Sawubona! Reflecting on ISQua’s Annual Meeting in Cape Town, South Africa & Global Health
ISQua’s 36th Annual International Conference was held in Cape Town, South Africa (the first time on the African continent) last week with 1,110 delegates attending from 84 countries. This year’s theme “Innovate, Implement, Improve: Beating the Drum for Safety Quality and Equity” provided the foundation for presentations, collaborations, idea-sharing, learnings and rich discussions.
An early speaker channelled a beautiful African Zulu greeting, Sawubona, which means “I see you.” This saying is grounded in the idea that “seeing each other” requires non-judgement and by one person seeing the other, you bring both into existence. To me, it signified a challenge we have in healthcare — that of not frequently enough giving voice to others and/or recognizing the value each person brings. Other words such as engaging, listening, emotional intelligence and kindness all personify this simple but incredibly meaningful greeting. Custom holds that once the person is welcomed by Sawubona, the response, Ngikhona, is provided which means “I am here.” What a beautiful and simple exchange that ideally grounds any conversation or exchange that occurs from that point forward.
While impossible to attend every one of the 96 sessions, I hope to highlight some that were meaningful to me during the four days.
Leadership in Driving Healthcare Quality, Patient Safety and Outcomes
More than at other ISQua meetings, I saw an increased focus on what leaders can do to create near- and longer-term success for quality outcomes. There were a few sessions that were dedicated to this, as well as two keynotes. It was wonderful to see this focus as the culture needed for change to take place is spearheaded by those in charge and all too often, I see a lack of leadership in driving quality outcomes.
Specific to creating the right environment for change, Gilbert Buckle spoke about establishing the right foundation when he arrived to lead a hospital in Ghana. When he arrived, he asked others there “what should things look like in the future?” and the response he received was startling to him. They didn’t know how to respond and couldn’t think like that — they had never thought that way. His quote “no matter what quality the seed is, if the soil is not fertile, it will never germinate and grow to deliver the fruits you desire” resonated with the audience greatly and provided a great foundation for the remainder his story. He went on to provide examples of creating the right environment, which took months to do. He started by making sure people within the organization were asking the right questions. Instead of asking “how many patients do we have today?” or similar volume-based questions, he ensured they were asking more meaningful questions such as “how many patients left happy today?” or “how many patients got what they needed when they left?” All of this in an effort to shift the focus to the patient, their health and more meaningful outcomes. He also mentioned the following lessons:
- We have to be very sensitive to the realities and perceptions of those we are asking to lead quality within our organizations
- Do not assume it is common sense, nor it is easy
- Even in the same departments, we have to allow for different interventions and multiple personalities
- When the right questions are asked, everyone wants to get on board
Rolene Wagner also provided a keynote detailing her efforts to turn around a hospital and transform toward one with a focus on organization-wide quality improvement. She focused her efforts at Frere, located in East London on the Eastern Cape of South Africa, on four simple, but effective points of concentration. These led her, & her organization, to a wonderful turnaround that was impactful for her patients and the broader community.
4 Areas of Focus:
- Leading change through multiple levels of the organization
- Gaining alignment and coordination of efforts
- Developing a credible plan, supportive systems and impactful projects
- Monitoring implementation and assessing for broad and strong impact
Throughout her efforts, it was important for her to be seen as a person who can engage, enable and inspire people across her organization, while motivating them to do more than they, at times, think they can do. She realized wonderful results and leveraged the media to help communicate the changes that they were leading — such as reduced wait times, focus on patient-safety care, and increasing the right services needed wthin the community. She ended the session with a heart-warming video of patients singing “We Are One” — worth a watch & a wonderful demonstration of the culture she created at Frere.
In addition to the keynotes from Buckle and Wagner, there was a chaired session entitled “The CEO in the Driver’s Seat: Creating a Roadmap for Quality and Safety Transformation” that was designed to be an introductory discussion around this topic that will continue in future ISQua meetings. Participating in the panel discussion were Jeffrey Braithwaite, Carrie Marr, Erick Hollngel and Axel Ros. Timing of the session (45 minutes) didn’t allow for much detailed discussion, but some of the highlights included:
- Braithwaite offering up the difficulty in this work by stating “It is not a trivial problem to transform healthcare system as a whole and to engage stakeholders to create high performing, safe, high-quality healthcare.”
- Marr commenting that “we need to be moving from retroactive to predictive, proactive and anticipatory” efforts to improve quality care, and that our role as a healthcare leader is to “create the right conditions for change.”
- Focus on leadership and culture will shift outcomes and create a positive safety culture overall.
- Hollnagel used a sailing analogy to stress his point that the CEO is really the planner of change and not necessary the driver of it (who is the more important person on a ship — the captain or the navigator?). He provided multiple “models” of healthcare systems and remarked that currently we seem to be in one that is a black-box with little visibility into what’s going on. Change can only happen when this shifts.
- Ros provided a series of success factors for leaders to consider in driving change, such as: long-term commitment to quality improvement; stability of context and leadership; a clear consistent and motivating vision, strategy and education; balanced scorecard model for budget, planning and follow-up; culture and morale; support bottom up QI initiatives, led by clinical enthusiasts (love this term!).
Impactful Highlights from Various Sessions
Many of the insights and lessons from the four-day meeting don’t neatly fall into one overarching theme, except that all of them are designed to challenge us to make meaningful impact globally. The following are random highlights from several sessions attended:

Dr. Paul Batalden led a very interesting keynote around coproduction of healthcare and discussed the evolution of healthcare to one of service and value. His talk is worthy of a much deeper dive and writing; however, one of the key takeaways that resonated with me is the definitional structure he provided around elements that are common to value creating service systems. He described and differentiated value “chain,” value “shop” and value “network” and then used a wonderful example of coproduction that drove these concepts home.
He also stressed the importance of relationships by stating “you can’t get kindness out of a toxic environment.”

Another keynote worthy of an article on its own was Rocco Perla’s refocus on “health” as our optimal goal and charging each of us to ask the questions that matter. Realizing the efforts that will make the most impact in health of individuals and populations, Perla refocused his attention from the work he did in the Obama administration to organizations that were addressing the social determinants of health.
He stated “we’ve created a health system where we don’t think twice about ordering tests, but we don’t ask people about food insecurity.”
Start by asking people what they need to be healthy. People know themselves, so let’s stop pretending we know the answers for them.
Other highlights:
- When thinking about systems who provide care, one speaker correctly challenged us to remember that “no health service is good if quality is poor.”
- Simple efforts can make profound impact, such as a local hospital slogan “To serve with a smile.”
- A Nigerian team presented on efforts they implement to improve the health of their community, including apps to engage patients and the creation of “Nudge Hubs” to encourage better patient education and behavior. Love the concept of a “nudge hub!”

- The patient journey is still important, as demonstrated by an effort by another African effort to map chronic disease patients.

- New eye-tracking technology is being piloted which may shift accreditation surveys by allowing the surveyor to be remote. Further application of this technology, if proven effective, are limitless!
- Continued importance of leadership rounding to engage caregivers and promote efficient systems and quality outcomes.
- Creation of a multi-model approach (PRIME) to address patient journeys, decision making by patients, involvement of multiple stakeholders and achieve more impactful outcomes, courtesy of work from Macquarie University and team.
Sustainability & Our Responsibility in Healthcare
ISQua recognizes the importance of shaping healthcare and our environment in better ways for the future. As such, ISQua released its statement on sustainability during the meeting in Cape Town which received broad support and acclaim. Among the many sessions, there was one focused on sustainability as a first discussion opportunity highlighting the work that is being done globally and what we can all do within our own respective organizations. It was a wonderful session that highlighted the seminal effort and report from The Lancet (http://www.lancetcountdown.org) that emphasizes the connection between public health and climate change. The report (https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)32594-7/fulltext) is an absolute must-read.
The session also discussed the impact of eHealth to sustainability (or Green Care) efforts. It highlighted work from the Netherlands and lessons learned to date on how to make impactful change:
- Interaction between health/disease and the environment is bi-directional.
- Medical professionals are key players in the journey to sustainability with a focus on care, research and education. Leadership needs to also create the right environment.
- Moon-shot vision is for sustainable health and healthcare to be mainstream and business as usual — the new normal.
- The “Green Deal” in the Netherlands has a focus on many areas that will contribute to long-term sustainability, such as: CO2 reduction; socially responsibility procurement; reducing pharmaceutical waste in water; healthy care and work environment
Among examples provided was a roof-top garden on top of a nursing home that promotes visitation, growing food to be locally used and nature in an urban setting. A win-win-win for everyone.
Achieving “High Quality Health Systems”
One of the plenary sessions was dedicated to both a retrospective and current view of how well we have done achieving high quality health systems globally. Margaret Kruk and Laetitia Rispel grounded both of their talks on this topic in seminal reports and efforts that have spearheaded change across our industry and within a global context. Among these reports:
- The Lancet’s Global Healthcare Commission on High Quality Health Systems
- The World Bank’s Delivering Quality Health Services: A Global Imperative for Universal Health Coverage
- Crossing the Global Quality Chasm
- WHO’s Global Strategy on Human Resources for Health
- WHO’s Working for Health and Growth
Their talks re-grounded attendees in the importance of this work and several efforts that have been undertaken thus far. Among some of the key takeaways from this session:
- Major disparities in health continue despite global progress
- As of 2018, there are 8.6M deaths from treatable conditions as a result of low-quality health systems, 60% of which are due to poor quality among people using care
Kruk suggested we need a new definition of high quality health systems and provided the following: “Health systems are for people. A high quality health system optimizes health in a given context by: 1) consistently delivering care that improves or maintains health; 2) being valued and trusted by all people; and 3) responding to changing population needs”
- Kruk further provided a “high quality health system framework” that grounds itself in a focus on people and considers processes of care, quality and key foundations to support efforts
- Research found that health providers performed less than ½ of key clinical actions needed for common conditions and 1 in 3 patient reported poor user experience (source: Global Healthcare Commission report)
Feedback from patients demonstrate the immense work to be done in creating high quality health systems
- Rispel emphasized the importance of people and stressed that “Human Resources for Health are the Heartbeat of Quality Universal Health Coverage”
Quality Competition
ISQua held its first Quality Competition, where 19 “finalists” representing each of the WHO regions globally provided a 10–15 minute presentation during the course of Sunday’s pre-conference session, with judges picking the winner to present on the mainstage of the conference Tuesday. I had the pleasure of being one of the judges and hearing every presentation. The opportunity to hear so many wonderful examples of quality improvement from across the global was truly an honor. We learned something from each and every presentation.
Among the work presented:
- Reducing postpartum hemorrhage rates at a Nigerian hospital
- Addressing contextual factors that influence the self-management of adolescents living with HIV on the Western Cape of South Africa
- Collaborative efforts to reduce HAIs in an ICU in Portugal
- Involving children in their outpatient care by surveying them about what’s important to them in England, and do so in a visually engaging way
- Customized coaching efforts via technology to improve quality and patient standards at a tertiary hospital in Indonesia
- Improving equity in access to transplantation and treatment effectiveness in Brazil
- Evaluating “double-checking” of medication administrations to reduce errors in Australia
The winner of the competition was focused on developing an airway management process based on ERAS of patients with lung cancer patients that effectively reduced postoperative complications & reduced hospitalization time and expenses. It was a wonderful presentation that engaged the audience and demonstrated exceptional results from their work. Well done to all the participants.
In summary …
… it is clear that no article is lengthy or thorough enough to do the conference justice, or to dig deeply into the topics presented. When reflecting further on Sawubona, my hope is that each of the delegates that attended the meeting in Cape Town last week opened themselves up just a bit more and left with new perspectives they can take back to their countries, organizations, communities and places of work in an effort to further advance the change needed to elevate health, quality and patient safety globally (I know I did!). We have much to do, but together, we can address the needs of patients, individuals and communities in meaningful ways.
Ngikhona. I am here (& ready to see you and make the needed change in healthcare).