I think um in healthcare,especially in a quality and
safety role, you have a wholehost of different things that
are coming up that are tend tobe a reactive situation related
(26:42):
to either patient safety orquality of care or overall
experience.
Um for this, I think it wasreally building trust within the
clinical team members as well asa team that was willing to
investigate.
(27:03):
Now, our investigation took overnine months to figure out this
actual problem.
And so we did start withtraining, and it was around the
framing to the point of careclinicians around we want to try
this training.
We're not 100% sure this is thetraining issue, but can you work
(27:25):
with us?
And we made it verycollaborative.
Um, we had weekly meetings wherewe had on-site um discussions,
we had forum meetings, we hademails to really uh overly
communicate and um build thetrust.
And I think the thing that wasso interesting in this situation
(27:47):
was it was actually a point ofcare nurse actually recording
the event happening andrealizing what was going on.
Um, so responding, recording,and then um being able to work
collaboratively with us aroundthe identification of an issue
and then having the trust thatthere was a team able to respond
(28:10):
and um help problem solve it,and that it wasn't rate back to
the individual being involvedwith the issue.
SPEAKER_01 (28:18):
Yeah, it sounds like incredible learning.
And uh the fact that you had asystem with enough psychological
safety that this nurse was ableto freely report this.
And and I I would guess thatafter he or she reported the uh
the issue, that other nursesprobably came forward and said,
Oh yeah, I've seen that too.
SPEAKER_00 (28:39):
Yeah, well, and we had proactively had the
conversation as well.
And so I think what wasconcerning for us is that when
we started to dive intoidentifying this issue, we
weren't the only ones that hadhad this issue.
That I think this issue had beengoing on for many years, but it
tended to go back to theindividual having to actually
(29:02):
load the tubing and not theactual technical piece of it.
I think the part that it spoketo for me is the importance of
trust and transparency in asystem.
And so all of us have differentroles to play in a health
system, but the importance islike really trusting and
(29:23):
respecting your point of careclinicians and also your point
of care clinicians having thattrust and respect and connection
with other members, um, likeeither support services or
leadership or even yourexecutive teams.
Um, because they were reallyresponsive in this example for
(29:44):
us.
SPEAKER_01 (29:45):
Congratulations again on that success.
It sounds like it was profoundand like global recall that you
know saved probably uh, youknow, a really hard it's hard to
imagine how many lives mighthave been saved by that recall.
Now to kind.
of reflect a little bit.
So one of the the themes of thispodcast is is about leadership
and how we lead quality.
(30:06):
And I'm wondering now thatyou've had such a a strong
career up until now, what what'sthe most common mistake that you
see leaders of all stripes,whether it's clinicians or
non-clinicians, what is the whatare the mistakes that you see
leaders making when uh when theytry to improve quality and
safety?
SPEAKER_00 (30:25):
That's a good question.
I think for me it would be twothings.
So one is giving yourself thetime to really listen and be
curious.
I find often in operationalroles they're so taxing and so
(30:45):
time consuming and there's somuch coming at leaders
specifically that it often tendsto be just checking things off
your list.
And it's really hard to maketime and space to like really
listen and hear and even watchand shadow what's actually
happening within theenvironments and and how care is
(31:08):
being provided and what thatexperience is for patients, what
that experience is for theproviders and the staff and how
we can potentially do better.
I think the other one that Ithink is super important is it's
very easy to focus on thenegative and not focus in on
what's going well.
And for me, you know there's alot of work around safety one
(31:30):
and safety two, which is um withEric Honnegel and um really
looking at like so safety onebeing like retrospective or like
reactive and safety two beinglike anticipate anticipating and
looking at how things are goingwell in the system.
But I think for me identifyingwhere things are going well and
(31:54):
how you can scale and spreadwhat's working well as opposed
to fixing what is wrong all thetime is a really important area
with leadership.
SPEAKER_01 (32:04):
Yeah, absolutely.
This is the the uh book ThinkingFast and Slow by Daniel Kahnman
is that what you're referringto?
SPEAKER_00 (32:10):
Yeah, exactly.
Yeah there's a variety ofdifferent um like academic books
and other books as well thatlike talk about that as well.
And yeah fast and slow is key.
I think it's I know when inCOVID it was like working 14, 16
hour days and just it being acomplete blur and getting so
(32:32):
much done but then also makingsure that you're supporting your
team that you are aware ofwhat's happening within the
environment and that you'reanticipating in a way that isn't
just leaving people behind.
SPEAKER_01 (32:49):
Looking ahead what are your aspirations for Health
Quality BC and and your workthere what what excites you
about uh what lies ahead well Ithink right now uh across Canada
we're in an unprecedented timewith challenges and uncertainty
within healthcare and so I dothink that there is a lot of
(33:12):
opportunity to showcase what'sworking well, the highlighting
areas of success.
SPEAKER_00 (33:20):
But also I think for me with Health Quality BC, some
of the areas that I think aresuper important for us is really
expanding our dimensions ofquality so really focusing in on
how we provide quality of careacross the province.
I know we're doing some workwithin patient safety again, but
(33:42):
patient safety in a way thatbrings in what I just mentioned
around really looking in what'sworking well within the system,
how do we scale and spread thatand how do we proactively make
things as safe as possiblerather than just focusing solely
on reviews and events and theyneed to happen together.
(34:04):
But you can't have one withoutthe other I think.
SPEAKER_01 (34:08):
I can imagine there's some maybe some barriers
to to being proactive whenthere's so much that there's so
many tasks you can react to.
SPEAKER_00 (34:18):
Yes, absolutely and so I think it's making the space
to do a little bit of that focusin on what's working well I
think building that trust andtransparency in the system is
key.
And I do think that now morethan ever us listening into what
is happening at the point ofcare, what the experience of
(34:41):
patients is but also what ourclinical teams are experiencing
and how we can help design asystem to help them not feel
like they are restricted in thework that they're doing, but
that we are integratingtechnology in a way that makes
sense, that we're not putting upburdens and like administrative
(35:02):
challenges that make things hardfor people to do the right
thing.
SPEAKER_01 (35:07):
I love that.
And I think that's a great placeto round out the conversation
I'm so grateful to you for forhaving this conversation with me
today.
And I'm glad that I got toselfishly kind of deepen my own
knowledge of human factors andof your story.
If listeners want to follow yourwork or get in touch um what
would be the best way for themto connect with you?
SPEAKER_00 (35:29):
They can go to our website at healthqualitybc and
our emails contact is on thereas well and you're feel free to
email me or to reach out to ourorganization we'd be more than
happy to share what we're doing.
We have lots of free resourcesand try to share as much of what
(35:49):
we do so that other people inthe province within Canada and
even globally can utilize thetools and things that we've
developed.
SPEAKER_01 (36:00):
That's great.
Ali thanks so much again foryour time it was great having
you today.
Thanks Jason thanks so much forlistening to today's episode of
Leading Quality.
If you enjoyed the show pleasetake a moment to like subscribe
and share it with someone whomight find it useful.
You can find all our episodes atleadingqualitybugsprout dot com
(36:21):
or in your favorite podcast app.
The show is written and hostedby me Jason Meadows edited by
Milan Milosafievich and producedby Thrive Healthcare
Improvement.
See you next time last
I think right now across Canada, we're in an
unprecedented time withchallenges and uncertainty
within healthcare.
I do think that now more thanever, us listening into what is
happening at the point of care,what the experience of patients
is, but also what our clinicalteams are experiencing and how
(00:21):
we can help design the system tohelp them.
SPEAKER_01 (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 Ali Muniac, theExecutive Director of Health
(00:50):
System Improvement at HealthQuality British Columbia.
Ali brings a rare and powerfulmix of psychology, human factors
engineering, and deep healthcarequality experience.
Her work spans from observingsurgical teams in action to
uncovering hidden technicalflaws in medical devices.
She's led major system scalesafety investigations, most
(01:12):
notably discovering a defect ininfusion pump tubing that
triggered a global recall bypartnering clinical,
engineering, and vendor teams todig beyond the usual refrain of
just retraining the frontlinestaff to finding the real root
causes.
At HealthQuality BC, Allie nowleads efforts across primary
(01:34):
care, mental health, long-termcare, and physician
administrative burden.
Bringing those frontline detailsto system leaders.
She's someone who refuses toaccept the usual line in
healthcare that says that's justhow it's done.
And she's passionate aboutbuilding systems that support
clinicians, not constrain them.
Allie, it's a pleasure to haveyou on Leading Quality.
SPEAKER_00 (01:57):
Thanks, Jason.
Thanks for having me.
SPEAKER_01 (02:00):
The pleasure's all mine.
And you and I have known eachother for a little while.
We got to uh do a professionaldevelopment program together a
few years ago.
But I I love to I'd love to divea little more into kind of your
background.
And so can you uh tell us a bitabout your journey, kind of what
drew you from a bachelor'sdegree in psychology and then
(02:21):
human factors engineering andhow that led you into healthcare
quality improvement?
SPEAKER_00 (02:25):
Yeah, absolutely.
I think anyone who I have talkedto about human factors
engineering has a unique journeyand how they've discovered the
science and the area and thediscipline.
And so mine also, I never wentto university thinking I'd be a
specialist in human factors.
Started in the typical pre-medprogram, and uh then fell into a
(02:51):
human factors course in myundergraduate in psychology at
the University of Calgary.
I fell in love with thediscipline and I found it easy
and interesting.
And um, I had an opportunity towork with um some great mentors,
um, Dr.
Jeff Carrot and Dr.
Jan Davies at the University ofCalgary, and slowly shifted my
(03:16):
area of focus into humanfactors.
And so had the opportunity tothen pursue a grad graduate
degree um at the University ofToronto under uh the mentorship
of Dr.
Paul Milgram.
And it was my career just kindof took off from there.
So it was an area that I findthat human factors becomes part
(03:38):
of everything that I do, an areathat I think is super important
for um the healthcare system.
SPEAKER_01 (03:44):
Yeah.
And so I've met other types ofengineers in the healthcare
space who've done through, gonethrough um industrial
engineering, processengineering, that kind of stuff.
And a lot of them went into thatknowing that it was a discipline
they could apply to somethinglike manufacturing, just like
they could to healthcare andotherwise.
Was yours a specific, did itbecome a specific focus towards
(04:07):
healthcare?
Or was there a period therewhere you were thinking you
might do human factors researchin in other disciplines?
SPEAKER_00 (04:14):
So I actually started my human factors journey
in the psychology department.
So I'm not an engineer, but Idid do my graduate work in
engineering.
What I ended up starting in isactually transportation safety.
So working at the University ofCalgary, we had a full car
simulator, and we would be atthat time doing different
(04:37):
research studies on novicedrivers and elderly drivers.
We also did a lot of studiesaround cell phone use in
driving, which was a big thingat that point in time before
legislation was in place and uhwent from there.
So I shifted um when we weredoing transportation safety at
(04:59):
that time, uh, when I was inCalgary, there was also an
opportunity to be exposed tosome areas in healthcare.
And that was my area of passion.
So yeah.
SPEAKER_01 (05:09):
That's great.
So, like a lot of us in thequality improvement world found
uh an interesting way to stumbleinto it.
SPEAKER_00 (05:15):
Yeah, and there was um there was a big um event
within Calgary um around amix-up of potassium chloride and
sodium chloride.
Um, and so at that point intime, um, there was some
opportunity to be involved injust some different types of
reviews and understanding someof the human factors
requirements to medicationmanagement, um, mislabeling and
(05:41):
other different areas aroundinfusion pumps and how they
actually work within healthcareenvironments.
So it felt like I kind of fellinto it, but then very quickly
uh found that it was veryinteresting.
It was very needed inhealthcare.
And there was a big opportunityto really bring that human
factors expertise into workingin partnership with clinicians
(06:05):
on identifying how we can makethe health system safer.
SPEAKER_01 (06:09):
When you first entered where your training
wasn't in kind of an explicithealthcare provision discipline,
what did you think about workingwith clinical people about how
clinical systems were designed?
Do you remember some of thosefirst impressions you had?
SPEAKER_00 (06:28):
Yes, there was a couple.
And when I first started, I hadgreat um advice from Dr.
Jan Davies, who was a practicinganesthesiologist at that time.
And what she said to me was formy career, if I was to work in
healthcare, it would be veryimportant for me to partner and
(06:49):
have strong partnerships withclinical individuals, bringing
my expertise and bringing theirexpertise together.
I think one of the things that Ifound so surprising was just the
conversations around, well, thisis just the way that things are
done.
So the number of interviews ormeetings is like, well, this is
just the way we've always doneit.
(07:10):
So I kind of got this uh driveto really challenge the status
quo and be curious withindividuals around, well, how
can we potentially make thingsbetter for you?
SPEAKER_01 (07:22):
Yeah.
And that that has led you toultimately to your current role
as an executive director withHealth Quality British Columbia.
For listeners who might not befamiliar, uh, what is Health
Quality BC and how does it fitinto a landscape of provincial
care?
Are you providing direct patientcare or is it uh is it something
other than that?
SPEAKER_00 (07:42):
Yeah, so health quality BC, we're arm's length
to the health authorities and tothe Ministry of Health.
And so what our value is, isthat we have um an impartiality
to how we can actually look atthe health system.
So our key purpose is to improvehealth care quality across
British Columbia.
(08:03):
So we're a provincial entity,and we our main driver is to
really bring health systempartners together to accelerate
action on key quality of careissues within the province.
So this could look a whole bunchof different ways.
It's system-wide impact throughthings like reactive or
retrospective types of thingswhere there's like patient
(08:25):
safety concerns, or how we'reactually driving quality
improvement forward throughinnovative thinking,
evidence-informed strategies,and areas where we can really
shift the culture and improveclinical practice.
So the opportunity, why I lovethis organization and um enjoy
(08:47):
working here so much is that itprovides that holistic view of
the system, but we have theopportunity to really work at or
work with individuals from pointof care to leadership and
management to executive, board,and ministry, as well as other
external partners like doctorsat BC and MPBC, et cetera.
SPEAKER_01 (09:09):
How do these projects kind of come through
the door?
Are you embedded in hospitalsworking in some of the same
hospitals all the time and newprojects emerge?
Or how are those prioritiescoming in and how are they set?
SPEAKER_00 (09:23):
So we try to align our priorities with um key
mandate components out of theministry, but also um having our
ear to the ground with ourpartners at the point of care
and within the healthauthorities around what are
emerging areas of concern orconsistent areas that we need to
(09:44):
be um raising the attention ofand that uh need to be
prioritized within operationalprioritization.
SPEAKER_01 (09:52):
Yeah.
Shifting gears a little bit tokind of your present work,
you've talked uh about theimportance of how people
interact with tools, not justthe fact that the tools exist.
And you and I talked a littlebit offline about your work in
surgical safety checklists.
I'm curious what that lookedlike and and how the, you know,
(10:16):
how you use the tool versus justhaving the tool was uh became a
rough concept for you.
SPEAKER_00 (10:22):
So I started actually when I moved to British
Columbia, um, I met uh Dr.
Doug Conquerin at that time.
And um, this was in around 2008,and we had an interest both in
making surgical safety betterand safer.
And so at that point in time,Atul Gwandi's work was uh
(10:47):
emerging around the surgicalsafety checklist and the work
with the World HealthOrganization.
And so it seemed like a naturalarea to uh focus on.
We also did a bunch of workaround bringing some of those
human factors components intothe system as well.
And so looking at things likenon-technical skills and how
(11:08):
teams actually function.
And so, in hindsight, lookingback to it, a lot of the work
was very much about introducinga tool like a checklist and the
implementation of that tool.
But there weren't as manyconversations around the how the
tool is used with complex teamsand how those conversations are
(11:30):
so important to increase thingslike situation awareness,
problem solving, anticipatorytypes of behavior around
anticipating what the potentialrisks are within this space, and
then how a team couldpotentially um respond to um
with like role clarity and howthey would potentially respond
(11:51):
to things that were coming up.
SPEAKER_01 (11:53):
And so when you when you did this work, one thing you
shared with me was that youwatched cases in the OR, I'm
guessing on video, and youlooked at 300 plus cases looking
for important features of howpeople carried out the
checklist.
Tell me about that.
SPEAKER_00 (12:12):
Yeah, so it started with uh, I'll say with Doug's
vision.
And he uh unfortunately he didpass away last year, but I know
he is okay with me sharing this.
But our first conversation thathim and I had was him reviewing
video of a surgical procedure hehad been completing with one of
(12:34):
his fellows.
And there was a conversationaround what the two sets of
hands were doing within thattechnical case.
And he provided feedback to hisfellow uh based upon what he
thought was an improvement onthat one set of hands.
And what he realized was it wasactually his set of hands that
(12:54):
um he should have been providingthe improvement to.
And so what he said to me whenwe started this conversation was
he asked me, would I be willingto come and do some shadow
shifts within the operating roomwith him?
Because what he said is I don'tknow what else I'm missing and
what I'm not seeing from thelarger team.
(13:17):
And so he was one of the firstpeople that I had interacted
with who was very, very awarebut curious about what those
non-technical components, howthey were potentially impacting
his cases in a positive way orpotentially in a way that was uh
potentially decreasing thesafety of the case.
(13:39):
So we started um doingobservations just by looking at
having a third, like kind of afly on the wall type of
approach.
And I know that there's likemuch more technical ways of
doing this, but we wanted toslowly make this and normalize
it for the team members ofbringing in people to observe in
(14:03):
a curious way, as opposed to itbeing a punitive or a technical
type of review.
So we started by actuallylooking at how many times the
doors open and closed in theoperating room, which sounds
kind of simple, but it wasactually fascinating from a
culture perspective around howthe doors open and closed, the
(14:25):
conversations that happened.
Technically, that the HFACsystem probably wasn't keeping
up with the number of times thedoors opened and closed within
the space.
But we did 30 cases looking atthat.
Um, and then what we did wasonce people were comfortable
with um having an observer inthe room, knowing that that
(14:46):
observer was not looking atindividual factors of
performance, but more on thatsystem level opportunity uh for
looking for opportunities forimprovement.
And then we shifted to thingslike the surgical safety
checklist.
So, how are people doingbriefings?
How are they doing timeouts?
How are they mobilizing the teambefore the procedure begins?
(15:10):
And then how are they doing andpreparing that handoff to
perioperative um like recoveryrooms and so and so forth?
SPEAKER_01 (15:19):
And I can imagine, I mean, you've gotten so into the
weeds there in terms of doorsopening and closing, you know,
the eye contact, the uh theusing the uh the checklist and
using it well or using it as a acheckbox, you know, purely as a
as a as a checkbox in your day.
I love diving into theseconversations, and I'm realizing
(15:40):
we haven't taken the time tokind of define what human
factors is for people who mightnot be as initiated.
Can you, you know, given whatyou've just described, can you
tell us how, like, what is humanfactors and how does a human
factors um engineering personthink?
SPEAKER_00 (15:56):
Yeah, so human factors is a large discipline.
And so the high-level definitionthat I like to use is by
Alphonse Schiphanis.
And what he says is it's reallyaround um the human
characteristics of how teams,systems, tasks, jobs,
environments all come together.
And so um, what we want to do isreally understand both the
(16:20):
physical characteristics, butalso the human characteristics
of how a system works.
And so these human abilities,human limitations, and other
human characteristics that arerelevant to design are things
that could be both the physicalinteractions, which we're very
familiar with with things likeergonomics, but it's also the
(16:43):
cognitive component, so howpeople respond, the decision
making, the reaction times, theinformation processing that
people do, and then the teamdynamics on top of it.
And so I think what's uniqueabout human factors is that
there's a variety of differentways to get involved in the
(17:04):
area.
So some people have a straightpsychology background, some have
a straight engineeringbackground, some have gone
through computer scienceprograms, and then there's some
of us who have a mix of two orthree of those different types
of disciplines.
There's also areas like humankinetics and anatomy types of
(17:25):
areas as well.
So I think what's helpful inthis area is that it often
brings a variety of differentexpertise from different areas
together to really understandhow people and technology and
the physical environment andteams all come together.
(17:45):
And so you can focus in on oneor two of the components, or you
can focus in on like a largerarea within that space.
SPEAKER_01 (17:53):
Yeah, I'm reminded as you're talking about uh
essentially what you're talkingabout is is uh systems thinking
and you know, envisioning, youknow, this is something that has
gained a lot of traction, but Ithink depending on where you go
and who you talk to inhealthcare, the idea of systems
thinking as a part of your yourregular work is is maybe a novel
(18:15):
concept.
And I wonder if that's kind ofone of the challenges in
demonstrating value, in gettingin the door for uh like to work
with healthcare people is justto to um you know present
yourself as an expert in systemsand an expert in how the human
and the infrastructural and theother components of a system are
(18:39):
working together and that thatadditional expertise, which I'm
very bought into, but that thatadditional expertise is needed.
SPEAKER_00 (18:46):
Well, and it's something, you know, I've
thought about it often, and um,and when I've talked with other
human factors experts aboutthis, what I find so interesting
is that many of the things thatwe're identifying often feel
like common sense in anenvironment, but when things
aren't working well or whenyou're frustrated, it often
(19:08):
comes across as like a verystrong emotional response.
Like, you know, when you turn onthe wrong element of the stove
and you take that personally, oryou get frustrated, or you mix
up something with like an ETMmachine and the buttons aren't
where you expect it, or ifyou're paying for parking, like
there's all of these thingswithin our physical environments
(19:30):
and our day-to-day environmentsthat we either just accept or we
just assume that there's goingto be some level of frustration
and um challenge.
SPEAKER_01 (19:42):
You were very generous in using those examples
and not the the one that you andI just encountered together,
which was in trying to hitrecord.
I was logged in as a guest to uhto this platform and uh had to
log myself back in as the uh asthe host.
So I feel that frustration.
I felt it just a minute ago.
That's that's great.
With another powerful story fromyour career, uh has to do with
(20:06):
continuous infusion pumps and areally important finding that
you had, which led to a reallybig global impact, even beyond,
I think, where you thought itwould go.
Tell me about that.
SPEAKER_00 (20:17):
Yeah, it's interesting that infusion pumps.
I I started my career withinfusion pumps in the University
of Calgary, where we wereevaluating the different
infusion pumps that couldpotentially um come into the
health system there.
Um, and more on the procurementside and the usability side and
identifying where there waspotentially like safety um
(20:39):
factors that needed to beconsidered.
But I worked for 15 years atVancouver Coastal Health and
loved my experience there.
And one of the things that cameup in um around 2018 was that we
were implementing a new infusionpump into the health authority.
(21:01):
And at that point in time, wealso started to identify uh some
safety concerns withover-infusion events that were
happening.
And they were spontaneousover-infusion events.
And this occurred by an ICUnurse coming to our office and
identifying that this was aconcern and that they were quite
(21:23):
worried about this.
So, one of the things that wasso interesting is that it was a
multidisciplinary team that cametogether where we had uh quality
and safety and human factors, wehad professional practice with
nursing, we had our medicalstaff, um, we have biomedical
engineering, and we also had ourrisk department come together,
(21:46):
as well as the point of careclinicians and identifying what
could potentially be happening.
We also partnered with thevendor who was like super
responsive and wanting to workcollaboratively on trying to
solve this.
Now, the thing that was sointeresting about this was the
initial response was going tothat individual factor.
(22:09):
So it must have been somethingthat the nurse had programmed.
And so the nurses, therecommendation initially from
the vendor was to just requiremore training.
And we know from the hierarchyof effectiveness that training
is one of the least effectivemethods of improvement in a
system.
(22:29):
And I'll be honest, I didn'tthink it was a training issue.
And so knowing that we had ourhighly trained critical care
nurses having problems withloading the tubing seemed like a
bigger system concern and abigger issue with the actual
technology.
So it took us some time and itwas very unsettling because we
(22:53):
didn't actually know what theissue was, but through a variety
of different tests, and actuallyone of the nurses identifying an
overinfusion event, being ableto very quickly take the device
and remove the device from thepatient and keeping the
integrity of the device, we wereable to actually, with our
(23:15):
biomedical engineering partners,identify what the potential
issue was.
Um, and so they did a whole hostof different things that
included actually in partnershipwith the vendor doing uh a micro
CT scan of the tubing set andidentified a huge concentricity
(23:36):
uh issue with the tubing.
And what that means is that ifyou think of something looking
like an equal Cheerio or adonut, there was one wall that
was very thick and one that wasvery thin.
And when you use that with thedevice, it could impact the
occlusion of how the tubing setwould work within the pump.
(24:00):
Now, this was fascinating for meand for the team because it
really showed that it was atechnical issue or a quality
control issue with the tubingset that somebody couldn't
identify with their own eyes.
And so a clinician would beguessing because they wouldn't
be able to actually determine ifthere was an issue with the
(24:22):
tubing.
What ended up happening was thatthe tubing sets were recalled,
the vendor was involved with therecall as well, and globally
hundreds of million tubing setswere recalled.
And so it's one of the um areaslike this was me in partnership
(24:42):
with a variety of differentpeople.
This was the success of this wasbecause we were an
interdisciplinary team.
But um I think this onehighlighted to me that the
importance of listening to yourpoint of care team members.
And when something doesn't feelright, that the first response
(25:02):
shouldn't necessarily be thatsomebody requires more training,
but actually to dig a little bitdeeper into this uh to the issue
to see if we could actuallysolve a larger safety concern.
SPEAKER_01 (25:15):
I think a lot of our audience could relate to a lot
of the the themes that arecoming up in what you're what
you're sharing here.
You know, the the idea that Ithink so many of us who have
gotten into healthcare by anyroute are you know, have gone
through a lot of education.
And there is a stronginclination we all have to say,
(25:36):
first of all, as you as youmentioned, to have the
responsibility rest very heavilywith individuals.
And so if there was a problem,it was at the individual level,
not at the population or systemlevel.
And then to uh to think thateducation will be the answer and
maybe to skip some of thosesteps that we know to do,
looking at root cause analysis,for example, by various
(25:59):
modalities, and instead justsaying, okay, well, let's
retrain them.
Was this team that you'redescribing, were were they, you
know, naturally just able to saylet's push beyond training,
training, training?
Were they all thinking that?
Or was it a r was that one ofthe challenges to success here?
Was actually pushing people tonot think in that limited
(26:20):
training first kind of way?
SPEAKER_00 (26:22):
It was definitely a team who is very systems
focused.
And so I think um in healthcare,especially in a quality and
safety role, you have a wholehost of different things that
are coming up that are tend tobe a reactive situation related
(26:42):
to either patient safety orquality of care or overall
experience.
Um for this, I think it wasreally building trust within the
clinical team members as well asa team that was willing to
investigate.
(27:03):
Now, our investigation took overnine months to figure out this
actual problem.
And so we did start withtraining, and it was around the
framing to the point of careclinicians around we want to try
this training.
We're not 100% sure this is thetraining issue, but can you work
(27:25):
with us?
And we made it verycollaborative.
Um, we had weekly meetings wherewe had on-site um discussions,
we had forum meetings, we hademails to really uh overly
communicate and um build thetrust.
And I think the thing that wasso interesting in this situation
(27:47):
was it was actually a point ofcare nurse actually recording
the event happening andrealizing what was going on.
Um, so responding, recording,and then um being able to work
collaboratively with us aroundthe identification of an issue
and then having the trust thatthere was a team able to respond
(28:10):
and um help problem solve it,and that it wasn't rate back to
the individual being involvedwith the issue.
SPEAKER_01 (28:18):
Yeah, it sounds like incredible learning.
And uh the fact that you had asystem with enough psychological
safety that this nurse was ableto freely report this.
And and I I would guess thatafter he or she reported the uh
the issue, that other nursesprobably came forward and said,
Oh yeah, I've seen that too.
SPEAKER_00 (28:39):
Yeah, well, and we had proactively had the
conversation as well.
And so I think what wasconcerning for us is that when
we started to dive intoidentifying this issue, we
weren't the only ones that hadhad this issue.
That I think this issue had beengoing on for many years, but it
tended to go back to theindividual having to actually
(29:02):
load the tubing and not theactual technical piece of it.
I think the part that it spoketo for me is the importance of
trust and transparency in asystem.
And so all of us have differentroles to play in a health
system, but the importance islike really trusting and
(29:23):
respecting your point of careclinicians and also your point
of care clinicians having thattrust and respect and connection
with other members, um, likeeither support services or
leadership or even yourexecutive teams.
Um, because they were reallyresponsive in this example for
(29:44):
us.
SPEAKER_01 (29:45):
Congratulations again on that success.
It sounds like it was profoundand like global recall that you
know saved probably uh, youknow, a really hard it's hard to
imagine how many lives mighthave been saved by that recall.
Now to kind.
of reflect a little bit.
So one of the the themes of thispodcast is is about leadership
and how we lead quality.
(30:06):
And I'm wondering now thatyou've had such a a strong
career up until now, what what'sthe most common mistake that you
see leaders of all stripes,whether it's clinicians or
non-clinicians, what is the whatare the mistakes that you see
leaders making when uh when theytry to improve quality and
safety?
SPEAKER_00 (30:25):
That's a good question.
I think for me it would be twothings.
So one is giving yourself thetime to really listen and be
curious.
I find often in operationalroles they're so taxing and so
(30:45):
time consuming and there's somuch coming at leaders
specifically that it often tendsto be just checking things off
your list.
And it's really hard to maketime and space to like really
listen and hear and even watchand shadow what's actually
happening within theenvironments and and how care is
(31:08):
being provided and what thatexperience is for patients, what
that experience is for theproviders and the staff and how
we can potentially do better.
I think the other one that Ithink is super important is it's
very easy to focus on thenegative and not focus in on
what's going well.
And for me, you know there's alot of work around safety one
(31:30):
and safety two, which is um withEric Honnegel and um really
looking at like so safety onebeing like retrospective or like
reactive and safety two beinglike anticipate anticipating and
looking at how things are goingwell in the system.
But I think for me identifyingwhere things are going well and
(31:54):
how you can scale and spreadwhat's working well as opposed
to fixing what is wrong all thetime is a really important area
with leadership.
SPEAKER_01 (32:04):
Yeah, absolutely.
This is the the uh book ThinkingFast and Slow by Daniel Kahnman
is that what you're referringto?
SPEAKER_00 (32:10):
Yeah, exactly.
Yeah there's a variety ofdifferent um like academic books
and other books as well thatlike talk about that as well.
And yeah fast and slow is key.
I think it's I know when inCOVID it was like working 14, 16
hour days and just it being acomplete blur and getting so
(32:32):
much done but then also makingsure that you're supporting your
team that you are aware ofwhat's happening within the
environment and that you'reanticipating in a way that isn't
just leaving people behind.
SPEAKER_01 (32:49):
Looking ahead what are your aspirations for Health
Quality BC and and your workthere what what excites you
about uh what lies ahead well Ithink right now uh across Canada
we're in an unprecedented timewith challenges and uncertainty
within healthcare and so I dothink that there is a lot of
(33:12):
opportunity to showcase what'sworking well, the highlighting
areas of success.
SPEAKER_00 (33:20):
But also I think for me with Health Quality BC, some
of the areas that I think aresuper important for us is really
expanding our dimensions ofquality so really focusing in on
how we provide quality of careacross the province.
I know we're doing some workwithin patient safety again, but
(33:42):
patient safety in a way thatbrings in what I just mentioned
around really looking in what'sworking well within the system,
how do we scale and spread thatand how do we proactively make
things as safe as possiblerather than just focusing solely
on reviews and events and theyneed to happen together.
(34:04):
But you can't have one withoutthe other I think.
SPEAKER_01 (34:08):
I can imagine there's some maybe some barriers
to to being proactive whenthere's so much that there's so
many tasks you can react to.
SPEAKER_00 (34:18):
Yes, absolutely and so I think it's making the space
to do a little bit of that focusin on what's working well I
think building that trust andtransparency in the system is
key.
And I do think that now morethan ever us listening into what
is happening at the point ofcare, what the experience of
(34:41):
patients is but also what ourclinical teams are experiencing
and how we can help design asystem to help them not feel
like they are restricted in thework that they're doing, but
that we are integratingtechnology in a way that makes
sense, that we're not putting upburdens and like administrative
(35:02):
challenges that make things hardfor people to do the right
thing.
SPEAKER_01 (35:07):
I love that.
And I think that's a great placeto round out the conversation
I'm so grateful to you for forhaving this conversation with me
today.
And I'm glad that I got toselfishly kind of deepen my own
knowledge of human factors andof your story.
If listeners want to follow yourwork or get in touch um what
would be the best way for themto connect with you?
SPEAKER_00 (35:29):
They can go to our website at healthqualitybc and
our emails contact is on thereas well and you're feel free to
email me or to reach out to ourorganization we'd be more than
happy to share what we're doing.
We have lots of free resourcesand try to share as much of what
(35:49):
we do so that other people inthe province within Canada and
even globally can utilize thetools and things that we've
developed.
SPEAKER_01 (36:00):
That's great.
Ali thanks so much again foryour time it was great having
you today.
Thanks Jason thanks so much forlistening to today's episode of
Leading Quality.
If you enjoyed the show pleasetake a moment to like subscribe
and share it with someone whomight find it useful.
You can find all our episodes atleadingqualitybugsprout dot com
(36:21):
or in your favorite podcast app.
The show is written and hostedby me Jason Meadows edited by
Milan Milosafievich and producedby Thrive Healthcare
Improvement.
See you next time last
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