The health sector is not short of new ideas, many of them derived from basic and clinical research, which have the potential to improve outcomes for patients. The challenge for health systems around the world is putting these ideas into practice.
Two different gaps in this translation process have been identified. The first describes the process of converting fundamental scientific insights into specific interventions of proven value. This gap can and is being addressed by closer working between basic and clinical sciences and, whilst it has not yet been solved, we have a good idea of how to address it and progress is being made.
The second gap presents more of a problem: the process of ensuring that evidence-based interventions become part of routine practice, and are sustained and spread across organisations and health systems. Only if this happens will the benefits of the new ideas be fully realised. The very existence of this gap still comes as a surprise to many, even clinicians and managers working in health services. And yet there is mounting evidence that the gap is significant and actionable.
Research tells us that, on average, we implement only about half of what would generally be accepted as good clinical practice, and perhaps even less of good managerial practice. Closing the second implementation gap is one of the most significant and complex challenges we face.
The problem is that the basic and clinical sciences that are helping us to close the first gap are sometimes found wanting when applied to the second gap. The complexity of achieving the change required of systems and of individual behaviours at scale would benefit from an adaption of established assumptions, theories and practical approaches. There is a growing consensus that the solution can be found in the science of improvement.
The term ‘improvement science’ draws on a range of basic and applied sciences and aims to increase the effectiveness and efficiency of efforts to improve health care for patients and populations. Some commentators regard it as a branch of health services research. Its origins lie in the application of scientific approaches to improve industrial manufacturing processes, led by pioneers such as Deming and Juran in the 1950s.
The principles and practices of improvement science were introduced into the health sector more than two decades ago. Terms such as ‘implementation science’, ‘translation science’ and ‘delivery science’ are sometimes used synonymously but ‘improvement science’ is rapidly becoming the accepted generic term to encompass any approach to improvement, covering:
- organisationally-based initiatives (eg PDSA cycles, Lean and Business Process Re-engineering)
- traditional professional initiatives (eg the use of audit, guidelines and peer review),
- governmental approaches (eg regulation, performance management and legislation)
- economic approaches (eg competition, financial incentives and choice).
Improvement science is multi-disciplinary and highly practical. Originally drawing on operations research, industrial engineering and management science, it has expanded to encompass disciplines such as health and behavioural economics, sociology and anthropology, psychology, statistics and mathematics, epidemiology, policy analysis, philosophy and ethics.
Because the principle aim is to change practice, a close partnership between researchers and practitioners in co-design and co-delivery is a defining element of the science. Improvement science is not something that can be detached from improvement practice.
We think that there is a real need for improvement practitioners, researchers and funding bodies to engage with the science of improvement. Like all new ventures, the improvement movement has, over the last two or three decades, focused on building will and developing its methods. But all emerging disciplines reach a stage when they have to ask themselves hard questions and start building a rigorous evidence base to underpin their practice. Improvement science has the capacity to guide and inform this process.
In addition, there is a large and important stakeholder group out there; scientifically trained clinicians, who are sceptical about some of the claims of the improvement movement. If we can engage them with the science underpinning the practice, then we’ll persuade them where there is substance to the claims.
We at the Health Foundation are now making a major commitment to developing the science, building capacity and capability in the field through our new post-doctoral Improvement Science Fellowship programme. For us, the future of quality improvement is intricately woven with the future of improvement science and we’re looking forward to seeing these fellows become leaders in this emerging field.
Martin is Clinical Director and Director of Research and Development at the Health Foundation.