Exploring Improvement Science in Healthcare: Insights from Caroline Angel

The session, titled 'What is the Model for Improvement,' is part of a series of four recorded sessions organized by the Eastern Academic Health Science Network and funded by the East of England Leadership Academy. Caroline Angel, the Director for Patient Safety at Eastern HSN, welcomes participants and outlines that the subsequent sessions will be released every fortnight, with live Q&A sessions scheduled for November 11 and November 17.

The objectives of the session are to understand the principles of improvement science and to introduce the model for improvement. Caroline emphasizes the importance of addressing the pressures faced by the workforce, particularly in the aftermath of COVID-19, and the necessity of innovation and improvement for both patients and staff.

Quality is a subjective concept that varies among individuals based on their experiences, backgrounds, roles, and expectations. Before discussing improvement, it is crucial to define quality. The U.S. Institute of Medicine outlines six dimensions of quality care: safety, timeliness, effectiveness, efficiency, equity, and patient-centered care. A system excelling in these dimensions will better meet service user needs, resulting in safer, more reliable, and integrated care.

Quality in the NHS is defined using Lord Darzi's 2008 framework, which includes safety, experience of care, and effectiveness. This definition was simplified in the NHS Next Stage Review and is enshrined in law under the Health and Social Care Act 2012. The NHS aims to organize itself around a unified definition of quality care that is effective, safe, and provides a positive experience.

Quality improvement is driven by various policies, including the NHS Long-Term Plan and the Care Quality Commission's key lines of inquiry. Caroline highlights the importance of understanding what quality improvement entails and its implications for healthcare delivery.

Improvement science is described as an applied science focused on real-time data rather than snapshots. It emphasizes prospective approaches, small tests of change, and predictions over hypotheses. This multidisciplinary field draws from clinical science, systems theory, psychology, and statistics, aiming to enhance healthcare quality through continuous improvement.

Caroline introduces three key pioneers of improvement science. Walter Shewhart, an American physicist and engineering statistician, is recognized as the father of Statistical Process Control (SPC). His work at Bell Technologies focused on improving transmission system reliability, shifting from defect inspection to reducing variation and continuous process adjustment, which ultimately improved quality.

W. Edwards Deming, an engineer, statistician, professor, author, and management consultant, championed the work of Walter A. Shewhart, leading to the development of the PDSA cycle from the Shewhart cycle. His collaboration with Japan post-World War II significantly contributed to Japan's economic resurgence in the 1950s and 1960s, helping it become the second-largest economy globally, influenced by Deming's ideas.

Joseph Juran, a Romanian-born American engineer and management consultant, worked independently of Deming but focused on managing for quality. He applied the Pareto principle, asserting that 80% of problems stem from 20% of causes. Juran's approach shifted from production-focused to considering human elements, complementing Deming's System of Profound Knowledge.

Deming's System of Profound Knowledge serves as a theoretical framework for understanding and optimizing organizations. It emphasizes the appreciation of systems, which are interdependent groups of items working towards a common purpose. This system also highlights the importance of understanding human interactions and motivations during change, predicting reactions, and fostering dialogue.

A critical aspect of improvement science is understanding variation, as everything observed or measured varies. Knowledge of variation is essential for making informed decisions and taking appropriate actions. This topic will be explored further in upcoming sessions focused on measurement for improvement.

Quality improvement lacks a singular definition but generally involves a systematic approach that includes continuous testing, measurement, and the empowerment of frontline teams. It emphasizes specific methodologies, with NHS organizations increasingly adopting preferred improvement methodologies to enhance service quality.

The speaker expresses a strong passion for empowering frontline teams, drawing a parallel to customer feedback in restaurants. Just as customers often identify ways to improve their experiences, staff and patients should also be consulted for their insights on potential improvements, fostering a culture of continuous enhancement.

Various methodologies exist in quality improvement, some of which are more complex or context-specific than others. While some methodologies complement each other, such as Statistical Process Control (SPC) and Total Quality Management (TQM), the session will primarily focus on the Model for Improvement, emphasizing the importance of a systematic approach.

The speaker emphasizes the importance of consistently applying improvement methodologies over time to build experience and understanding within organizations, particularly in the NHS. They highlight that many NHS organizations utilize the Model for Improvement, which can be complemented by Lean or Six Sigma principles when focusing on process improvement.

The Model for Improvement is introduced, with a focus on its accessibility through simple language that resonates with all staff levels, from frontline workers to executives. The speaker notes that organizations such as the NHS Institute for Improvement, IHI, and NHS England actively teach this model, making it a common language across the healthcare system.

The speaker discusses the dual nature of continuous improvement in quality improvement (QI), stating that both positive and negative outcomes contribute to learning. They stress the importance of understanding the aim before measuring success, warning against premature movement through the model's stages without clarity on objectives.

The speaker critiques the common misconception of conducting a single PDSA cycle, asserting that true quality improvement requires iterative testing and adaptation. They illustrate this with a personal anecdote about adjusting their routine while walking their daughter to school, demonstrating the PDSA cycle through planning, doing, studying, and acting based on real-time observations.

The speaker outlines the critical questions to consider in the Model for Improvement: defining the aim statement, establishing a measurement plan for success, and identifying change ideas for PDSA testing. They indicate that these foundational elements will be explored in greater detail in a subsequent session focused on practical application.

The PDSA (Plan-Do-Study-Act) cycle is a structured method for testing change ideas in improvement projects. Teams typically generate five or six change ideas and prioritize them based on predicted impact and likelihood of success. Testing all ideas simultaneously complicates understanding their individual impacts, so teams proceed through multiple cycles of change, adapting based on lessons learned from previous cycles. It's essential to maintain records of all PDSA cycles to track which changes had specific impacts, especially as the number of cycles increases.

In quality improvement (QI) work, involving patients is crucial. The speaker emphasizes that neglecting to ask users can lead to ineffective solutions, as seen in hospital car parks. Placing patients at the center of improvement efforts can lead to safer, more effective care and innovative working methods. The speaker highlights the importance of co-design at the system level, co-production at the pathway level, and shared decision-making at the patient level, noting that what seems like a good idea to health professionals may not resonate with patients.

The speaker references Marjorie Godfrey from the Dartmouth Institute, who posits that healthcare improvement is 20% technical and 80% human. This underscores the importance of understanding human reactions to organizational changes brought about by QI initiatives. Improvement efforts can fail if the human dimensions are overlooked, often due to a lack of insight into why individuals may resist change. Effective communication and understanding of team dynamics are essential for successful project delivery.

The speaker discusses two primary approaches to improvement: the anatomical approach, which is a hard project management method, and the psychological approach, which focuses on the softer, people-oriented aspects of change. Successful improvement initiatives require leaders to balance both approaches, ensuring that the concerns of those affected by changes are addressed. The NHS Improvement Guide from 2005 remains a valuable resource for understanding common reactions to change and managing the human aspects effectively.

The speaker references Rogers' Diffusion of Innovation theory, emphasizing the importance of initially engaging with innovators and early adopters in improvement efforts. These individuals are crucial for creating momentum before reaching the tipping point, after which the change can spread to more cautious individuals and eventually to the late majority and laggards. This progression highlights the need for strategic engagement to foster widespread acceptance of improvements.

The speaker discusses the concept of 'laggards' in the context of improvement initiatives, noting that while some individuals may be enthusiastic about new projects, others may not share that enthusiasm. This discrepancy can stem from various reasons, including past experiences with previous projects. The speaker encourages reflection on personal experiences of being a laggard, using examples such as social media platforms and payment systems like Apple Pay, which some may adopt only after encouragement from others.

The speaker emphasizes the necessity for everyone to understand the basics of improvement, particularly in addressing complex quality and safety issues. It is crucial for individuals to have the tools to solve challenges independently in their daily practice. By adopting an improvement lens, individuals can avoid unnecessary workarounds and waste, fostering a mindset focused on continuous improvement. The speaker highlights that improvement is a skill that requires ongoing practice and refinement, especially in busy environments.

The speaker stresses the importance of integrating the science of improvement into daily work, regardless of one's professional background, whether as a nurse, doctor, or data technician. Understanding improvement science can enhance how individuals analyze data, perceive processes, and appreciate the systems they work within. This knowledge can lead to better patient engagement and workflow management, driven by a desire to learn and improve continuously.

The speaker announces that the next session will be available during the week commencing October 4th. This upcoming session will focus on applying the model for improvement in practice, including discussions on PDSA cycles and practical tools for daily use. The speaker expresses gratitude for the audience's participation and looks forward to their virtual attendance in the next session.