Culture of inquiry: Doing things a little differently

November 30, 2021 | Author: Dr. Susan Moffatt-Bruce

In this article:

  • How a culture of inquiry and learning health care system are related
  • The qualities of a learning health care system
  • The six steps to apply a culture of inquiry to professional development (and a creative example of a Fellow-led QI project)
  • How to amplify local changes for global impact

Have you ever asked yourself: how can I do things differently? Better yet, how do I make this a habit?

We talk more and more about continuous quality improvement (CQI). In fact, this fall, I shared how the Royal College’s Maintenance of Certification Program has put a new emphasis on CQI.

For some, this may feel like an extra strain — especially in the context of pandemic-related constraints and backlogs — however I suspect most of us are already asking these questions as we go about our days, particularly with all the changes we have had to make. When we pair this inquiry with deliberate actions, we have the potential to truly transform how we deliver care for every one of our patients in both small and meaningful ways.

I would suggest that a culture of improvement comes from a culture of continuous inquiry. In other words, a mindset that enables a learning health care system by rethinking “the way we’ve always done things” and looks for opportunities to grow, to ask questions, to evaluate and then move towards different outcomes. Learning health care systems help our patients and all those who work within them.

So, how do we get started?

The learning health care system

We have to think differently in order to get different (and better) outcomes.

A culture of inquiry is the foundation of a learning health care system. By this I am referring to the concept of a system or an environment that puts research, and the knowledge generated from that research, into practice through a cycle of continuous improvement.

To enable a learning health care system, we need

  • a culture of inquiry;
  • leaders who are committed to nurturing a culture of continuous learning, research and improvement;
  • patients to be included as vital members of the learning and research team;
  • systems to capture, analyze and share data so to improve care.

The learning health care system can be thought of as a learning cycle. The cycle is around generating knowledge so to improve outcomes and performance, then understanding performance to understand the data that comes from it and, finally, transforming that back into knowledge.

This cycle can be embedded in every aspect of health care — including professional development.

Continuing professional development

Ask yourself: what do you know about the care you’re providing now? How could you use data, both qualitative and quantitative, to look at how you could do things different? Perhaps a change to improve efficiency, make a procedure safer or render care more patient-centered.

If we focus on continuous inquiry and integrate research into our processes, health care scholarship and outcomes will improve. But it takes some discipline and an open mindset. We have to think a little bit different in order to really embrace this culture of inquiry. We must accept that there is no quick fix and no finish line. Instead, we must have an insatiable appetite for improvement.

To apply these principles to our continuing professional development, there are six basic steps:

  1. Understand the care you provide in your care environment (using simple tools, supports)
  2. Use data to identify gaps and learning opportunities
  3. Create a process improvement plan (i.e. set goals)
  4. Implement your plan by engaging in learning activities that support your objectives
  5. Measure and report on outcomes (assess the data, report outcomes, apply changes)
  6. Repeat the cycle (and keep repeating)

Whether a small test of change or a larger project, just remember this sequence: learn, research, implement and learn again. For example, we recently learned from Brian Wong, MD, FRCPC, and Lynfa Stroud, MD, FRCPC, that a small investment of time during COVID allowed their care team to improve the safe use of PPE. Well done team!

And always, always evaluate the impact of your actions on patients.

Act locally, impact globally

There is also a tremendous opportunity to amplify your local improvements. Small actions lead to big change.

Years ago, I had the opportunity to write a paper with two scientists: Dr. Peter Embi, an informatics professor, and Dr. William Smoyer, a pediatric nephrologist. At that time, we were looking at how we can develop and nurture local learning health care systems. What we landed upon was this: you have to do what you can within the system you exist (i.e. where you are providing care) but then think more globally about how those local changes can impact all of us.

An often-overlooked aspect of this cycle of continuous improvement is the potential to share our lessons learned. After all, the learning cycle is continuous and bi-directional. I would argue that we have a responsibility to disseminate our findings so that we can all benefit from the learning. The Royal College is committed to helping to share and disseminate ideas, solutions and collective improvements.

In closing, a culture of inquiry at every phase of our learning, training and care continuum can truly leverage the learning health care system. It allows us to be inquisitive and to improve outcomes by engaging in research and implementing improvements so to serve patients and ourselves. Healthier patients support healthier doctors and, ultimately, a healthier system.

Together, let’s keep asking: how can we do things a little differently?


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SLEEM FEROZE | December 5, 2021
Discrimination and Race have been Major factors in both Peer acceptability & Tolerance and Patient attitudes and acceptance. What Have the Medical Ruling bodies both the regional colleges and the Royal college has done to eradicate this and stand behind the Physicians? Even the Mayo Clinic have!
Dr. Susan Moffatt-Bruce | December 15, 2021
Thank you for your comment, Dr. Feroze. The Royal College strongly advocates for positive workplaces, free from mistreatment in all of its forms. Currently, we are working with the levers we have available to influence change at the resident level through our accreditation standards. We are also working with the Indigenous Health Committee to extend learning on cultural safety. Finally, we promote professionalism standards through the CanMEDS Framework. We agree that more work needs to be done and that change will take time. Earlier this year, we shared some more details on our commitment to equity, diversity and inclusion. You can read more here:
Gervais Harry | December 2, 2021
Hi Dr Susan, Thank you for this - most refreshing - I am encouraged ! Please note that I am now 82 years of age and (finally !) retired, so my main concern in writing to you is the furtherance of the ethos and the success of our profession. I am particularly impressed by your paragraph ...... "If we focus on continuous inquiry and integrate research into our processes, health care scholarship and outcomes will improve. But it takes some discipline and an open mindset. We have to think a little bit different in order to really embrace this culture of inquiry. We must accept that there is no quick fix and no finish line. Instead, we must have an insatiable appetite for improvement." ...... you could not have said it better ! Some of us have, for many years, wished that our colleagues (and the system in which we work) would agree "talk it over" with those who think outside the box. Your proposition, that we should incorporate research findings and basic science discoveries into our "modus operandi", is a cherished dream which some few of us would love to see come true ! This note therefore, is written in the hope that you will be able to find some time, to spend in dialogue regarding this subject: if you can, I would be delighted to explain. With best wishes, Truly, Gervais A. Harry, MB,BS (London), LMCC (1969), FRCSC (Urology), ABAARM (A4M, 2016)...... RETIRED.
Dr. Susan Moffatt-Bruce | December 15, 2021
Thank you so much for your kind words, Dr. Harry. I will ask my assistant to reach out via email and set aside some time for us to discuss further. I look forward to it. Kindly, Susan
Robert Robson | December 2, 2021
A good beginning Dr. Moffatt-Bruce. Perhaps you have been deliberately gentle in your suggestions - in my experience this will require more than thinking "a little bit differently". I would add that the underlying philosophical stance must be one of humble curiosity - to a great extent we truly do not know what we do not know. The commitment to patient engagement must be primordial (beyond token) in the true sense of the word. Part of not knowing what we don't know is a reflection of not truly hearing what patients (and their families and the broader communities that we are treating) are telling us. Your inclusion of qualitative methods of inquiry and research (to complement the quantitive methods we have been raised to worship) needs to be emphasized more strongly I suspect. Healthcare is primarily a relational activity and unfortunately we have never been able to assign numbers to relationships - thus the importance of learning how to gather and analyze data quantitatively. And a final comment about the nature of the system in which we all practice and seek to improve the health of patients. I think it is implicit in your analysis AND I think it bears stating explicitly - healthcare is an unusual hybrid complex adaptive system (CAS). Part of the humble curiosity that we need to bring to our inquiry is learning what that means and how that can have an impact on our initiatives to improve care - whether at the individual or systemic level.
Dr. Susan Moffatt-Bruce | December 15, 2021
Hello, Dr. Robson. Thank you for your comment. I appreciate your framing of this mindset as “humble curiosity”. I really appreciate it. The Royal College is moving forward with a multi-year project to progress its Maintenance of Certification Program. Phase 1, announced this fall, is to introduce a greater emphasis on continuous quality improvement. A lot of that work and the concept of a learning health care system is complementary. It is our intention to continue to communicate the importance of this approach and mindset (e.g. true patient engagement, the value of qualitative study, etc.) in the months and years ahead. Thank you so much for your thoughtful feedback.
peter osberg | December 1, 2021
Doing things differently? that includes, apparently (my previous post expunged), deleting any deviation from the approved narrative. Something heretical like paying attention to data, best outcomes(?), or the elephant in the room. Just evidence that this epistle is hypocritical rhetoric and empty virtue posturing (the point of my previous post).
Royal College Communications | December 15, 2021
Hello, Dr. Osberg. Your previous comment was approved (as you’ll see further below in this comment list). To help manage spam, all comments are held in moderation until they can be manually approved by a member of staff. We apologize that this process led you to believe your comment was deleted. - Royal College Communications
David Heath | December 1, 2021
You talk about "transforming how we deliver care ", and "putting research into practice"- and yet the example you give- improving safe use of PPE-is hardly transforming care. Are you talking about Health Care Innovation? Because if you are, we have to reckon with the immense difficulties of transforming research into innovation in Canada. These difficulties were well described in Dr David Naylor's Advisory Panel on Healthcare Innovation report in 2015 In a nutshell, if doctors are going to go to the trouble of figuring out a way of " doing things differently" -they cannot do it alone. It usually involves the people who are responsible for providing health care services - who ain't doctors . And the system they work in is immovable in my experience ,except for a few exceptions here and there -which appear to be random I have been trying to transform how we deliver care - mental health care , since 2005 when my book " Home Treatment for Acute Mental Disorders was published My idea is simple: treat a proportion of patients in a mental health crisis who would normally require admission to hospital in their own homes with a 24/7 mental health team. A doctor in Montreal -psychiatrist Fred Fenton- conducted research in 1978 demonstrating this could be done. I launched such a team in Kitchener-Waterloo Ont in 1989 based on his research It's still the only one of its kind in Ontario Meanwhile nine countries feature this innovation in their mental health systems I discovered there is no innovation pipeline in Canada. No one could tell me how innovative ideas are put into practice. My communications with the powers that be usually went unanswered -or I got a letter full of bureaucratic gobbledygook For further information about this see
Dr. Susan Moffatt-Bruce | December 15, 2021
Hello, Dr. Heath. Thank you for your comment. I used this example to show how CQI and health care improvements can be found in all manner of daily activities — some are small efforts and some target bigger changes, but all, I would argue, transform care in some respect. In this case, new signage improved clarity of communications and the safety of medical personnel accessing these hospital spaces. I recognize your frustration with regards to bigger system changes and innovation pipelines in Canada. I wish I had an answer for you, but this remains a challenge. I have taken a look at your website and some of the news items you linked from it. I sincerely applaud your work transforming care for these patients. It speaks to a great deal of vision, effort and dedication on your part. I will ask someone from our Communications team to reach out. If you’re willing, perhaps we can help highlight this project in an upcoming news article.
Douglas Smith | December 1, 2021
Opportunities for learning are everywhere but we must be open to seeing them. A thoughtful article.
Dr. Susan Moffatt-Bruce | December 15, 2021
How wonderfully put. Thank you, Dr. Smith.
Richard Schuld | December 1, 2021
So what curative treatment are we talking about that would have magically stopped a worldwide pandemic? Magical thinking?
Anonymous | December 2, 2021
Magical thinking apples to the use of a non sterilizing 'vaccine' during an infectious outbreak, using a blood born antibody response expecting control of an upper airway (mucosal) viral infection with a 1% real risk reduction (gamed study) and no mortality benefit (25% more deaths in the vaccinated arm Pfizer 6 months). Uttar Pradesh, Bangladesh have done well in controlling their covid problems, even the Dominican Republic has 10 fold better survival stats than Canada (Stanford Loannidis).
Bea Ngai | December 1, 2021
I completely agree with a learning healthcare system. In fact all modern social institutions should have the same learning, feedback and revision/improvement system. However, additional examples and expounding on the various points provided in this communication would be helpful. Dr. Moulin has also raised an important barrier to quality healthcare: cost. In the era of COVID, rapidly worsening limitations also include severe staffing shortages and staff burnout. These issues and a lack of uniformity of quality assurance/improvement programs are another challenge. I would look forward to any further communications the Royal College provide on this topic.
Dr. Susan Moffatt-Bruce | December 15, 2021
Thank you, Dr. Ngai. We plan to communicate more on continuous quality improvement in the months ahead. As I noted in my reply to Dr. Moulin, cost is a recognized and formidable challenge but the learning mindset looks for opportunities in both small and big ways. We may be surprised by what efficiencies and cost savings we might influence. It is also my great hope that we can all continue to learn from each other, ideally alleviating some of the burden of original scholarship where instead proven projects can be appropriately applied/scaled.
Dwight Moulin | December 1, 2021
I found this message quite vague. We are all aware of the value of CQI. The biggest barrier to improved health care is that it has become unaffordable. We desperately need a dual public/private health care system to improve the quality of health care - virtually every other developed nation has dual public/private health care and they provide better quality health care than Canada. Survey after survey has shown that we have fallen behind all Western European countries and Scandanavia.- we are only better than the US.
Dr. Susan Moffatt-Bruce | December 15, 2021
Hello, Dr. Moulin. I agree that health care costs pose great challenges (and I suspect always will) but I am also encouraged by the small actions (individual, team-based, institution-based) that we can take now to make incremental improvements — sometimes with great benefits or cost savings. The literature in CQI is filled with such examples, which the Royal College hopes to continue to highlight as we roll out more supports and communications on quality improvement within the context of professional development. Improvements need not always be tied to quantitative outcomes; qualitative improvements are of equal importance.
peter osberg | December 1, 2021
The 'pandemic' could have been stopped long ago with the use of effective early treatment (and has been done so in some jurisdictions); the gaming of the mRNA trials was evident from early on, examining and following data instead of following Pharma marketing, discredited leaders (WHO, Fauchi), the fallacious modelling (Ferguson), or political opportunists, would have helped a lot. Without evidence of re-examination of the "vaccine narrative" and the censorship and punishment of those who advocate early treatment, your epistle is nothing but hypocritical, and empty, virtue posturing. References available for all those opinions.
Dr. Susan Moffatt-Bruce | December 15, 2021
Hello, Dr. Osberg. I share your frustration and fatigue with the ongoing pandemic. My advocacy for a culture of inquiry is not specific to any one topic. I have great respect for the research process and evidence-based data. Adding to scholarship benefits everyone and helps us consider new avenues of thought and action.
Anonymous | December 1, 2021
So what early treatment might we be referring to that would have magically stopped a worldwide pandemic? Magical thinking?
Douglas boyd | December 1, 2021
I really like the “ culture of enquiry “ clinician approach… this is a winning strategy when combined with provider and institutional “culture of excellence” !
Dr. Susan Moffatt-Bruce | December 15, 2021
I agree! Thank you for your comment, Dr. Boyd.
Martin Reed | December 1, 2021
I completely agree. We have to be careful that our first idea about improving the health care system is not to ask governments for more money but instead to ask how we can make it work better. We and our other health colleagues are the system so we should know it best and best be able to learn how to improve it.
Dr. Susan Moffatt-Bruce | December 15, 2021
Thank you for your comment, Dr. Reed. I agree with you that those who work directly in the system have a lot of untapped potential to pinpoint opportunities for improvements.
Dr. Don Prior | December 1, 2021
CQI is a very useful tool in improving an individual's or group's provision of healthcare. It is a concept that I embraced with the support of my CEO when I was Chief of Surgery in the early '90s, It was effective in a hospital institutional environment that required participation and buy-in by many different health professionals. But these individuals were human, and when the fiscal benefits accrued as well as the patient benefits and morale of the staff, they were eroded by a decision of the administration to reward those who did nothing and not to invest the savings into programmes that would benefit the original group's patients. The consequences quickly dissolved into the previous inefficiencies and a further buy-in from the group could not be achieved. It is important to look at the benefits of CQI programmes for all involved and ensure at the outset to whom the consequences of the process will accrue. Dr. Don Prior
Dr. Susan Moffatt-Bruce | December 15, 2021
Thank you, Dr. Prior. You’ve highlighted an (all too) common challenge with CQI. For it to work, we need a change in mindset from all those involved and a lasting commitment to change. It is not easy, by any means.
Trevor Theman | December 1, 2021
I applaud this effort. It is consistent with the document published by the Federation of Medical Regulatory Authorities of Canada some years ago. The Royal College and many other national medical organizations participated in that work. My suggestion is to expand step 1 beyond the provision of care. Physicians often have multiple roles beyond the clinical, as educator, researcher, advocate, etc. It should be the goal to first understand one's practice (what do I do?) and then to seek feedback about how well one teaches, provides clinical care, conducts research, etc.
Dr. Susan Moffatt-Bruce | December 15, 2021
You raise a very good point, Dr. Theman. Assessment and reflection of the full scope of a physician’s work is critically important.
Peter Dodek | December 1, 2021
Thank you for sharing these thoughts about improvement as part of a learning health system. I have been a big fan of this approach since I first started learning about CQI more than 30 years ago. I agree with everything that you have said. But I would add a piece about facilitation and accountability. Leaders need to facilitate this work by removing obstacles--make data collection easier, protect time for clinicians to do this work, reward this activity as part of regular evaluations, and celebrate accomplishments widely. In addition, all of us should have this kind of work built into our accountabilities to each other, to our patients, and to the system in which we work. Thanks for considering.
Dr. Susan Moffatt-Bruce | December 15, 2021
Thank you for your comment, Dr. Dodek. These are very important considerations. Thank you so much for sharing.
Chad Lund | December 1, 2021
In keeping with the above principles, would the Royal College consider ending it's partnership with the leading financier of fossil fuel development in Canada? The climate crisis is the greatest health threat (Lancet, WHO). It's hard for me to stomach the body that credentials all specialists in Canada is promoting a driver behind the climate crisis.
Dr. Susan Moffatt-Bruce | December 15, 2021
Hello Dr. Lund, thank you for this feedback. The Royal College’s multi-year strategic partnership with the RBC was entered into with a great deal of goodwill to offer increased and tangible member benefits. I will share your concerns with our executive leadership team and we will consider them during our program review at the close of our partnership. In the meantime, I am very pleased to share that, as part of our ongoing work to update our MOC Program, we will soon be introducing planetary health as an important and encouraged area of professional development and active consideration.
Anonymous | December 1, 2021
Unfortunately Canada is a country with most investment with what we can call fossil fuels. Not only liquids but the tar sands and exporting and transporting the products. The financial effects of abandoning extraction are enormous. Yet the evidence must drive us to \wards ceasing especially activities related to the sands. On can but hope the agencies such as ours can manage to phase out any investments which maintain those projects and actively seek alternative investments which can advance projects which counteract the world's use of all fossil fuels.