What is Improvement Science anyway?

Content

Professor Maxine Power, Haelo’s Chief Executive, de-tangles the web of improvement science.

This post follows Maxine’s first blog ‘Improvement is a contact sport’ packed with top tips when facing challenges as an aspiring improver.

This month I have been invited to three separate medical leadership meetings to ‘de-mystify’ improvement science. Going into these meetings it’s always a tricky balance between recognising that the essence of medicine is the one to one relationship between clinician and patient and encouraging a wider view of populations (of patients) and systems of care. For many, years of survival in inefficient systems have brought a degree of frustration and an inevitable sapping of energy. I’ll never forget years ago asking one surgeon about improvement and him telling me ‘I would settle for equipment that works in my theatre- every week it’s the same problems, broken lights, broken stirrups’. From that point on I became a firm convert to an approach I have fondly named ‘getting your gripes on the table’. So today I go into rooms like this and listen.

Getting your gripes on the table

It’s always quite interesting to watch the faces of clinicians when you ask them questions instead of ‘lecturing’. Many are very unsettled (one recently admitted to nearly walking out). It’s a fine line but if you can read the room and hold your nerve it works every time. Ninety percent of the time the problems they surface aren’t clinical ­ they are systems problems. One example being a renal team who reported their dialysis patients waiting 2-3 hours per day, 3 times per week for transport. This happens on top of a four to five hour session of dialysis. Patients’ days are long and exhausting and the wait brings unnecessary distress and tiredness. We all know this is wrong, the question is ‘Why don’t we fix it?’ ­ When you ask the renal team about ideas for change they are plentiful ­ change the booking system, different forms of transport, more flexible session times ­ so why don’t they ‘just do it?’

This is where improvement science comes in. Healthcare professional in the NHS are some of the most intelligent and talented people in the world. They are trained by some of the best academic institutions in the world BUT (with a small number of notable exceptions) our undergraduate educational programmes remain woefully lacking the sciences which underpin improvement.  We simply aren’t equipped with the toolkit required to engineer change.

Maxine Power Improvement Science

So…what does this toolkit look like?Four elements improvement science

At Haelo we use the system of profound knowledge, first developed by W. Edwards Deming as the basis for our scientific learning. With its roots in the 1930’s at the Bell laboratories in the USA this ‘system’ recognises four essential ingredients to improvement. First, and importantly it recognises that the improver needs to understand the psychology of change. How we use our understanding of the behaviour of individuals and groups, drawn from social science literature to support improvement. One notable contribution to this field and an essential read for all aspiring improvers is the work of Everett Rogers on the diffusion of innovation.

Second, Deming posits that the world is made up of interconnected systems and that ‘a system cannot understand itself’. In the early 90’s, Paul Batalden famously said ‘every system is perfectly designed to get the results it gets’. Our renal colleagues have a system perfectly designed to have people waiting 2-3 hours for transport!  The system of profound knowledge relies on transformation of the individual into a ‘systems thinker’. At Haelo we teach rudimentary linkage of systems and process mapping skills but are constantly looking to sciences such as operations research (rich pictures, lean and agile systems) and engineering (hard and soft systems) to stretch our thinking.

Third, the system of profound knowledge relies on curiosity about data and in particular a deep understanding of variation. Variation over time and between systems is used for learning. We want to know where the best conditions are, so that we can study them and replicate them. We want to know that a change (once implemented) is linked to an improvement which is sustained over time. For our renal colleagues this means studying the waiting times of patients ‘real time’ charting the wait times using run and control charts, looking for the bright spots when waits were short and learning about the reasons ‘why’ people are waiting. This is a far cry from the before and after statistics used in research or the in depth review of 50 historical cases (which we might use if we are auditing).

Fourth, we need a system for learning which Deming refers to as the ‘theory of knowledge’. Embedded within this is a system of inductive / deductive learning more akin to the action research advocated by Revens than the classical ‘research’ taught in most medical training programme. Plan do study act cycles (PDSA) are used to test ‘hunches’ or theories which logically seem to fit as a potential solution. For example, our renal team might decide that calling ambulance control 2 hours before the patient completes their dialysis to give them ‘advanced warning’ might help shorten their wait. This is a hunch or theory of change. Instead of saying ‘yep, we’ll do this for everyone’ we would test this on one patient on one day to see what happens. The learning from this test will feed into the next – where we might test on three patients. As our degree of belief in the change increases our tests become much wider scale until finally we implement. The process of ‘learning our way to a solution’ is built on 100’s years of empirical learning theory which dates back to Aristotle.

Importantly, the system of profound knowledge is dynamic. The experienced improver uses all four elements in unison to navigate towards a solution. I often refer to the four ‘elements’ as the improvers ‘toolkit’. Just as we wouldn’t ask a surgeon to practice a hip replacement without understanding the biology, chemistry, physiology of the human body. We shouldn’t ask leaders to carry out improvement without understanding social science, statistics, systems and learning. The scientific basis of a profession transcends the technician into a skilled artisan, able to improvise and improve. This is why we need to learn about the family of sciences which underpin improvement practice.

The science of improvement has to be combined with the appropriate subject matter knowledge (e.g. The practice of renal medicine) to be useful. This subject matter knowledge is what we are great at in the NHS. This critical idea of combining subject matter knowledge and improvement science to deliver change is often missed by people new to improvement.

 

Collaboration

 

Improvement Science Top Tips

My top tips for anyone interested in learning about improvement science are:

  1. Build on what you already know. Most of us will have some insights into psychology, systems, variation and “learning by doing”. You aren’t starting from the scratch.
  1. Focus on developing your  ‘blind spots’ or weak points. Sometimes the temptation is to delve deeper into the things which we naturally enjoy and are already good at – make sure you have proficiency in all four areas
  1. Make learning both theoretical and practical – remember, ‘improvement is a contact sport‘ not something we can learn in a library. Your skills as an improver will be guided as much by your emotions as your intellect
  1. Don’t let the word ‘science’ get in the way. The reality is that improvement isn’t one science – it draws from many sciences and it is impossible to have a high degree of mastery in all but we all need to commit to learning more. It is the commitment to life long learning which differentiates the improvement scientist
  1. Shamelessly learn from web based resources where the information has already been drawn together for you. Places such as: The Health Foundation; the Institute for Healthcare Improvement (IHI); the QulturumImperial CHLARCH; and most importantly, the Haelo website and film library. You don’t always need to start from scratch.

 

Resources

I would strongly recommend the following resources:

Demystified? Or more confused? We’d love to hear from you.

Tell us what you think below!

 

You can follow Prof. Maxine on twitter @powerNHS

Join Maxine as part of the QI Connect WebEx series, Thursday, 26 May, (4-5pm). A session not to be missed: ‘Taking improvement to scale in 2016

To find out more about Haelo’s Improvement Science programmes and our team of experts on offer here at Haelo HQ, explore our website or email info.haelo@nhs.net

 

Your reactions on twitter

What do you think?

Leave a comment below

Your email address will not be published. Required fields are marked *

34 Comments

  1. An excellent introduction to improvement science thanks Maxine. The top tips are great for those starting out in improvement and also for those of us who currently work within the field to remind ourselves how it felt to be starting out as improvers. The resources will also be really helpful for sharing with teams when discussing improvement. I’m looking forward to the next blog, and would be interested to see some going in to more detail on each of the elements of the system of profound knowledge. Interested to read others comments/thoughts?

    • Thanks Kayleigh. Might be quite useful to dig into the system of profound knowledge in a bit more detail over the next series of four blogs. A great idea to dig into more detail. Maybe we could produce a hybrid for the systems and ‘process mapping a cup of tea!’ – the improvement equivalent of Lennon and McCartney!

  2. I think this is a great piece to read! Not only does Maxine describe what improvement science is, she also provides examples which make this easier to relate to and make it real. I think this introduction shows how we can make changes and demonstrate them using a toolkit which appreciates all elements, not just assuming things we implement without really testing are either a good or bad thing. I wonder Maxine, does improvement science always lead us to success?

    • Hi Stuart, thanks for your comment. I think it is fair to say that improvement almost never leads to immediate success. In fact, quite the opposite. I think you are insightful in asking that question. In improvement we achieve success through failure. Our testing allows us to test a hunch or a theory and figure out how this might fail (our prediction). Predictions are powerful because they begin to examine our beliefs about how things might work. I’ll never forget working with a team who believed that wearing a badge saying ‘ please ask me to wash my hands’ was the solution to a lonstanding problem with hand hygiene compliance. The wore the badges and tested thier theory asking patients before and after wearing the badges how comfortable they would feel asking a nurse to wash her hands. The real value in this was the opportunity to ask ‘why not’ and to get back the qualitative information which allows a more informed second round of testing. In the case of our hand hygiene warriors this was learning that people would feel this was rude. The next test included some coaching about how busy healthcare professionals were and advise to patients that they may need their help as ‘even with the best will in the world, sometimes they forget’. This educational work helped to set them up for the next round of testing. There are lots of examples like this one. The best way to learn — is fail, fail, fail

  3. This is a great article. Although I understand that improvement methodology is based on science I think its possible to over-egg the title ‘Improvement Science’. I’ve experienced clinicians who downplay the science angle – science to them is quite different to tools used for improvement and I this can have an impact on their engagement.

    • Hi Jez. I completely agree. For most clinicians science is only science when its biology or chemistry, just as evidence is only evidence when its a systematic review or randomised controlled trial. I think a potentially better way to think of this is as ‘the science that underpins improvement’ . The disciplines we draw from are so diverse that pulling them together feels unnecessary. Glad you enjoyed the blog. Maybe we could invite you to blog for us sometime? GOSH has a global reputation in leading improvement and we sure have a lot to learn from you guys??

  4. Thank you for writing this Maxine, I’m really enjoying your blogs which I’m sure will inspire others.
    I believe even those who are experienced in using the methodology need to be reminded from time to time to pay attention to all four elements, particularly, as you say, those outside their comfort zone. For me that’s remembering the importance of including service users, which I think comes under the ‘psychology’ and ‘knowledge of the system’ lenses. Having service user involvement can bring empathy and a provide a “burning platform”. Imagine if it was your family member! They can also provide a different perspective – I remember a group of NHS staff who were working to improve out patients. The group were focussed on one part of the system and completely dismissed waiting times in clinic as an area for improvement as they felt that wasn’t a problem. The patient in the group completely disagreed and it made the team see things quite differently! If service users are included in the right way, it can completely transform the way a team tackle improvement.
    Thanks again Maxine!

    • Hi Katherine. Thanks for your comment. Its interesting you mention patients – Deming describes this as ‘the voice of the customer’ and we know that those organisations who regularly seek out ‘the voice of the customer’ significantly out perform those who operate in a bubble. I think a really excellent blog could address the successes and pitfalls of involving patients in improvement and perhaps a list of top tips!!!! Fancy having a go??

  5. Interesting blog – thank you – and a great overview . I read with interest your response to Stuart about having ‘permission to fail’. Do you think this is something widely accepted throughout the NHS or do we still have some work to do to persuade those higher up the organisation that we can still learn from what might be classed as a failure? It seems in these times of austerity, it feels like there’s even less wiggle room to try things out than there was previously.

    • Hi Beki – this is a really insightful question. The answer, of course, is yes and no! The NHS is littered with catastrophic failures, such as Mid Staffordshire hospital and Maidstone. Typically these failures are ‘handled’ through inspection, regulation and public enquiries. All of these mechanisms are critical to a safe system but bear heavily on our workforce as they are ‘judgement based systems’. The work of Joseph Juran shows us that quality assurance is one of three vital elements of a healthy and mature system, the other two being quality planning and quality improvement. A system that wants to improve CANNOT blame. The leaders of the NHS would be well served to become students of Juran. In the meantime I think we have enough good guys around right now to possibly break our cycle. Fingers crossed.

  6. This is great Maxine. Thanks. The links to the resources are so very helpful. You’re definitely right when you say “improvement is a contact sport” , it’s the doing that cements the learning, allowing for those connections between theory and practice to be formed. I am wondering what your thoughts are on how we now move NHS staff away from self-limiting ways of improving and make it a core and natural part of the job role. For example, are Health Education England programmes integrating improvement science into their training modules?

    • Hi Cara – thanks for your comment. I’m not sure whether you know about the recent publication from the Kings Fund ‘Improving Quality in the English NHS – a strategy for action‘ published in 2016. This document absolutely supports the direction of travel you suggest. I think there are a lot of people working hard to make this happen but the change is frustratingly slow. My feeling is that whilst we wait for national organisations to catch up, we all work towards this goal in our local systems. Its an army that’s needed. Thanks for the comments and keep us posted on your journey.

  7. Thanks Max. Always love your work. Intrigued to know your thoughts about what makes something go from being “new” to being “what we do”.

    So in my head, as an example, I can remember the journey we took as individuals and as a society when “recycling” emerged as a new concept. It had huge number of advocates, detractors, plans, initiatives and debate. It certainly felt all new at the time. Somehow we have moved to a position where this feels integrated into everyday life.

    Do you think we will move from positions of advocacy and explaining the discipline of Improvement Science to one of assimilation? Improvement Science becomes part of our DNA? The 1930s seems a long way off for this still to be deemed new in large parts of our health and social care cultures.

    • Hi Chris – its interesting isn’t it. If you think about the change in our digital world over the last decade it seems that we have all gone from the library to ‘google’ in less than 10 years. Everett Rogers talks about this in his latest edition of ‘diffusion of innovation’. The internet has changed everything! and will continue to carve out its mark on society as generations of leaders assume that technology will be part of their life and work. For me, I think improvement and its attendant family of sciences has been quite slow to embrace and exploit this ‘new world’. Here in Haelo we are resolute in creating a beautiful digital place which appeals to the next generation of public sector workers in an attempt to ‘mainstream’ improvement and its sciences. There are no easy answers but my thoughts are we stop saying this isn’t possible and start communicating. You’re at the helm! What’s happening in Liverpool???

    • Thanks Joanne – I believe that improvement should be accessible to all and that most people already have part of the skill set. I’m glad you agree and that we achieved this for you. If you have 5 minutes we’d be interested to know how you might use this blog to help others become improvers?

    • That’s exactly the goal here Joanne – hopefully we can make improvement something that everyone feels skilled at.

  8. This was a great read on improvement science Maxine having only just started with Haelo and being unfamiliar with improvement sciences. Having recently studies Business Management with Leadership & Change, I too agree that aspect of improvement sciences is very poorly conducted at undergraduate level as I didn’t study anything around this.
    The blog gave me a great start to learning about improvement sciences and the top tips were very useful as well.

    I am looking forward to the next blog and gaining more insight into different elements. It would also be great to see other blogs on improvement science theories to expand on this current discussion.

    • Hi Ben. Thanks for your comments and welcome to Haelo. It would be good to hear how you were taught about change on your undergraduate programme and maybe we can compare and discuss how this is aligned to (or different from) the improvement science we outline here in this blog? Maybe one to think about for the future? Look forward to hearing more from you.

  9. Very nice exploration of the science of improvement using the lens of Deming’s System of Profound Knowledge. Deming emphasized that the “deep” knowledge about improvement will be found in the interactions of the four components. A number of new ideas have recently come from “cognitive psychology”, the interaction of theory of knowledge and psychology. And, a lot of current activity in “data analytics” is focused on prediction – bringing the components of systems, understanding variation, and theory of knowledge into play.

    How do we all learn how to consider the interactions of the four components of this science when we are trying to make improvements to health care systems?

    • Thanks for this comment Lloyd. It is fascinating to me that this concept of integrating the four elements of the model is gaining so much interest. I have often thought how learning to be an improver is a little bit like learning to drive, in the first few weeks / months every move feels exaggerated and awkward. The transitions between systems thinking and psychology or variation and testing are somewhat ‘jerky’ and awkward. However, as you gain experience and skill the ease with which you transition from one to another definitely improves, until suddenly the process is automatic. This ‘automation’ helps with transitions and applications and is almost an implicit part of someone’s tacit knowledge. Its great to surface it and learn more about how our social science partners are interpreting and understanding this behaviour. Thanks for your comments and look forward to hearing more from you in coming weeks. Keep your eyes posted for our up coming blog on aim setting.

    • Hi Anna,

      Want to find out more? Due to the popularity of Maxine’s recent blog series – we’re hosting a one-day workshop with Prof Maxine Power.

      You will leave inspired, fully equipped with your improvement toolkit for 2016, complete with theory and practice examples

      http://www.haelo.org.uk/improvement-workshop/

      Register today – We hope to see you there!

  10. Fascinating read. The top tips extremely helpful – particularly struck by the need to focus on the blind spots or weak points. I facilitate events where I talk about leadership and managing change but often wonder afterwards if I am just “talking a good game” but not actually running to a problem or challenge in reality. There’s a great Lewis Gordon Pugh talk on-line where he talks about the need for teams to be made up of optimistic enthusiasts – I wonder how many of those get dragged into an organisational inertia that drags improvement to a snails pace allowing the ineffective systems to continue?

    • Hi Geoff,

      Want to find out more? Due to the popularity of Maxine’s recent blog series – we’re hosting a one-day workshop with Prof Maxine Power.

      You will leave inspired, fully equipped with your improvement toolkit for 2016, complete with theory and practice examples

      http://www.haelo.org.uk/improvement-workshop/

      Register today – We hope to see you there!

  11. This is a really useful and accessible summary of what sits behind improvement methods. If we are going to move the science forward, we need to find ways to get funded, and to publish – any opportunities to do this in the UK Maxine?

  12. A very good blog on the science of improvement. Really needed as a solid foundation for health and social care professionals and managers in their quest to improve quality care.