HiQuiPs: Quality Improvement in the time of COVID-19

In Education & Quality Improvement, HiQuiPs by Ahmed TaherLeave a Comment

You are attending your monthly ED staff meeting where the main topic of discussion is the COVID-19 pandemic. Recent events around the world have compelled your hospital to make changes to better prepare for the expected increase in local respiratory cases. The ED staff meeting has a debrief about some changes that will be happening including personal protective equipment use changes, new COVID-19 swab testing, ED triage and flow changes and many other operational changes. You wonder to yourself how the front line staff will be able to accomodate all these changes. 

Welcome to a special post about QI in the time of the COVID pandemic. This post aims to be a high level discussion of the QI paradigm during large scale, highly dynamic changes that EDs are facing during this pandemic. We have introduced foundational topics in QI previously. The classical QI methodology entails: wide stakeholder engagement, detailed process mapping, forming a clear aim statement, and carrying out an implementation strategy while observing a family of measures, learning and implementing further changes. While the QI approach is pragmatic and meant for the clinical realm, pandemic planning and constant changes present certain nuances that can be beneficial for leaders to consider. 


An essential classical QI step is to compile a comprehensive list of stakeholders who will be affected by the changes. These may include frontline clinicians, porters, cleaning staff, security, patients, administrators, lab personnel, etc. Ensuring that each stakeholder group has representation will assist in helping delineate the current process and create changes that are sustainable. However, in the time of pandemic planning there may not be sufficient time to organize meetings of all relevant stakeholders to carry out lengthy discussions and full process mapping exercises. This is compounded by the constantly changing recommendations coming from public health units or ministries of health. Things need to move faster! 

A practical and time efficient strategy is to gemba. This comes for the Lean paradigm and is a Japanese term that means “actual place”, i.e. the place where value is created.​1​ In the healthcare context a leadership team might apply gemba to understand a given clinical care process. For example, a team might “walk the gemba” from the perspective of the patient (for whom we are creating value). This would involve following a patient through their ED visit while detailing the existing processes from triage, room preparation, patient movement, investigations, assessments and disposition planning. This is a nimble way to inform the process with relevant time stamps and decision points. In the pandemic-planning context, an important example would be to walk the gemba for a patient requiring protected resuscitation from patient arrival to disposition.  Different stakeholders should be present for input during the gemba

This process may be followed with every cycle or intervention to gain insight on current workflows. Workflow changes that are disruptive can result in front-line workers applying workarounds that may lead to unintended consequences. Updating policies without understanding the current process may result in further workarounds and unwanted variation and thereby decrease quality. 

Implementation strategies

Given the highly complex nature of healthcare, changes in one part of the process may have consequences (intended or unintended) in other areas. Implementing changes to a process during the COVID preparations needs an efficient organized, sequential approach to study the effects of each intervention and make quick adjustments accordingly. Rapid PDSA cycles present a flexible, pragmatic and sustainable structure to organize implementation of changes to the ED. 

Given the frequency of changes during pandemic preparations, an abundance of changes are happening in EDs without understanding their effects. Resource permitting, it is important to ensure process changes are measured to inform future interventions. Moreover, defining a family of measures may provide useful data about how these changes are impacting the ED. Pragmatism and efficiency may need to supersede a detailed family of measures during pandemic changes. However, an important takeaway from the family of measures concept, is to ensure the team considers unintended consequences of the interventions. 

Interventions should be viewed through the hierarchy of effectiveness (Figure 1). Educating clinicians and running simulation for example is a great way to prepare for protected resuscitations. However, as we go up the ladder of effectiveness other interventions may include a door alarm on negative pressure rooms, removing aerosolizing equipment to prevent its use when unnecessary, and creating a dedicated intubation team. While the specific changes will vary based on a hospital’s overall strategy, centres should consider implementing the most appropriate “system-focussed” interventions for their setting. This may help cognitive offloading so that providers can focus on patient care activities. 

Figure 1. Hierarchy of effectiveness​2​

Use of Checklists

Reducing variation is a core feature of delivering high quality care. Standardizing certain processes has been met with much success in the safety literature from other industries such as aviation and nuclear power,​3,4​ as well healthcare for example with preventing surgical complications​5​ as well as central line infections.​6​ The power of the checklist has been to standardize core elements of a routine yet possible high risk process while allowing experts to communicate about nuances in the process when needed.​7​ This can be helpful for example when running a protected resuscitation (Figure 2).

Figure 2. Protected Airway Checklist. St Michael’s Hospital Toronto.​8​

Derivation of simple checklists need strong stakeholder engagement and rapid cycle PDSAs with ample feedback collection to ensure their effectiveness and fit within the workflow. Checklists can also be utilized for non-patient care tasks, such as safe handling of samples in laboratories and environmental services COVID room cleaning procedures. Checklists integrated into electronic systems may also allow for process measures during the interventions.


During pandemic planning there are a plethora of changes happening at all levels. It can be challenging to anticipate the unintended consequences of these interventions. This is especially true if changes are mandated by administrative teams that are removed from the front line by several degrees. Clinicians with QI expertise are necessary to fill in the gaps to ensure that the front-line processes and workflows are understood by leadership teams (i.e. a team that can gemba). This will help necessary changes be implemented in a coordinated fashion while minimizing disruption to pre-existing workflows. A coordinated approach to interventions is also important to ensure that various changes are supplementing one another and not competing for resources or undoing their effects. Many hospitals across Canada have already taken this approach with physician and nursing leadership contributing to pandemic planning decision making.


Pandemic preparation and response at the local and institutional levels will benefit from a QI/Patient safety lens given the dynamic and complex nature of the changes. Consider walking the gemba to understand front-line processes, using rapid PDSA cycle techniques with a broad family of measures, using checklists when possible, and ensuring central coordination. It is a trying time for the entire healthcare system, but the QI paradigm has flexible and robust approaches fit for the challenge.

Junior Editor: Edward Mason

The HiQuiPs team wishes to commend all healthcare services and ancillary workers both frontline and behind the scenes for their courage, dedication, and sacrifices. Thank you for all that you do.

**UPDATE (November 2020): The HiQuiPs Team is looking for your feedback! Please take 1 minute to answer these three questions – we appreciate the support!**


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    Berenholtz S, Pronovost P, Lipsett P, et al. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med. 2004;32(10):2014-2020. doi:10.1097/01.ccm.0000142399.70913.2f
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Ahmed Taher

Ahmed is an Emergency Physician at University Health Network and Mackenzie Health in Toronto. He completed the Toronto FRCPC Emergency program, and a Masters of Public Health program at Johns Hopkins Bloomberg School of Public Health with certificates in Quality Improvement & Patient Safety, as well as Public Health Informatics.

Lucas Chartier

Dr. Lucas Chartier is an emergency physician and Deputy Medical Director for the University Health Network (UHN) emergency department (ED). He is also UHN's inaugural Medical Director of Quality and Safety, the ED Lead for the Toronto Central Local Health Integration Network (TC LHIN) and the Chair of the Quality Improvement and Patient Safety (QIPS) Committee of the Canadian Association of Emergency Physicians. With training at McGill (MD CM), University of Toronto (FRCPC) and Harvard (MPH), he now tries to spread the QIPS gospel in all the ways possible!

Shawn Mondoux

Dr. Shawn Mondoux is an emergency physician at Hamilton Health Sciences (HHS) and faculty at McMaster University in Hamilton, Ontario. He obtained a masters of Quality Improvement and Patients Safety (QIPS) at the University of Toronto and serves as QI advisor to all projects within the ED. He has a strong interest in clinical QI work as well as the education of PGME learners in QI principles.