​"We all broadly use the word quality, but we really do not understand its complexity," shares Jeanette Edwards, Strategic Lead, Community Health, Quality and Learning and Acting Provincial Lead, Indigenous Health at Shared Health in Manitoba.  "If you say quality to a healthcare worker, administrator or a patient, it means something different. For many patients in care facilities, quality may mean the food or the availability and ease of parking. To the surgeon, quality may be the efficacy of surgery, including patient outcomes. What we're trying to do is look at a system and think of quality as a complex construct."

Manitoba's healthcare system is undergoing major transformation and Jeanette led a quality and accreditation project that ensured input from across health services delivery organizations to guide the development of a provincial quality framework and approach to accreditation as a key quality improvement process. In addition,  "We had public representation, families involved with critical incidents who shared their input, Indigenous input from Ongomiizwin– all had contributions," she said.

It's all about safety

The project team felt that the province needed "a framework to help us talk about quality on all fronts and that we had a consistent view of what quality is," Jeanette said. Furthermore, "safety has been separated from quality in the past," she shared, but we now need to bring quality and safety together. "You cannot have a quality system unless it's safe, so [in our solution], we pulled safety in. We feel that safety is about everything."

The team additionally wanted to:

• Ensure quality was built into everyday practices: "In organizations from top to bottom, from 'board to ward,' out to the community"
• Improve learning: "I felt very strongly that humans have to have ongoing learning and we needed to look at how we can insert learning into everything we do."
• Breathe life into accreditation: "As an accreditation surveyor, I observed that accreditation was becoming a 'happening, (the peer surveyor visit)' instead of an ongoing quality process tool."
  

Solution: Continuous improvement and alignment

One of the outcomes of the transformation project was the Manitoba Quality and Learning Framework, which was intended to "support a culture of continuous improvement and drive alignment throughout the health system." Its purpose is to guide healthcare quality improvement for all Manitobans.

The resulting infographic (please see below) "helps people speak the common language, but it also helps provide a frame to apply," Jeanette said. "We have all the buzzwords, such as 'culture of safety', but what does that MEAN? Now we have common definitions that align us."

Jeanette continued: "As part of system transformation in Manitoba, the infographic was our way of bringing together the IHI quadruple aim. You'll see "healthy Manitobans" and "healthy teams," which are key guiding principles in Manitoba, aligned with Accreditation Canada and Health Standards Organization's quality and safety dimensions. We're trying to show people this isn't another flavour of the month: this framework brings together all of these aims to support system excellence. It's meant to be a way of simply demonstrating to users that all of these domains are important."

The Canadian Quality and Patient Safety Framework

Jeanette linked with committee members who guided the development of the Canadian Quality and Patient Safety Framework for Health Services. "The Framework is meant to be overarching to help guide policymakers, senior decision makers, and clinical services," she says.

The Framework is made up of five overarching goals to create positive change:

1. People-Centered Care  

People using health services are equal partners in planning, developing and monitoring care to make sure it meets their needs and to get the best outcomes. 

2. Safe Care  

Health services are safe, and free from preventable harm. 

3. Accessible Care  

People have timely and equitable access to quality health services. 

4. Appropriate Care  

Care is evidence-based and people-centred. 

5. Integrated Care  

Health services are continuous and well coordinated, promoting smooth transitions. 

With definitions for common terms to help teams speak the same language, the five stakeholder groups who interact with the health care system have accompanying Action Guides and implementation resources to help teams work in tandem while improving quality and safety in their own jurisdictions.

The Manitoba Quality and Learning Framework Infographic

Five Goals for Safer Care in action

"The infographic reflects all five of the Canadian Quality and Patient Safety Framework goals and builds them out for Manitoba," Jeanette stated. "For example, the goal of "Integrated care" is a process, but what are its domains? What we aimed to do with the infographic was boil it down a bit for our province. The Canadian Quality and Patient Safety Framework has broad system goals. Embedded in those goals are quality metrics."

Jeanette shares three examples to illustrate how Manitoba is advancing the five Canadian Quality and Patient Safety Framework goals with the Manitoba Quality and Learning Framework infographic.

1. At one of our sites we have the Rehabilitation Centre for Children, Specialized Services for Children & Youth in Winnipeg. The board mapped all the metrics they're measuring in their quality plans and reports to these four quadrants. It shows how the site monitors quality and dimensions at a leadership level and they posted it where everyone can see. It's a daily reminder to patients and staff that they are part of a quality and learning organizations, and patients and families can bear witness. We owe it to our public to be accountable for quality and service excellence."

2. "We're moving in Manitoba towards a provincial clinical governance approach. I have a student right now looking at the evidence around clinical pathways, specifically for people arriving in emergency room with a traumatic hip fracture. In doing that and in asking questions like, 'What should that pathway be?' and "What will the measures be to track the implementation of the pathway?', we're applying this framework. We're overlaying it on top of this process and saying 'It needs to be efficient. It needs to be effective. It must be equitable.' You can also zoom out and look at provincial standards to decrease variability. This is a real, concrete clinical standard that we're providing to all of the teams to help them think about how clinical standards need to be measured. I think this framework can be applied to help folks ask questions like these."

3. "COVID-19 is ideal to illustrate the quadrant about 'Healthy Manitobans.' Remarkably, Manitoba has not had an outbreak on a First Nations community. If you think about the actions that were taken to limit transportation between the north and south – we had community driven restrictions, where First Nations people collectively limited access to their communities – those actions are all about a quality system. The biggest action in the success of limiting access was community design. This wasn't about doing to, it was about planning with. We had tables that included First Nations, Metis and Inuit communities, federal departments, provincial departments. It wasn't about an action, it was about a collective action. I think you will see more and more of our Indigenous groups having far more control over health services and influence – I think that is key. If you look at the population focus in the quadrants where it says "work with communities." It's putting action to co-design."

Over to you

The Canadian Quality and Patient Safety Framework for Health Services is intended to be used by all people and all health systems in Canada to unify and align how we work to improve quality and patient safety as a country. Use it to speak the same language as teams and organizations, identify gaps and strengths in your plans and work with us towards raising the bar on healthcare quality and safety in Canada.