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.
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.
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.
My top tips for anyone interested in learning about improvement science are:
I would strongly recommend the following resources:
Demystified? Or more confused? We’d love to hear from you.
You can follow Prof. Maxine on twitter @powerNHS
Useful top tips for leaders to carry out improvement using: social science, statistics, systems and learning https://t.co/nrj6HbYxCm
— elizabethmmorrow (@elizabethmmorr1) May 13, 2016
— ✨hellomynameisSharon (@SharonPoll) May 14, 2016
— Katie De Freitas (@Katie_DeFreitas) May 17, 2016
— Amar Shah (@DrAmarShah) May 17, 2016
— InMyWrightMind (@InMyWrightMind) May 18, 2016