Mary Smillie, Health Quality Consultant, Saskatchewan

Ever heard ofTim Horton’s Brier?  TheScotties Tournament of Hearts? No?  Well, I’m guessing you’re not Canadian. They’re Canada’s national curling championships, and I don’t mean hairdressing. If you’re into quality improvement in health care, you’ve got something to learn from curling.

Curling is a frozen cousin of lawn bowling. The game is played on ice. Players slide 40 pound polished circular stones down a sheet of ice 170 feet long to a set of 4 concentric rings spanning 12 feet in diameter (the house). Teams of four have eight rocks each per end (an end is like an inning in baseball).  There are 3 basic shots: a draw to a specific spot in the house; a guard that protects a stone from being removed by the opponent; or a takeout, which knocks an opponent’s stone out of play.  At the highest level it is a game of extreme precision. A team scores points for each stone closer to the center of the rings (‘the button’) than any of the opponents’ stones after all 16 shots have been made.

Though the game was not invented by theInstitute for Healthcare Improvement, it is a veritable poster child for theModel for Improvementand Plan, Do Study, Act Cycles.   In the 1980s and 90’sAssociates for Process Improvement (API)worked closely with W. Edwards Deming, the grandfather of quality improvement to learn his techniques. API developed the Model’s framework to synthesize Deming’s concepts for developing, testing and implementing changes that result in improvement. Using the Model involves answers to three fundamental questions:

1. What are you trying to accomplish?

2. How will you know a change is an improvement?

3. What changes can you make that will result in improvement?

 Underlying all of three questions is the Plan, Do, Study, Act (PDSA) Cycle.

Curling can help us learn how to apply this model. The initial question forces health care teams to think deeply about what outcomes for patient populations they’re seek to achieve. In curling it’s easy: win the game. In health care answering this question is surprisingly difficult. If we want to improve  health care performance, we have to be clear about the end game for patients/families.

The second question requires data to inform the team whether they are making progress towards the aim from question #1. Again in curling the answer is straightforward:  the scores after each end are perfect indicators of whether our changes are leading to improvement. In health care deciding which  data best indicate  whether we are getting closer to or further from our aim is more challenging, though just as important as tracking the score of a curling match.  .

The third question is an invitation to try, test and learn about which changes actually improve performance.  It is this final question, “what change can we make that will result in improvement?” where curling really shines as a teacher of improvement. The PDSA cycle becomes the team’s mechanism for testing different ideas to see which contribute to better outcomes, and which do not.

The vast majority of curlers have never heard of the Model for Improvement or PDSA cycles but they perform them the entire game. All four team members continuously make changes based on the results of their previous shots (PDSA cycles). Did the stone curl more or less than predicted?  (Making explicit predictions about what you think will happen is an often overlooked key learning aspect of PDSA cycles.)  Is this particular game’s ice surface fast or slow?  Did the team accurately direct the stone at the broom (target), and were errors systematic or random?   Based on this learning, the skip will modify the call for the next rock. At the same time, the opposing team is running its own PDSA cycle.  Both skips and teams will continuously learn from each other’s success and failures to improve their chances of scoring in each end, and ultimately winning the game.

Every stone thrown presents an opportunity for testing and learning as does the overall strategy for each end. The team with the last rock advantage will try and set up the end to score at least two points.  The opposition will work to cover up the center of the rings to counteract the last rock advantage and ideally ‘steal’ one or two points through a defensive strategy. The skip for each team will have a plan (and prediction) at the start of the end based on whether or not they have last stone. If, as the end progresses, the skip recognizes the strategy will not work as planned, he/she will modify the strategy based on  the opposition’s performance and the strengths and weaknesses of the other team members. It is a perfect incarnation of continuous improvement theory and practice in real time.

Contrast this rapid learning and improvement approach with the conventional approach to planning and change in health care. A team is created. They spend months in discussions and planning. They implement a suite of directives. Everything is implemented in one fell swoop, and not  evaluated until after full implementation.

When you compare the traditional approach to change with the Model for Improvement approach, you can appreciate why health care practitioners find the Model for Improvement so foreign. Short and simple are revolutionary concepts in health care.

Healthcare teams could learn about improvement science from watching curling. They just have to look past those terrible pants from Norway.

Mark Wahba, Emergency Room Physician, Saskatoon Health Region, Saskatoon SK Canada
mywahba@mac.com

In 2004 Greece stunned the soccer world by winning the Union of European Football Association quadrennial championship tournament - Euro 2004. 

Not Italy.  Not Germany.  Not England.  Not The Netherlands.  Not France. 

Greece. 

Better known for starting the Olympic Games and feta cheese, Greece had never been a soccer powerhouse. Prior to Euro 2004 the Greeks hadparticipated only twicein the final round of a major tournament:  the 1994 FIFA World Cup and the 1980 UEFA European Championship. Entering the tournament bookmakers pegged them as 150-1 long shots to take home the cup. On January 20, 2012, theodds against libertarian Republican Ron Paulbecoming the next US President were only 35-1.

So how did this obscure soccer nation steal the championship from the traditional powerhouses of Europe?  (The Greek team actually earned the nickname“The Pirate Ship”in the Greek media during this tournament for “stealing” the wins from the established soccer nations.)

The answer: a boring, but exceptionally effective defensive strategy.

I looked at the stats from the official UEFA Euro 2004 website for all of Greece’s games in the final tournament.  Here are the results.

Goals scored:                   Greece:  7                Opponents: 4

Attempts on target:         Greece:  21              Opponents: 30

Attempts off target:         Greece:  19              Opponents: 50

Corners:                            Greece:  21              Opponents: 51

The statistics, and anyone who endured watching Greece’s slow boring style (if it could be called that) for 90 minutes confirm that Greece played a very defensive strategy. Their opponents had double the number of scoring attempts and over twice as many corner kicks. (To win a corner kick the ball has to be deep in your opponent’s end.)  In the final against Portugal, Greece had ball possession for only 42% of the match, a mere 38 minutes compared to Portugal’s 52!

Sure it was dull to watch and soccer purists abhorred Greece’s tedious style. After all, soccer’s tagline is “The Beautiful Game.” Yet tedium was the key to whatBBC Sportcalled “one of the biggest shocks in football [soccer] history.”  So if being dull gets you the end result that you are looking for, maybe we ought to consider whether dull is beautiful after all.

Now, soccer is (supposed to be) entertainment and you can have an honest argument about whether winning ugly is ultimately good for the game. Health care, on the other hand, does not aim to entertain. But it does have to deliver results. Preventive medicine is a lot like Greek soccer in 2004. Sadly, many people find it uninteresting. It doesn’t get a lot of fanfare or respect.

Let’s look at some things that people might consider boring, and at what we could do if we really focused on them.

Hypertension:“It has been estimated that a 5 mm Hg reduction of Systolic Blood Pressure in the population would result in a 14% overall reduction in mortality due to stroke, a 9% reduction in mortality due to Coronary Heart Disease, and a 7% decrease in all-cause mortality.”

Quitting smoking:“Smokers who quit at about age 30 reduce their chance of dying prematurely from smoking-related diseases by more than 90 percent.”

Weight loss:In obese people, “modest weight loss, such as 5 to 10 percent of your total body weight, is likely to produce health benefits, such as improvements in blood pressure, blood cholesterol, and blood sugars.”

Physical activity:  Exercise helps to reduce high blood pressure and reduces risk for type 2 diabetes, heart attack, stroke, and several forms of cancer. It helps reduce arthritis pain and associated disability. Physical activity also reduces risk for osteoporosis and falls. Exercise even reduces symptoms of depression and anxiety.

Eradicating poverty:Lower socio-economic status is associated with worse health outcomes. An amazing 3.5 million Canadians live in poverty. That’s 10% of the population.  

Improving Literacy:Literacy is a significant health determinant. Incorrect use of medications, failure to comply with medical directions, and errors in administration of infant formula are some of the health risks associated with illiteracy. The Canadian Council on Learning reported about 60% of adult Canadians lack the literacy skills to manage their health adequately.

Unfortunately, none of the above seems very exciting when compared to the sharp end of the medical spear. Prevention and health promotion don’t get the respect they deserve. Not from the medical community nor the media nor the politicians. Perhaps if “winning the game” meant improved health outcomes and better population health, prevention would get a status upgrade. We need to realize that an ounce of prevention truly is worth a pound of cure.

So maybe healthcare could learn from Greece’s Euro 2004 victory. Defense and prevention might lack glamour and the adrenaline rush of an immediate and dramatic payoff. But they can be enormously effective in achieving better outcomes for both individuals and populations.

Steven Lewis, President, Access Consulting Ltd., Saskatoon Canada
Steven.Lewis@sasktel.net

It begins in February and runs to the end of March. Raw rookies and twenty year veterans, bench warmers and megastars, all of whom have played baseball since their single digits. It’s spring training time, and no one is exempt. The playing field is literally and figuratively level. You come, you drill. Practice, practice, repeat. Over and over, until you get it right.

And once you get it right, do it some more. A ground ball to the right side, between first and second. The pitcher reflexively takes off to cover first base. It is easier if he is right-handed because his follow-through will turn him in the right direction. Lefties must either stop and change direction, or pirouette. If the first baseman has moved to field the ball, keep going. Aim to touch the infield side of the bag with your right foot; the runner owns the rest. Take a curved path so your last steps are parallel to the first-base line to avoid colliding with the runner. Catch the toss from the fielder; if perfectly executed it is like a quarterback hitting his receiver in full flight.

It is rarely perfect. Sometimes pitchers are slow to react and fleet runners beat them to the bag. Sometimes they fail to angle off and collide with the runner. Sometimes the toss forces them to break stride, slow down, miss the mark. Most of the time they don’t need to be perfect – there is a tolerance range. But good isn’t good enough at this level. If you’re good, you can be better. And it’s easy to lose your edge.

There is no such thing as permanent credentialing in baseball. You are only as good as your performance. Yes, great players in a slump will be cut more slack than novices. Managers know that physical errors, though rare (about one every other game), are inevitable, and they forgive them. Mental errors areverboten. You can’t always execute, but you can always concentrate. You train your physical reactions to be automatic so you can focus on the larger patterns of the game.

In spring training, and all through the real season, every player gets coached. Coaches pick up subtle things, like an arm angle, a slightly altered batting stance, inefficient footwork. These are the greatest players in the world, and still their skills are fallible, their deeply ingrained knowledge fragile. They take no shortcuts; they are always roughs in the diamond.

Baseball is a team sport, and players must adjust their skills to complement their partners. The most obvious is the double play combo of shortstop and second baseman. Here precision and timing are paramount and preferences matter. Should the feed be high or low, to the right or left of the bag? Does the shortstop have an average or superior arm (if the former, the second baseman must get the ball to him faster)? In the era of free agency, players rotate among teams frequently, new partnerships must form and long-standing processes must be recalibrated. It is always the same and never the same.

Baseball is a game, and while livelihoods are always on the line, lives aren’t. Health care is more fundamental, and the tolerances are far less elastic. There is far more variation in the human condition and patient presentation than there is in the stitching on a baseball or the trajectory of a fly ball. Both enterprises require highly skilled practitioners and complete mastery of fundamentals.

So it is no small irony that in baseball, professionalism is defined by structure, repetition, coaching, surveillance, and measurement, while in health care, professionalism has largely meant autonomy, independence, and freedom from scrutiny. In baseball, if a pitcher’s control is off by six inches, hitters will whack him all over the park. In surgery, if a surgeon errs by a centimetre, someone might die. Yet, asAtul Gawande recently observed, clinicians don’t have coaches who can pick up minor flaws in mechanics and counsel adjustments.

A surgeon working with new members of an OR team is no different from a shortstop who finds himself with a new second baseman. The newbie might be infinitely more talented than the guy he replaced, but that doesn’t it itself make a better duo. They have to create their own partnership and unlearn the processes that worked in another context but won’t here. They talk, they do, they adjust, and eventually they fuse. It’s the same with new lines in hockey. PDSA, every day.

Maybe clinicians – not just surgeons, but everybody – needs the equivalent of spring training. We can’t send them all to Florida or Arizona every year for 2 months, and there are no exhibition games in health care (though there are cadavers and dummies to practice on, roles to play, cases to review). Everybody can benefit from real-time observation of their work and skilled coaching for improvement. Mastery is fleeting and skills and performance erode subtly. Contrary to evidence and logic, health care assumes that once competent means forever competent; baseball doesn't.

Baseball has it right.