Monday, September 2, 2013

What makes a good QI coach?

Give a man a fish and he eats for a day.
Teach a man to fish and he eats for a lifetime.
Show a man how to use a phone and he can order pizza.  Who wants fish everyday?

How do you go about selecting a quality improvement coach? 

A coach could be a mentor, guide, cheerleader, or teacher (and probably all these at different times).  The origin of the word gives insight into its true meaning.  “Coach”, in its original use, refers to a carriage or means of transportation.  Later, it referred to someone who helped students (or, carried them) through exams.  In both usages, a coach helps someone reach their goal. 

I distinguish a coach from a consultant.  I see a consultant as someone who assesses the problem and prescribes a solution.  We were interested in working with someone who could help us develop (or rekindle…) an independent capacity to identify and solve the problems in our practice.  Also, we wanted to develop a sustainable quality improvement process.

While we wanted someone to help us eventually develop our own capacity, we recognized that this coach would likely need to do some of the initial diagnostic work to jumpstart the process.

In retrospect, after having been in the coaching process for almost 9 months now, I judge the 2 key qualities of a QI coach to be patience and breadth of experience.

Novices make mistakes; it’s a powerful way to learn.  The coach may be tempted to curtail exploration and experimentation, intending to speed the journey along.  Feeding the student the “correct” answer may shorten the process, but deprives him of the experience of understanding what doesn’t work.  This is particularly important in QI work where the solution(s) may not be known and experimentation (PDSA cycles, action research, etc.) is the only way forward.  An experienced coach may have seen certain initiatives fail in other settings, but must be patient in allowing students to conduct learning trials and develop their own understanding about what works in their system.

The coach’s patience was particularly important as we started to rank the importance of problems areas to be improved.  I suspect our coach had preferences as to which improvements would have the greatest impact on patient, staff and physician satisfaction, but kept quiet about it.  Instead, we were shown methods to reach a consensus around which projects were our priorities.  This has been an important factor in maintaining enthusiasm around the work: The projects we’re working on are meaningful for us, not ones foisted on us from outside.

This relates to the “give a man a fish” aphorism that I tweaked at the start of this post.  The kernel of wisdom in the original saying is very much the philosophy of coach over consultant.  A consultant may give you the fish/answer, whereas a coach will show you how to get the fish/answer for yourself.  I think the next step in QI independence and sustainability is to give the team the tools to decide what they want to have for dinner.  And that means the coach has to give up control of the direction of the work.  Therefore, we wanted a coach who was not personally invested in “fish for dinner”, i.e. a predetermined direction that our QI work would take. 

A coach’s breadth of experience is important when the QI team wants to develop an independent, sustainable capacity.  This relates most closely to the common use of “coach” in athletic training.  Athletes who specialize in a particular event seek out coaches with expertise in that area.  A specialized coach may help elite athletes reach their potential in individual events, but these athletes may not have well-rounded fitness, may be prone to certain injuries, or find that they cannot sustain that level of training in the long-term.  A particular training technique may work for some athletes, but a coach who is familiar with a variety of techniques will be able to help many athletes achieve their goals. 

In Saskatchewan, our health system has adopted Lean as our quality improvement system and is investing heavily in training providers and administrators.  I’m excited that we have a consistent method to guide our QI work.  At the same time, I’m conscious that “when all you have is a hammer, everything looks like a nail.”  Lean may not be the right hammer for all our nails.  Rather than signing up our QI team for Lean training, we decided to take a non-denominational approach that would let us pick and choose from various QI models.  That required a coach with broad exposure and experience with different QI systems.  Also, we wanted to start our QI work immediately rather than spend weeks in formal training.  This approach demanded a coach who was confident and expert enough to give us just-in-time training as we proceeded.

Whew! That is a tall order for a QI coach.  Where would you find such a person?

Right under our noses…