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The application of improvement science

Martin Marshall
Martin Marshall
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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.





 
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Re "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"

and add, and from "evidence of effective implementation and spread strategies" from the emerging science of implementation and other disciplines which have found which approaches to applying proven changes can be most cost-effective in different situations.
Hi Martin, I wholeheartedly agree with your sentiments. Clinicians are in fact experienced practitioners of Improvement Science because every patient they see is an exercise in improving the health of one system - that patient. It is a small step to map that clincial skill across to improving the health of the process of care - a managerial skill whioch seems sadly lacking. Fortunately there are a host of tried-and-tested tools, techniques and theory that we can learn and adopt - we do not need to invent a new solution. The benefits are huge for everyone - patients, staff and taxpayer - so how can we justify NOT investing?

www.improvementscience.net
Martin, your mention of Dr. W. Edwards Deming put me in mind of a story about his invitation to speak in Scotland. At that point he was well into his 80s but still giving his 4-day seminars and travelling around the globe. When he got to the room where he was to speak he noticed the walls were adorned with Total Quality Management (TQM) posters. Not one to let this go unchallenged, his typically wry response was “Is this a TQM meeting? If I’d have known, I wouldn’t have come. There is such a thing as guilt by association”.

In relating this story (emeritus Professor) David and Sarah Kerridge had an important point to make. Most of the quality improvement initiatives inspired by Deming’s contribution to the post-war reconstruction of Japanese industry are but a ‘faint echo’ of his teachings. Perhaps those carried along by the enthusiasm of these quality movements (TQM, Six Sigma, Lean) would have had a change of heart if they had known that Deming cautioned us to see ‘process improvement as essential but unimportant’. Improving only ‘visible processes that produce figures’, he wrote, would tap into only 3% of the potential gains.

That there might be something more profound to learn from Deming is not entirely unexpected given his formative scientific training. Like his mentor Walter Shewhart at Western Electric in the 1930s and 40s, Deming had graduated with a doctorate in Physics. So what is it in Deming’s teachings that many people miss or have not fully understood? This seems a question worth asking in view of fact that, as you say, “Healthcare improvement work over the past 15 years or so has not achieved as much as many had hoped and the best improvement practices have not been taken up widely enough.”

Influenced by David’s early career experiences in medical research, the Kerridges suggest answers may be found by drawing an analogy with the two broad approaches found in health, ‘the quality of life itself’ as they put it. In one version people get sick then they are given comfort and sometimes a cure. The more subtle approach, which does more good in the longer term, is to focus on the whole population most of whom are healthy. Cough medicines, painkillers and surgery versus efforts to reduce tensions and pressures that lead people to smoke.

In life more generally we cope with crises and set up teams in workplaces to tackle problems. But it would work better and be cheaper if we took a more positive approach to ‘improvement’, acting before problems even arise. After all who waits until the fuel tank of their car is empty before visiting the petrol station? Yet the former is much more common than the latter. The Kerridges considered the obstacles faced by those lobbying to increase the priority given to prevention in health to explain why improvement, as Deming envisioned it, was not yet more widely practiced.

The first set of obstacles are to do with prevention being largely ‘theoretical’. People tend to more easily latch onto the theories behind specific treatments than they do to the theories behind preventative measures which can seem airy-fairy or remote in comparison. Where a soundly-based prevention theory does exist and this is grasped it will come too late for a lot of people. Attending to their suffering takes up much of our time and energy leaving little for research and education. With prevention we wait a long time between taking action and seeing the results. Longer than is typical with most health treatments. And it is often only when the results are in that we have proof that it was the best method of prevention.

These obstacles could be a minor hindrance were it not for another set that we confront in the shape of the way things are organised and human nature. Short term-ism takes hold and even when they know their health is being damaged many people find it difficult to change their lifestyle. More generally the prospects for improvement are damaged because the systems we work in discourage people, directly and indirectly, from making a similar shift to thinking long term as Deming advocated.

This is reinforced by structures as we see in the health providing system which puts care of the sick a long way ahead of health promotion. Institutional structures create some powerful vested interests. Doctors and nurses for example not only gain a strong sense of job satisfaction but also earn themselves high approval ratings from grateful patients and their loved ones. As scientifically trained clinicians, oncologists and specialist cancer nurses, would not be sceptical about claims that helping smokers to find ways to stop would reduce the incidence of lung disease. They might though be worried this would be bad for business and detrimental to their reputations as ‘miracle workers and ministering angels’.

Even when knowledge is lacking, care of the sick can often of course do good if only because everyone believes in it. When it comes to preventing disease however, such enthusiasm would get us nowhere fast: it must work whether anyone believes it or not. That requires rigorously tested scientific theory, the same reason that treatments are subjected to double-blind testing. The preventative measures that emerge from this rigour can be embarrassingly simple and less exciting than building new hospitals.

‘Prevention based on medical knowledge’, the Kerridges observe, ‘has done more to improve health than new treatments’. Going about things this way is successful because it usually brings a stream of unforeseen additional benefits in its wake. For example, stop smoking to reduce the risk of getting lung cancer and your chances of getting heart disease, ulcers and impotence also reduce. Getting wrapped up in dealing with immediate problems on the other hand seldom brings unexpected extras. For instance when pressure on budgets leads to cost-cutting measures money is saved but that’s where any improvement ends - not unusually these measures add costs later down the line or to another budget owned by someone else.

In my experience of ‘improvement science’ in clinical care settings (and elsewhere) there is a great tendency to start by teaching people about the ‘proven’ tools and techniques. If nothing else this helps make the case for people spending precious time away from the workplace. They will return, it is argued, equipped with a set of practical skills that can be applied on projects once they get back to work.

In helping us get back to the core of Deming’s teachings where we will find ‘the big gains, 97%, waiting’, the Kerridges take issue with the ‘teaching tools’ approach. The tools certainly have their place but the gains to be had are much more modest - representing the other 3%. So improvement projects can be used as part of the process whereby people learn about the transformation needed. ‘But these must not distract’, they say, ‘from the real aim’ of management (in its fullest sense) which is to establish that there is a long term future. Only then will there be a foundation sufficient to allow new ideas to thrive and people’s confidence to grow.

In the Vin McLouglin Symposium video someone says we need to stop thinking ‘hospital’ and start thinking ‘system’. In the spirit of Deming’s philosophy, the aim of that system could be (following Illich): to create and maintain the environmental and cultural conditions needed by people to live a life of constant autonomous healing.

If we want to be in a better place in 15 years or so then we need to do something different, recognising the very best of intentions behind and, in some places the favourable results from, efforts to date. Without that we will most likely witness patchy achievement as the majority are forced to yield to short-term pressures with more tampering, the very opposite of Dr. Deming’s message to us.


Many thanks for your thoughtful response. You remind me of an important bit of history that others who knew Deming have also highlighted - that much of what we attribute to the great man actually came from his devoted followers - and Deming himself didn't always agree with them!
Hi Martin,
I worked at mount pleasant hc in Exeter with you during GP training several yrs ago
I'm now a board member of Birmingham clinical commissioning group
My ideas are quite simple and I think easy to adopt
1.,using diagnostics before referral to hospital greatly reduces activity ( I have studies to back this up ) and greatly reduces patients getting trapped in outpatients , it is a very satisfying way to work and patients and consultants greatly appreciate it

2. Use of advice and guidance is a very useful way of gps and consultants talking to each other via email with again reduction in activity , this in my mind is far better than referral management
We have demonstrated an 80% reduction in new outpatients of the patients we have used this for.

3 use of hospital webpages to monitor admissions , chase outpatient letters and consultant ordered results sitting on a desk waiting for another potentially useless appointment - we look at the result ourselves and if normal advise our patients not to go back if their symptoms have resolved - again reducing activity !

At my practice we find these ways of working very useful and I am trying to spread the word across my ccg and country wide

I welcome your thoughts on this and whether this falls into improvement science in these troubled economic time for the NHS


Kind regards
Savio
Thank you for these practical ideas on how your practice is working to provide better value care for patients. The aim of improvement science is to work both on new research into what works to improve care and also to work with healthcare providers to encourage implementation in practice of well-researched interventions and to better understand the barriers that arise to implementation.

The Health Foundation is working with researchers and clinical teams to bridge the gaps betwen what we know from the evidence are effective ways to improve safety, value and quality of care and what happens in practice.

We are funding several projects looking at how better use of communication between clinicians and between clainicans and patients, as well as more effective use of communications technology can improve care.
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