Building the Next Era of Healthcare Quality: Lessons from Belgium’s FlaQuM Model

Why This Episode Matters

For years, many Belgian hospitals invested heavily in accreditation. It brought structure, standards, and visible progress. But Kris Vanhaecht and other healthcare leaders began to notice a deeper problem: when accreditation became the goal, quality could become episodic. Energy rose before the survey, then faded after the label was achieved.

The question became how to keep the useful discipline of accreditation while building something more durable. In this episode, Kris discusses the Flanders Quality Model, or FlaQuM, and the shift toward a co-created quality management system that connects bedside care, leadership, governance, culture, and shared learning.

Key Ideas Explored

• Why accreditation can help, but still fall short of sustainable quality
• The FlaQuM pillars of Think, Do, Learn
• How Juran’s trilogy informs modern quality management 
• Why leadership, culture, and context matter alongside technical quality methods 
• Co-design with clinicians, patients, executives, nurses, engineers, and other stakeholders 
• Why quality models require local translation, not simple implementation 

Takeaways for Quality Leaders

• Clarify your quality vision before beginning with indicators, audits, or standards. 
• Treat quality management as an operating system, not a quality department project. 
• Involve the people closest to the work early.
• Preserve the discipline of accreditation, but do not let the label become the aim.
• Build regular structures for shared learning across teams and organizations.
• Adapt leadership, culture, and context locally.
• Aim for quality that is sustained every day, not revived before external review.

Continue the Conversation

Connect with Professor Kris Vanhaecht on LinkedIn or through his website.

Resources & Frameworks Referenced

• Flanders Quality Model (FlaQuM)
• The Juran Trilogy: quality planning/design, quality control, and quality improvement
• Accreditation Canada
• Joint Commission International
• Safety-II
• Institute for Healthcare Improvement

Leading Quality is a podcast for healthcare leaders committed to improving systems, culture, and outcomes.

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New episodes published every other Thursday at 7AM Eastern Time.

Credits:

Host, Writer, and Executive Producer
Jason Meadows, MD

Produced by
Thrive Healthcare Improvement

Edited by
Milan Milosavljevic

Transcript

The Invisible Engine Behind Outcomes

SPEAKER_00 0:00

We see that the variation in mortality in our country is not depending on the region. It's not depending on the number of beds, teaching hospital or no teaching hospital. I think that the variation exists because of a kind of invisible engine in an organization. What I hope is that we will learn to understand that invisible engine. And what I hope is that FLACUM or the quality management system that we are building, the unicume for the future, that that will describe the invisible engine. We will only be able to change it if we understand it first.

Welcome And Guest Introduction

SPEAKER_01 0:37

Welcome to Leading Quality, the podcast spotlighting the people moving healthcare forward from the front lines to the C-suite. I'm your host, Jason Meadows. Professor Chris van Hocht is a full professor in quality and patient safety at KU Leuven in Belgium, where his work focuses on health care quality management, patient safety, care process redesign, clinical pathways, person-centered care, and support for clinicians after patient safety incidents. He is also an IHI improvement advisor, a member of the International Academy for Quality and Safety, and chair of the board of directors of CienSano, Belgium's National Public Health Institute. Chris has published extensively in the field with more than 13,000 Google Scholar citations and in 2026 received the BMJ IHI Inspirational Story Award at the International Forum on Quality and Safety in Healthcare, recognizing an individual whose quality and safety journey has moved others and sparked change. In this episode, we focus on the Flanders Quality Model, or Flockham, which emerged after hospitals in Belgium began asking how to move beyond episodic, accreditation-driven quality work towards something more sustainable. Floccum was co-created with hospitals, clinicians, executives, patients, and quality leaders, and combines classic quality thinking with serious attention to leadership, culture, context, and shared learning. Chris brings an exceptional combination of academic depth, practical implementation experience, and policy perspective. We talk about why co-design matters, why context and culture can't be ignored, and why quality leaders need both universal principles and local translation. Professor Christoph Hocht, welcome to the show.

SPEAKER_00 2:38

Thank you for uh having me and thank you for the invitation, Jason.

SPEAKER_01 2:41

You're very welcome. Been looking forward to this. I'm

A Teen Volunteer Learns Care

SPEAKER_01 2:44

curious if we can start with a a bit of a broad overview of you and your background. You know, I will have given uh a fulsome introduction, but I'd love to hear in your own words um kind of what pulled you into quality in in healthcare as the the work that you want to devote to devote yourself to.

SPEAKER_00 2:59

Well, it's it's an interesting, it's an interesting question, and uh it goes uh way back. Um if I if people ask me where my career started, uh I have to tell them the story of uh 38 years ago, I'm 52 uh right now, but at the age of 14, I saw an ad in the local newspaper that they were looking for people or clinicians working or coming to work in the National Multiple Sclerosis Center in Belgium, and that was just the town next to where I live, or I lived at that time. So I took my bicycle and uh um took a ride to the to the the city, uh the town next door, and they told me, Chrissy, you are too young to do something here, you're only 14. And so I told them, but it's impossible that I cannot do anything here. And so they told me, Yeah, you can work as a volunteer, but we cannot offer you a job, of course. We cannot pay you, you're too young. And I told them, I am not looking for money, I just want to do something. It uh if I see all the people here in their wheelchairs, I must be able to do something for them. So the next day I took my bicycle, went back to the to the center, and I started to work there from my 14, and I spent all my holidays, uh, school holidays, I was at uh at the MS Center helping uh uh people, helping uh patients uh um riding with with the wheelchairs from their rooms to the physiotherapy, and I knew everybody, and everybody knew me, and it was really fun, and I'm sure that that had an enormous impact on my life. I even met my wife later on in the hospital, who was also working as a volunteer and is now a dermatologist. I learned at a very young age what what care was all about, not the clinical content, of course, but was taking care of people, uh, and it had a huge impact on my on my work and and still has a huge impact on my work right now.

SPEAKER_01 5:08

That's that's an inspiring background. I'm I'm curious as you went on from those teenage years, kind of what the the subsequent steps in in that path were for you.

From Nursing To Policy Leadership

SPEAKER_00 5:20

Yeah. Well, then um I I was uh studying science and mathematics uh uh until I was 18, and so everybody thought that what that I would go into economics or engineering or or medicine, and then I did my my bachelor in nursing and my mastery in healthcare administration and policy, and then later on I started to work uh at university. Uh, it was around 1999, the year 2000, when I started to work there as a research fellow. And then between 2003 and seven, I did my PhD, and I obtained my PhD in public health, and then some additional studies on economics and uh operations management. And then importantly, I did a postdoc at the IHI in Boston, and then it all uh started. I became uh professor at Liver University, and now I'm combining uh some academic work, uh some work at our academic medical center within the team of quality managers. The academic medical center is the top 40 hospital on the Newsweek top hospitals worldwide. So it's an interesting, large academic medical center. So I know what quality of care is on a daily basis and how to collaborate with clinicians and with managers. And my third role next to my academic role and my work at a hospital, I'm the chairman of the um National Public Health Research Institute in Belgium. We have more than 1,000 researchers in our organization doing uh policy work uh for the uh Belgian government. So I'm combining uh research with a research team of about 15 highly talented researchers, PhDs and postdocs, and then part-time work at the hospital and some additional policy work as the direct as the uh chairman of the board of directors of the uh National Public Health Institute. So that's the combination.

SPEAKER_01 7:21

That sounds like a really interesting mix that I would guess, you know, in academia, maybe there aren't uh as many people who wear that many hats. Um, to have the clinical role and and uh the academic role and also the research chair role. Is that is that common?

SPEAKER_00 7:38

Well, it's common that we try to do it, and and I have some other colleagues who also uh combine it. Certainly within the Faculty of Medicine, we have some real clinicians. I'm not doing clinical work, I'm doing managerial and supportive work at within the management team. But uh joint appointments are something that we really uh try to work on also at the university, and that's a very interesting combination because uh I can do some research about adverse events or my second victim work or my work on quality management systems that I think we will talk about later on. But I also know what it is to implement it in an organization, and I know what the pitfalls are, I know the challenges. So um sometimes with working only at academia, uh you get a you become a kind of dinosaur and and only in uh uh reading and and thinking. But uh I know the challenges. I know the challenge of explaining the things that we write about at the academic, uh in the in our academic world and our academic output, but also to translate that later on today. I have a uh I have a meeting with uh with clinicians on on second victim support. Um, so it's combining the research, but also trying to understand it, to understand what it means in practice. And that's a very interesting combination. The third role is a new role since two years, more a policy role uh on on government level, um uh a lot of politics involved, but it's all but I also learn a lot for my academic and my clinical world by understanding how politics works.

SPEAKER_01 9:15

Wow, uh you must be you must be a busy guy.

SPEAKER_00 9:20

Well, it gives me positive energy, and as long as I uh as I don't learn to say no, that's my problem. But it's positive. It's positive, it's um it's interesting. Uh certainly working with um like yesterday I was teaching to 18-year-olds, uh, first year of medicine students in their first year of medicine. I was explaining them about joy in work and uh anti-burnout. And then uh today I was I was uh working for Brussels, and this evening I have a meeting with clinicians on second victims. So that combination, it's a really it's a privilege to to be able to do these different things.

SPEAKER_01 10:01

Yeah, and with that broad overview, um, I think listeners will understand why it was uh challenging to whittle down a single focus for this episode because uh because there are uh a lot of things, as you mentioned, the the second victim work and and many, many other things in policy and and government and research. So we will um we'll do our best um and uh and go, you know, one bite at a time, as it were.

The Quality Thinkers Who Shaped Him

SPEAKER_01 10:25

Um but I'm curious in that journey, what were the specific to healthcare quality, what were the the quality thinkers that you think most shaped your thinking? And what did they help you to see more clearly?

SPEAKER_00 10:41

That's an interesting question because I I'm uh I'm a real fan of the of the old quality gurus, and then we always refer to to Deming and to Jiran. Um, and then we talk about Feigenbaum, and then we talk about Don Abidian, and and that is really interesting stuff, certainly the Deming and Joran, the Juran's trilogy I'm I'm using at a daily basis, also in our new quality management system, design control improvements. It's really so interesting if you talk and and if you read about new uh models or new um methods in quality management, you can always see the link with the with the old stuff. And so, also at university, I I teach about Deming, I teach about Duran. Uh so that's that's really interesting. But one of my favorite quality gurus or or people that I that that really helped me in my thinking is Philip Crosby. And uh Crosby was there in the 1980s, uh interesting guy, but uh we mainly know Crosby from his zero defects theory. And zero defects, I know and uh and I agree with Deming and Duran that zero defects is impossible because you always have system variation and and the process never under control. But what I really think that is really interesting about the zero defects uh theory of of Philip Crosby is that that can be your only aim. Your only aim can be zero falls in hospital. You cannot say, well, we will expect this year our goal is five falls, because that will be significantly better than last year, but you cannot say we expect five. So the zero defects, there is only the zero defects, that is the aim. Um, and that's interesting work that we are also now using with one of my PhD students when we have a PhD study of Alexander, one of my PhD uh students, who is looking at the cost of poor quality. We're always also using the Duran work, but also the Crosby work with the zero defects and trying to understand that while we hope that he's correct, that focusing on prevention, that the total cost will go down. Uh, so that's one of the old gurus um that that uh really uh uh helped me in in my thinking about about uh uh quality. But if I look at the that people that inspire me right now, well, if I look at at the work that that uh Lucian Lee did over the the past uh years and decades, and the work that that don Berwick or the messages that Don Berwick is is providing us, or Maureen Bissoniano, these are real people who are inspiring me on my um on my daily work, in my daily work.

Listener Invite To Share Stories

SPEAKER_01 13:45

I wanted to pause for a moment to invite you into something I'm starting with this podcast. If something from this episode connected with your own experience, where you've seen it work or not work, I'd love to hear about it. There's a short link in the show notes where you can share what you're seeing in your own work. It takes about a minute. I read every response, and over time I'll be sharing what we're learning together in future episodes and in other ways, and giving shout-outs during future episodes to people in the community who share ideas that really move the conversation forward. If you're up for it, I'd really value your perspective. Thanks.

Why Flacum Began After Accreditation

SPEAKER_01 14:26

As you've mentioned, the the focus um of our discussion today is going to be on quality management systems. And this is a particular focus for you. I know you've you've run a few workshops at this point at the International Forum for Quality and Safety and Healthcare and perhaps in other venues. And this is when you're presenting this, this is the Flanders quality management system or FLACM. I don't know if that's how you you pronounce the uh the acronym. So I'm wondering uh if you can just get kind of level set for me, you know, what Flaccum is, how it came to be, um, so that our audience kind of understands where uh where that started.

SPEAKER_00 15:08

Yeah, it's been an interesting uh uh it's been very interesting over the past years to to develop that Flanders quality model, uh Vlacum, as we as we call it. And so the region where we work, um we're in Belgium, and and Belgium, most of the international colleagues know Belgium because of the capital Brussels. Uh, but Belgium is divided into a Flemish-speaking community and a French-speaking community. Brussels is in the middle, but in the Flemish-speaking, in the in the whole of the country, in the whole of Belgium, we have about 11 million inhabitants, and 6.5 million inhabitants live in the Flemish-speaking side of the country, where we have about more than 50 uh general hospitals. And a lot of these hospitals, or nearly all hospitals, were working on hospital accreditation. So they were really using accreditation standards. They were using the Dutch accreditation system that is linked to the to accreditation Canada or Joint Commission International. But around 2019, 2020, there were hospitals who were saying, well, it it has a positive aim, it had a positive impact, the accreditation, but we want to go to a next level of quality. We want to use the money that we have for real quality improvement. And our goal should be to bring quality from bedside to boardroom. And what we saw that happened in a lot of the organizations with accreditation, and I see a lot of positive effects of accreditation, was that it was a kind of top-down thing. The goal was to get the accreditation, the goal was not to improve quality, the goal was to get the label, to get a certification. And so hospitals contacted us and said, can we develop a kind of new model that will bring quality not only top-down but also bottom-up, but also more stakeholder involvement of patients, of kin, and of providers? And can we try to build a kind of roadmap that can help us by keeping the positive things from the accreditation, but building on top of that a layer that will make quality sustainable and not sustainable from an eco-friendly point of view, but really implemented because what we saw in a lot of our organizations, and I also hear it now from other countries, is that one month after the accreditation, the level went down, and six months before the next wave, we all started to work again on quality or the focus was on quality, and so the goal was that momentum, and that momentum is positive. But but I would like to find a or that is my maybe naive goal or naive aim. I want to find a model or develop a model where it will be sustainable quality, where it's 24-7,365. And I know that it is naive, but that's the challenge. And we are happy that we have a group of uh more than 20 hospitals in our region that are developing that model together with us. So Flacum is not developed by LEUVE University, it is developed by LEUVE University who has the coordination role, but together with more than 20 general hospitals, academic medical centers, two rehabilitation centers, and two mental health institutes. And that combination, we learn a lot from each other. So it's a co-design, a co-designed model where we have three main parts in the model where we say the first thing you have to do

Think Do Learn And The Roadmap

SPEAKER_00 19:00

is to rethink your vision on quality. Because in the in the previous phase, the vision was the goal, is the accreditation. We do JCI, we do accreditation Canada, we do QualiCor, we do Autorité de Santé. And now we have we are using our multidimensional quality vision model, what we call our house of trust, to make them really think about their priorities and what is quality all about. It's more than the six dimensions of quality. So we developed some models for that. The first thing is quality vision. We call it think. The second is our do. That's quality co-creation. We developed within one of the PhDs developed by Finn Klassen. We developed a roadmap how to help organizations in making quality sustainable in a six-driver driver diagram with 19 building blocks that that is published, uh uh uh open access that hospitals can use. But we also developed some maturity matrix to measure the maturity. And maturity were developed by Philip Crosby years ago. So we have learned from Philip Crosby, and in our roadmap, our roadmap is based on Durant's trilogy, including then additionally leadership and culture and the context. And so we have two phases: the the think, the quality vision, with the house of trust and our multi-dimensional model. We have the do, quality co-creation, make it happen. But then a third pillar of the Flacum model, next to think and do, is learn and innovation. And so we are convinced that you cannot make that happen on your own. You have to do that in what we call a consortium, uh, a group of organizations who want to learn from each other. So that is the these are the three pillars of our Flacum model think, do, and learn. As easy as that, but very complex to make it happen.

SPEAKER_01 21:11

Yeah, yeah. Simple, but not uh not easy, I can imagine.

SPEAKER_00 21:15

Not easy, not easy, not easy.

SPEAKER_01 21:18

Yeah. So you're talking about the the six pillars, and maybe you can just elaborate a little bit more on that for me. What I hear is the Duran trilogy um plus three more pillars around leadership, culture, and context you mentioned. What inspired the inclusion of those those components?

SPEAKER_00 21:38

Well, those components, there is nothing new in those components. If you read them, and if you read the plus one paper that Fiend Klassen published as part of her PhD, there is nothing new in there. But what Fiend did was a two step approach. She first looked at all the available models in literature. And that's why when we were presenting in Oslo, for example, a few weeks ago, our model people were saying, well, there are some similarities with our model. Of course, of course, because we used the best of all things and combined it into a new model. But then what Fedon did was to redesign the knowledge from the evidence and of all the published models in published literature and gray literature, and she used more than 50 different models to make the first version. But then we redesigned it together with these hospitals. And so the model, the roadmap with the six drivers, where the first driver is quality design and planning, the second is quality control. Then we have quality improvement. So design control improve, that's Duran. And then on top, we said, okay, if you do the design control improve, then you can work on leadership. And if leadership is involved, then you will work on your overall quality culture. So that's the fifth driver, quality culture. And the sixth driver is a kind of umbrella driver, is quality context, internal context and external context. And

Co-Design Benefits And Stakeholders

SPEAKER_00 23:18

the way that we translated all the evidence from the literature and all the models, like Scottish models and NHS and IHI and EFQM and everything, that was translated by quality managers from our participating hospitals. And so that is why we think that we now have a model that can work because it was developed with and co-designed with people from general hospitals, academic medical centers, rehabilitation hospitals, and psychiatric hospitals. And so that is a that was a very interesting approach that we used to develop the roadmap in Fiennes PhD. And now we are redesigning it continuously because we have new ideas, there is new evidence, there are new findings, and right now there is interest, interest from other countries to translate the model into other contexts. And so I think in a few years' time we will have a 3.0 or a 4.0 model based on well, the world is changing. So our models also have to change. But the co-design and the co-creation, together with the organizations, that's the strength of the model. It was not something that was developed by a PhD student on a desk in an old university. No, no. It was developed and discussed and discussed and discussed together with organizations. Um organizations with 250 bets up to an organization with 3,000 bets. So that's the interesting thing. That's the interesting combination, I think.

SPEAKER_01 25:05

Yeah, I'd like to tap just a little more into that because of, you know, I hear you leaning into that. And the diversity of perspectives is certainly one of the uh themes that I'm hearing there. Uh, that you had these different hospital contexts, different uh managers, quality managers, a lot of different people uh contributing to that co-design. Um so diversity of perspectives maybe maybe one of the advantages there. What uh for someone who's not maybe bought into that co-design, maybe it sounds like it's a lot of, you know, uh a lot more work than just a top-down prescription. What are the other kind of tangible benefits in your mind? What how has that been uh a force for good in this effort?

SPEAKER_00 25:51

Well, the different perspectives are, of course, uh hugely important. Uh, not only the difference between the general hospitals and the academic medical centers and the rehabilitation and the psychiatry, that was that was a huge advantage. But also a huge advantage where the people that were among our co-designers, our uh flacum builders, we call them. And there were clinicians in there, there were psychologists, there were engineers, there were CEOs, there were nurses, there were medical doctors, there were physiotherapists, there were patients, there were and so the different perspectives, it has cost us a lot of work, a lot of time. It has cost us two to three years' time, but that's why it was a PhD. And all the steps, all the different steps were published. You can read about it in the literature if you look at the Vlacum website, you can read the different steps that that we took in in that fabulous PhD of Theme. But although it was a usual work and a lot of co-design work, also uh online in Teams, in Zoom, but bringing people together, and that was the main advantage. And we see that that is also one of the main advantages of using Flacum at the moment in organizations, where in our first quality design and planning driver, we have a building block on involvement of stakeholders. And I think that in previous years, a lot of quality management systems were developed by starting to measure indicators or starting to audit standards without first taking the time to think about our aim and our priorities and our goal. And what I see right now is that that co-design work that we are also using within the organizations to make Vlacum happen in an organization, it takes time. But it is something that also clinicians really like to do. Because what they hate about quality is that the chief quality officer will tell them this is what you will do. And certainly with medical doctors, they hated accreditation because they were told what to do. But if you ask a medical doctor where are the most unsafe acts or risks in your organization, they can tell you. So we will start with this type of co-design work. But what we have available right now are the models and the roadmaps and the methods and the surveys and the algorithms and the feedback report, because we we produced all these different things, and that is also the work that we are now trying to translate into other countries, like British Columbia and Canada and in the Netherlands and in Australia. And they will, I think they will win about two to three years because they will not have to do all the work again that we did, but they can immediately start with the translation in their context, and so they will win a lot of time and a lot of money if they start with what we learned already, but they will have to translate it. You cannot just implement Flacum in your you will have to translate, and it will take you two to also I think two to three years. But the first work that we did in the beginning of bringing all the evidence together, all the things, that is already done. And so that is what we are now. Um well we think it it it will save other ecosystems a lot of time and money if they if they do not have to start from nowhere and nothing.

SPEAKER_01 29:59

Yeah, and I've had uh a few guests on here from British Columbia that I imagine are among your collaborators. Uh you know, you mentioned uh offline, you mentioned uh Ali Muniac's episode and uh as I call her. She's uh she's one of actually our most uh our most listened to episode, and she's uh she's great. We had uh and a few others, Kurt Smetcher and uh Lawrence Yang and Gail Grout and some others. It's uh it's been great. So I'm glad you're able to collaborate with them. And uh I'm curious, uh I do want to talk about the spread um beyond borders, and that was a focus, uh, it sounds like with a variety of your collaborators uh in Canada, as you mentioned, Australia, Norway.

Implementation Across 23 Organizations

SPEAKER_01 30:44

Um but I'm curious first about the spread or the adoption kind of within this 20, guess you said 20 hospital system. What do you know about the, you know, kind of the the spread, the culture change, the the adoption? Um, and if you're able to comment also any differences in kind of clinical care, clinical outcomes that we're that we're aware of. What are the kind of the downstream effects of all this great work that you guys have been doing?

SPEAKER_00 31:12

Yeah. So um I really look forward to collaborate with, for example, British Columbia. And it's Christina Krause, the CEO, who will take the lead uh in that. And and and I I have been collaborating with Christina for years, and and we really trust each other. And we have to we will collaborate and we will rethink the models. And and and Christina is a great is a great leader. Uh also uh the group in in the Netherlands uh with Relinde, uh it will be it will be huge fun and and a good collaboration also down under with Australia, the University of Tasmania, and Peter Van Damme, who is uh taking the lead there. There will be a PhD starting very soon in Tasmania on Vlacuum. So this is really great to understand the difference in context. And I think that our overall goal in a in five years' time should be to have not a vlacuum, but but an a unicume, a united quality model that we can learn from. That is my very naive goal, a naive dream. But but but we have to do it with people who trust each other, who want to collaborate and and who can uh collaborate. And we learn the same thing within the country or within the region. So at this moment we have Flacum implemented in 23 organizations in our own region. Uh so that that that's really good. Um, but we also see the different the differences between the organizations, and in some organizations, it's really a strategy where the CEO is totally aware. In some of the organizations, it's more a project. So it's not a good news show. Flacum in the 23 organization organizations, well, there's still a lot of room for improvement of the model, but also of the implementation. And what I learned there is what I learned over the past 30 years in healthcare, it depends on people. It depends on people who really want to take the lead. So the the leadership driver in our roadmap, I think that is really an important one. And in our roadmap, with our 19 building blocks and six drivers, uh, we talk about leadership. We talk about leadership on three levels: on personal and clinical leadership, on visible supportive management and staff member leadership, and on executive and governance support, the three levels. And we will need all three levels, and there I see differences within within our own ecosystem. And there will also be a difference um between uh if we look at at BC in Canada, well, it's it's incredible for us, it's 2,000 kilometers wide. Yeah, it's Vancouver with a flagship hospital, but then up north or in in the middle of of the province, you have very small hospitals. And I uh when I was in in Canada, I learned about a hospital with 10 beds and with one nurse. There, the clinical leadership will be hugely important. But what I hope, or what we see in our region, is that having the models and the components and the basic components ready uh in visual models, into PowerPoint presentations, into validated surveys that you can use, that that is a huge privilege and and and uh positive thing, that you don't have to start from scratch and say, what how will we do that? So learning from and then bringing those people together, if I if I look at one of the strengths of our Flacken consortium, and it it's a small region, Belgium, uh the Flanders, uh, because we're now translating it into the French-speaking community, also about 20 hospitals who will start to use that and are involved in in the PhD of Mathieu Louiset, a very good friend and a PhD of mine, PhD student Mathieu, is translating into the French-speaking community, other context. But one of the main things that is happening in our region, in the Flemish, is that we bring those, what we call our Flaccum coordinators, we bring them together every month, one month virtually, a Teams meeting where they change IDs and we send some new information. And the second month we see each other a full day at Leuve University, and they all come to the university and they share their experience. And then somebody is saying, Well, I had a problem with the implementation of that part, and then 22 others. Oh, we too. Oh, I had a solution, oh, I solved it like that. And so, with the three pillars of Vlacum, the think, do, and the learn, that's the third one, the learn, that is of major importance, and that we will have also to learn from, for example, Tasmania or from BC with real rural health and flagship hospitals, how we can also develop the learning pillar in Flacum. And that you can only do if you have real quality leaders like Christina and Ali and people there that know and understand the context. So it will be um, I'm sure it will be an interesting journey, but a challenge.

SPEAKER_01 36:32

So, as you have you know discussed more and more with with the the leaders you mention uh from around the world, what how has your thinking evolved around quality management systems?

What Must Stay Universal Or Local

SPEAKER_01 36:45

What components feel maybe universal or or essential, and and which components or or ideas maybe are more context-specific?

SPEAKER_00 36:58

I always have a lot of discussions, but positive discussions about that with our uh with the chairman of our international advisory boards. In Flacki, we have an international advisory board with with a bunch of highly respected people and and experts. And the the chairman of our international advisory board is Peter Lackman, the former CEO of ISCO, pediatrician, and uh a good friend. He's my mentor. And Peter always tells me, well, there are very there is there are a lot of differences worldwide. But there are more things that are in common, also on quality thinking. So together with Peter Lachman and with Paul Beteldon, we developed a multidimensional model and our house of trust that was created in in the brain of Peter and Paul, and I had a privilege to collaborate with them. But also in our roadmap thinking, in our second pillar, in our do, so the thing, do, learn in the do, in the roadmap, Peter always tells me it starts with planning. The basic ideas are also in the planning, combining the stakeholders who are patients, the next of kin, the families, the relatives, but also the providers. And we need to, I think that that is a universal thing. That's global. The planning, the control, and the improvement that's global. I think the leadership should also be the same, but the leadership is highly related to culture. It will be different in Flanders. Well, it is different in Flanders and in Walloon, the French-speaking side of our country. There is a difference. So how leaders will take the lead will be culture dependent. If we would let's imagine that we can uh introduce flakum not only in Tasmania and in BC and in the Netherlands and in Belgium, but for example, in our I was last year in Singapore. That's a total other organization, total other context, also another culture. What if we would implement flakum thinking in India or in Arab countries or in Africa? So I think that in that in our thinking, in our quality vision, worldwide on global level, quality is multidimensional. It's about heart indicators like safety and effectiveness and efficiency, but it's also about dignity, respect, kindness, empathy, compassion, partnership. So it's front office and back office, as I explain it in our House of Trust. It's about front office and back office everywhere, worldwide. But the culture and the context, for example, the legal structure of your organization, if you have a very good or well-developed inspect inspection system in your country, it will be different than if you don't have an inspection. Maybe in some countries you really need accreditation, and in others, maybe not. So that will be different. And that is the reason why we will not implement or develop FLACM in other contexts without what we call a regional hub, like healthcare BC, because they know the context, they know the structure, they know the people, and they know the challenges. We will not do it from Lew University in Tasmania, impossible. But we don't know the so I think that the Duran trilogy, the first three drivers of our driver diagram, design control, improved, these are global. But the three on top, the leadership, culture, and consta context driver, those three are local. And it will be the combination of both that will make it happen. Because if it would only be the three basic drivers, design control improved, and we have been working on that for 50 years, for 60 years, for 70 years, because these were developed by Jiren in the 1950s. That's uh uh 67 years ago. Then it would all be solved. But we still see variation that we that is unwarranted, and I think that the that the very that the unwarranted variation has got more to do with leadership, with culture, and with context than with design control and improvement. But I cannot prove it. That's what I'm discussing with with my mentors and with my coaches and with my colleagues on international level. Um, and these are the type of discussions that we have in our international advisory board.

SPEAKER_01 41:49

It sounds like in the same way that you described the the learn part of it and the getting together once a month and the managers uh talking together or not the managers.

SPEAKER_00 42:00

What was the term you used for the we call them or they call themselves? Um uh so we call the the meeting the the FCI, the uh flakum uh coordinator intervision, and they call themselves right now I'm an FCI. So that was their choice, but it was in co-design, so they created it, and so we call them our FCIs, our Flaccum coordinators who go into Intervision. Uh so we call them our FCIs. It's it's a great group of people who are really the strength behind all the models.

SPEAKER_01 42:36

And so it sounds like the in the same way that these FCIs, so the Flaccum coordinators, you know, get together, share learning, and and try to kind of uh grow together. You are kind of the beneficiaries of of similar learning and sharing when you're working with local um organizations. You mentioned Health Quality BC as one, and and then uh also the people in Tasmania, that there's a uh probably a shared learning and and uh your own models might be influenced or evolve as a result of kind of kicking the tires on uh on that when you when you do you know change the the leadership culture and context.

SPEAKER_00 43:18

Well, that that's what we hope. Well, our university is a very good university, and I have a great team, but we also know that we that we only that we have to learn from other from other people, and that's the huge privilege that we have in in these times that we can zoom and collaborate and teams uh with people worldwide. Okay, we have to look at time difference. Uh, my meetings with Christina Kraus uh uh is late afternoon for me, early morning for her. Um and but but that works, so we have to learn from each other, we have to bring people together, and also in our international advisory. We have people from around the world in our internet and we can learn from each other. And that's what Peter Lattman is always saying. There are more things in common than that are different. And we have to also, from a safety two-point perspective, learn from the good things that we can learn from each other and not only think at the differences. But I hope that in four to five years' times, time, our models and our methods and our surveys will be 2.0, 3.0, 4.0 next level based on the international what the international community learned us.

SPEAKER_01 44:44

What's uh what do you think uh you know looking forward? Um

Variation In Mortality And The Engine

SPEAKER_01 44:50

what do you think this work looks like in in five years if you know it's evolved to the you know 4.0, 5.0 version? What is happening in the world um when when that is uh you know uh when that new newer, more refined version is unleashed and unleashed more broadly?

SPEAKER_00 45:10

What I really hope is that we will understand variation. I had a discussion this morning uh with one of my PhD uh students, Mathias, and his PhD is about understanding variation in healthcare quality and quality from a quality management system point of view, a teamwork point of view, and an outcomes point of view. If I look at one of the previous uh PhDs that we did with Astrid van Wilder and we looked at really on patient level hospital minimal data, and we looked at variation in mortality, we see that the variation in mortality in our country is not depending on the region, it's not depending on the number of beds, it's not depending on um teaching hospital or no teaching hospital. So it must be something more well, I always say I think that the variation exists because of a kind of invisible engine in an organization. Something is, there is an invisible engine. What I hope is that we will step by step try or learn to understand that invisible engine. And what I hope is that Vlacum or the quality management system that we are building, the unicume for the future, that that will describe the invisible engine. And once we understand the invisible engine, then we can change the engine. Then we can put some more oil or more, I don't know what. We can change it, but we will only be able to change it if we understand it first. And so what I see right now is that what we what we thought 10 years ago, if if we build in structures and we build in uh quality standards like accreditation, which has a positive impact, then then it all will be solved and we will go from structures directly to the outcomes. But what we see right now is that even in a region where all the hospitals have the same structures, or nearly the same structures, that there is a huge unwarranted variation in outcomes. So I think that we have to go to Don Abidian again and to say it's not a there is no direct relation between structures and outcomes, there is the process in between. And that process is what I call or what we call the invisible engine. Something is happening in that organization. And so what we what our idea is that you you have to think about that invisible engine, you have to make it happen, do, and you have to learn about it. And so what we or what our goal is, is to understand that engine, and that engine we call vlacum at the moment. That is our think, do, learn is trying to understand what is really happening on organization level, on hospital level, for example. But also we are measuring at the moment within our organizations psychological safety on team level, because also that will be part of the invisible engine. And if I look in five to ten years' time, I my hope is that before I retire, I have another 15 years to work at least, that we understand the invisible engine or understand it better. Maybe that's also naive, but that's the goal of people working at academia, I think, to be a bit naive and to to keep on searching. We will not be able to search or find the solutions if we do it alone. We have to do it on an international level with people who are critical friends and uh have an open psychological safety that that you can ask the critical and and the stupid critical questions and the stupid questions because that's the only way to understand the variation. I would not accept the variation as patients, so we have to learn from it. The invisible engine, understanding the invisible engine, that's the goal.

SPEAKER_01 49:21

What do you think is important for leaders?

The Leader Mindset Shift Required

SPEAKER_01 49:28

What what mindset shift is important for leaders who might be the future adoptees of this model?

SPEAKER_00 49:36

It's an interesting one and it was a surprising one for us. We uh totally underestimated the uh change that leaders uh had to make not the change in signing a contract and saying we will now collaborate with you, but in as I call it, in their mainframe. Because we have been trained to think that structures lead to outcomes. And we were trained if we follow the protocol, care will be okay. We were trained like that as medical doctors, as nurses, as physiotherapists, also as managers. If you do what is in the evidence, then it will but but it's not enough to do it, we have to continuously improve it. And what I have seen over the past years, and I also see the discussion right now in other countries, if we talk about quality management systems, is that if we want to go two steps in the positive direction, we need to do a step back first and to really think why we are doing that. And so what I saw in and and what I what I uh feel in the discussions that that we have with CEOs and with chief medical officers of organisms and chief nursing officers and chief quality managers of organizations is that it's very difficult for them uh to explain what their goals are, what their vision is. Uh yes, we want to do quality, but what do you mean? And so I underestimated personally, I underestimated the effort for the mind shift. Because we were trained as protocols, procedures, uh doing it and then accreditation, certification, going to a course. No, no, it's daily work, it's hard work. Also, for a CEO to understand the complexity of the work of a quality manager. I see a lot of CEOs and chief medical officers who have no idea about the complexity of the work of the quality team. If leaders want to adopt or adjust the work that we have been doing or translate it into their own organization, the first thing is that they have to um be convinced or accept that also they will have to change their vision about quality. That's our first pillar to think I think that that is uh one of the most important things to have the leaders and and um and also for quality managers. It's not easy to to make the mind shift. We underestimated that, but the models that we produced and the surveys and the in the measurement instruments are helping these people to uh objectivate it and to to measure it and to receive feedback and benchmark reports, for example, benchmark reports on psychological safety, benchmark reports on quality vision, benchmark reports on your maturity level of your quality management system. But it means being open to some types of feedback that is something else than number of bets, um, profit, patient satisfaction. I see that as one of the main challenges, uh Jason.

SPEAKER_01 53:19

Yeah, well said. Um and and as I I've come to experience um with all of these conversations, uh we opened so many more doors, uh, so many more hallways that I want to walk down in the conversation that then we have time to

Optimism Next Steps And Where To Connect

SPEAKER_01 53:33

do. I do wonder, as you look forward in this work, what gives you the most optimism?

SPEAKER_00 53:41

Well, the most optimism uh is if I if I was teaching yesterday to uh my class of uh the first years of of medical school at Leuve University, where I see 500 highly talented uh young people, 18-year-olds, like my daughter, friends of my daughter in my auditorium, and then they are sending uh pictures of me presenting to my daughter. Um but if I see them and I and I and I explain them some things about what care is all about, the first time I I talked to those uh young, highly talented people, I I told them about my own patient story with my pancreatitis. And so they didn't understand what it was because they they didn't have a clue about, but I explained them what I felt and and what I noticed. And when I see them and and when I see the eager of learning, and I see the positive, that makes me very positive. But I that also make me positive if we have the opportunity to have the time to explain about quality management systems to highly experienced CEOs and CMOs and and worldwide, that they say, oh, this is interesting, this is something I have to do. So the seeing people that are uh motivated by our work uh and inspired by our work, but I also see in the young people, but also in the not the old, but the experienced people, that they are all willing to make care better. If you talk about quality with a medical doctor, he will say, Well, no, it's about procedures. But if you ask them, hey, how can you improve your care, or what would you improve if you had all the possibilities, they can then you see them, then they receive it, it it gives them joy in work. And so that makes me positive that I see a new generation that is ready for that, but that they also see the experienced generation that they understand we we really have to do some work about it. But it will take time and it will be working on the think, on the do, and on the learning from each other on international level.

SPEAKER_01 56:01

Perfect place to round out our conversation today, Chris. Uh, I'm so grateful for uh for you and your work and your time today. Um, for listeners who'd like to follow your work or connect, what's the best place uh for them to do that?

SPEAKER_00 56:14

Well, uh LinkedIn, my LinkedIn page, I try to update it uh quite uh frequently uh and also my chrisvanhaag.be website. But I think that LinkedIn is the best place uh to uh learn from each other. It's a great community and uh that works. So um it would be nice to see some new friends uh on LinkedIn.

SPEAKER_01 56:36

Very good. Uh so we'll we'll link to the the resources as well as uh the things that we mentioned in the uh the conversation today. Um thanks thanks so much. This was a rich conversation. I really appreciate you going through all of the incredible work you've done with with Flockham. I know we only scratched the surface and and also didn't get to dive into many other areas that you've you've worked on, but uh so grateful for the conversation today and um thanks for for sharing everything that you do. Thank you, Jason. Thank you. Thanks so much for listening to today's episode of Leading Quality. If you enjoyed the show, please take a moment to like, subscribe, and share it with someone who might find it useful. You can find all our episodes at leadingquality.budsprout.com or in your favorite podcast app. The show is written and hosted by me, Jason Mellows, edited by Milan Milostaviewich, and produced by Thrive Healthcare Improvement. See you next time.