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Education & Practice Online First, published on June 2, 2014 as 10.1136/archdischild-2013-305193 QUALITY IMPROVEMENT
Equipped: overcoming barriers to change to improve quality of care (theories of change) Peter Lachman,1 Jane Runnacles,2 Jan Dudley,3 On behalf of RCPCH Clinical Standards Committee 1
Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK 2 Department of Paediatrics, Royal Free Hospital, London, UK 3 Department of Paediatric Nephrology, Bristol Royal Hospital for Children, Bristol, UK Correspondence to Dr Jan Dudley, Department of Paediatric Nephrology, Bristol Royal Hospital for Children, Bristol BS2 8BJ, UK; [email protected] Received 11 November 2013 Revised 7 March 2014 Accepted 5 May 2014
To cite: Lachman P, Runnacles J, Dudley J. Arch Dis Child Educ Pract Ed Published Online First: [ please include Day Month Year] doi:10.1136/archdischild2013-305193
INTRODUCTION Quality improvement is about the patient; the child who comes to us to be cared for. It is our obligation to meet the needs of the child in a reliable way, to get care right the first time every time. Yet we often fail to achieve this. The key is to develop systems of care that will more than meet the rising expectations of the population. This article explores the complexity of change in healthcare, based on Deming’s theories of change1 with practical ideas for introducing improvements in quality of care. BACKGROUND In his review of safety in NHS England post Mid Staffordshire, Berwick2 recommended that “Mastery of quality and patient safety sciences and practices should be part of initial preparation and lifelong education of all health care professionals, including managers and executives”. This places a requirement on all of us to take the lead in quality initiatives. To achieve this duty, we require an understanding of the science of improvement and of theories of change. Despite the impressive clinical gains in the past years, the problems of waits, delayed diagnosis, harm and lack of equity remain. Healthcare professionals do not always provide evidence-based care for a variety of reasons, including lack of awareness, or scepticism of the validity of the data, beliefs derived from our own experiences and a perception of the individuality of patients. In addition, healthcare has become unaffordable in terms of waste and cost. Although we may be aware of what needs to change and how to go about it, introducing change can be extremely challenging. It may be difficult to convince doctors or organisations to do things differently.
Clinical standards reflect the distillation of best evidence into guidelines that then are applied in the clinical environment. The National Institute for Health and Care Excellence (NICE), the American Academy of Pediatrics (AAP) and the RCPCH clinical standards committee all set high-quality standards for healthcare, but the implementation of these standards into practice is erratic. Professional autonomy and inherent conservatism may contribute to this. We need to understand how to overcome barriers to change. THE CHALLENGE OF CHANGE The need to transform the way healthcare is provided has become more pressing with the rise of consumer-oriented society and the demand for safe, reliable care. This change in expectations requires a focus on clinical outcomes to ensure we meet the needs of children and their families. The issues of quality and safety in healthcare are central to the future delivery of service: how care is delivered is now as important as what is delivered. Improvements in the understanding of the complexity of healthcare, changes in consumer demands for reliable care and the realisation that healthcare is often of variable quality are important drivers for change. It is now clear that there is widespread unwarranted variation that does not add value in the delivery of healthcare for children in the UK.3 A major problem is the lack of data and/or transparency when data are available. Clinicians should take local ownership of data quality measures in order to demonstrate responsibility for the delivery of high-quality care.4 The complexity of healthcare calls for a new type of leadership from paediatricians,5 who need to promote improvement and patient safety. In order to achieve this, paediatricians will need to understand how
Lachman P, et al. Arch Dis Child Educ Pract Ed 2014;0:1–6. doi:10.1136/archdischild-2013-305193 1 Copyright Article author (or their employer) 2014. Produced by BMJ Publishing Group Ltd under licence.
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Quality improvement to improve quality of care within their healthcare system. Changes should aim for reliability so that safe, effective and equitable care is always delivered. The real aim of quality is the integration of the Triple Aim6: ▸ good population outcomes ▸ increased patient satisfaction ▸ decreased cost.
This overall aim for a health system can be devolved to the clinical micro system—the consultation and care of the child, where we aim to deliver the best outcome for the child, at low cost and with excellent child and parental satisfaction. To achieve this, we need to continually improve. QUALITY AS THE FOUNDATION FOR CHANGE Lemer et al7 provided a basic introduction to the concept of how we define quality in the first of the EQUIPPED series. Quality is a dynamic concept involving continual improvement, which aims to achieve the outcomes desired and required by the person receiving care. Healthcare quality has six domains,8 all of which provide impact. Quality care is 1. 2. 3. 4. 5. 6.
safe (no harm) effective (evidenced-based care) equitable (available to all) timely (no delay) efficient (no waste) patient-centred.
Translated into practice, this means we have to provide reliable care at low cost, without any waste in the system. Increasing allocated resources is not the answer to the challenge. Instead, it requires a fundamental change in the way we deliver services, from a traditional reactive approach to a proactive and generative construct. THE UNDERLYING THEORY FOR CHANGE IN HEALTHCARE When we embark on a quality improvement programme, we start out on a journey that has a strong theoretical basis, as strong as the biomedical tradition of research. The key theories for continuous quality improvement emanate from a line of statisticians and theorists and can be summarised in the concepts of Profound Knowledge as postulated by Deming.1 Profound Knowledge consists of an understanding of four key lenses. Each lens is essential in order to develop an effective change improvement programme. LENS 1: SYSTEMS THEORY FOR CHANGE An understanding of systems is essential in order to improve processes. The interaction between the macro system (eg, the NHS), the meso system (the hospital) and micro system (the clinical team) is crucial in the way we deliver services. Improvement takes place at the level of the clinical micro system.9 The requirements for improvement include knowledge of change methodologies, commitment to continual
2
Box 1 Characteristics of effective micro systems9 ▸ Integration of information ▸ Measurement of outcomes ▸ Interdependence of the care team—multidisciplinary teams ▸ Supportiveness of the larger system ▸ Constancy of purpose—know where we want to go ▸ Connection to the community and parent involvement ▸ Investment in improvement—want to be better ▸ Alignment of role and training with the improvement methods.
improvement, understanding of ways to measure change and training aligned with the improvement aims (box 1). One of the most effective system changes in healthcare has been at Virginia Mason in Seattle (box 2). The total approach to solving healthcare challenges is one that can be replicated if there is the will to change. We all work in a clinical micro system, and therefore all have the power to improve within that system at all time. If all clinical micro systems could improve, the impact to the overall macro system would be immense. LENS 2: THE PSYCHOLOGY OF CHANGE Understanding the dynamics of people and how they interact is essential. To affect change, we need to understand the beliefs, values and assumptions of people working within the system. Particular attention needs to be placed on engagement of different professional groups. The culture of the different systems will impact on the performance at all levels. There is an extensive literature on how to achieve buy-in from clinicians to improve care. Key principles are 1. 2. 3. 4.
to engage clinicians at an early stage to make the change relevant to day-to-day work to reframe questions in an engaging manner to use data as a driver for change and improvement rather than for judgement.12
Rather than simply muddling along, making the process work in the current construct, we need to lead, and generate a vision of change. Kotter13 postulated eight steps needed to achieve change (box 3). In order for change to happen, front-line staff need to change. This is difficult and we have to constantly reframe the reasons for change and develop the desire for a new way to improve care. Ganz13 postulated that we should address both the rational and the emotional sides of the mind in order to mobilise people to change. This involves making the commitment to change and the clinicians’ own experience a unifying
Lachman P, et al. Arch Dis Child Educ Pract Ed 2014;0:1–6. doi:10.1136/archdischild-2013-305193
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Quality improvement Box 2 Systems thinking and collaboration across organisational boundaries—Virginia Mason Health system, Seattle, USA The Institute for Healthcare Improvement (IHI) High Impact Leadership framework10 describes five behaviours for healthcare leaders to consider when driving improvement and innovation in their organisation: 1. Person centredness; 2. Front-line engagement; 3. Relentless focus; 4. Transparency; 5. Boundarilessness. The latter concept encompasses both ‘mental boundarilessness’; asking open-ended questions and encouraging non-traditional approaches to problem-solving, which is therefore linked to innovation, and leadership across organisational boundaries. By achieving boundarilessness, leaders can ensure true collaboration, connecting colleagues on multidisciplinary teams and from different parts of the organisation, and with external partners including patients. They seek shared aims, harvest ideas, share resources and use systems-thinking to frame problems and challenges. Virginia Mason Health system in the USA is an exemplar of boundarilessness.11 It invests in training clinicians on idea-generating techniques so they learn and work to redesign care processes. Its leaders understand the necessity of innovation and use Lean methodology. This involves understanding the current processes by using value stream maps of all major processes. Value stream mapping is a method of analysing the current state and designing a future state for the series of events that take a product or service from its beginning through to the customer. An example of this is a joint replacement pathway, which starts in primary care. Value stream mapping encourages collaboration across organisational boundaries. Virginia Mason focuses on clinician engagement in rapid-cycle improvement workshops, and their metrics measure the total value stream map rather than its individual components, which further encourages collaboration and systemsthinking.
Box 3 Kotter’s steps to lead for change13 1. Establishing a sense of urgency of why change is needed; 2. Forming a powerful coalition of people who want to change; 3. Creating a vision for where we want staff to go; 4. Communicating the vision to the front line in a way they understand so that it is relevant to them; 5. Empowering those in the front line to act on the vision to achieve change by providing training in quality improvement and the data to change; 6. Ensuring that there are early short-term wins and achievements that demonstrate the purpose of the change; 7. Consolidating improvements to produce more change over time; 8. Sustaining the change by making it the way things are done.
Box 4 Engaging staff in change through commitment building
process so that there can be shared vision and understanding of the need to change (box 4, table 1). An example of how complex change can be is the Matching Michigan programme (box 5).
Healthcare organisations and systems are more likely to deliver sustained transformation change through commitment than compliance. Commitment approaches build motivation, proposed by Bevan,14 as the best possible starting point for mobilisation for change at scale. The NHS change model,15 created by senior leaders, clinicians, commissioners and providers to support the NHS to adopt a shared approach to leading change, emphasises ‘our shared purpose’ in building the energy for change.16 The first NHS change day in March 2013 illustrated how commitment building from all NHS staff can motivate and mobilise others in change, however small, to benefit patients. The concept of ‘connecting with hearts and minds’ is crucial in engaging staff in quality improvement efforts and overcoming barriers to change; clinicians are more likely to respond to real patient stories demonstrating why change is necessary than financial implications. During the course of a focused improvement effort, staff may modify their behaviour, but unless they emerge from the effort with new beliefs and a new sense of purpose associated with the change, old behaviours can return with lack of commitment.
LENS 3: A THEORY OF KNOWLEDGE TO TEST CHANGE The current theory used most widely is the Model for Improvement developed by Associates in Progress Improvement (API).18 Small tests of change, in which we are constantly predicting what will happen and then adjusting our actions, is the model used in most health settings. This concept of testing, predicting and
then adapting to changes, PDSA (Plan, Do, Study, Act) cycles, is the key for improvement. Data are on run charts and Statistical Process Control (SPC) charts, which are fundamental to the assessment of continual quality improvement.19 There are clear rules to assess when a change has become statistically significant, and this is a new language for most clinicians trained in biomedical statistics (boxes 6 and 7).
Lachman P, et al. Arch Dis Child Educ Pract Ed 2014;0:1–6. doi:10.1136/archdischild-2013-305193
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Quality improvement Table 1
From compliance to commitment14
Compliance
Commitment
States a minimum performance standard that everyone must achieve
States a collective improvement goal that everyone can aspire to
Uses hierarchy, systems and standard procedures for coordination and control
Uses hierarchy, systems and standard procedures for coordination and control
Delivered through formal command and control structures
Delivered through voluntary connections and teams
Based on organisational accountability (“If I don’t deliver this, I fail to meet my performance objectives”)
Based on relational commitment (“If I don’t deliver this, I let the group and its purpose down”)
LENS 4: MANAGEMENT OF VARIATION TO IMPROVE CARE In all activities and all processes we see variation. The key to improvement is to understand variation to see if this (a) is common to the system process, (b) is to be expected or (c) has a special cause, for example, due to a specific factor that influences the process. An example might be in emergency care, where some event has an impact on the arrival of patients. Natural
Box 5 Matching Michigan: the challenge spreading change in different settings17 ‘Matching Michigan’ is a patient safety programme aimed at reducing central line infections in over 200 intensive care units (ICUs) in England. It followed the successful introduction of a checklist with evidence-based infection control practices in Michigan ICUs with a dramatic reduction in line infection rates. Introduction of such checklists or guidelines rarely directly impact upon practice without facilitating mechanisms. These were theorised post-programme to include the desire to conform to group norms, a networked community with regular communication between units, sharing of data and a culture of commitment. Interestingly, the success of this programme may not have been replicated in England, with improvements in line infections that could not confidently be attributed to programme participation. Dixon-Woods et al17 have explained this by describing outer and inner contexts, which strongly modified the programme’s effects. The outer context included “previous efforts to tackle central line infections superimposed on national infection control policies that were perceived by some as top-down and punitive”, undermining engagement in the programme. The local context was also ‘highly consequential’: past experience of QI, the quality of data collection and feedback systems, and the success of local leaders all influenced the programme’s impact.
4
Box 6 Educating health professionals in improvement methodology—The Institute for Healthcare Improvement (IHI) open school for health professionals20 The IHI open school mission statement is “to advance healthcare improvement and patient safety competencies in the next generation of health professionals worldwide”. The Institute for Healthcare Improvement launched the open school in 2008 to provide all healthcare students with the opportunity to learn about quality improvement and patient safety at no charge. An online educational community has developed with e-learning courses, extensive resources and a network of local chapters worldwide. These ‘chapters’ are linked to universities and healthcare organisations, and organise events and activities locally to support improvement projects. They allow students, residents and faculty from all healthcare professions to connect. Resources online include case studies, podcasts, videos, improvement stories and toolkits to help implement quality and safety curricula across different health disciplines. The online courses, teaching the ‘Model for Improvement’ and its application, allow students and residents to obtain a basic certificate of completion and the opportunity to apply for continuing education contact hours. In the UK, local quality improvement education programmes, such as EQuIP at Great Ormond Street,21 use the online resources for their residents. The open school is now a popular and useful resource for young professionals through to experts worldwide. Such educational approaches focused on health professionals are crucial to ensure they have the skills to lead improvement efforts in their organisations.
Box 7 Overcoming barriers in healthcare Barriers in healthcare, which tend to increase the complexity of the process, need to be addressed early when introducing change. Often we need to simplify processes in order to ensure effective buy in. Amalberti et al23 considered the following key factors to achieve ultra safe systems: ▸ Accepting the inherent risk in all we do so that we plan for safety and quality; ▸ Eliminating unwarranted professional autonomy of doctors; ▸ Moving from the concept of being a craftsman to that of being an equivalent actor, where all members of the team are important; ▸ Promoting effective teamwork; ▸ Simplifying policies and processes by making it easy to do the right action.
Lachman P, et al. Arch Dis Child Educ Pract Ed 2014;0:1–6. doi:10.1136/archdischild-2013-305193
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Quality improvement variability lies in the clinical conditions of patients. Artificial variability refers to the way we design and deliver services. It is this variability that needs to be eliminated where possible.22 We need to understand what causes variation, and learn which is good in the interests of patient care, and which is not. Variation can be in flow—and this needs to be eliminated, or in how we provide care in terms of clinical standards. This must be driven by the needs of the patient, not by the needs of the individual clinician. REQUIREMENTS FOR TRANSFORMATIONAL CHANGE Large-scale change requires that leadership is distributed to the front line, empowering these staff to change. This is a highly replicated feature of reliable organisations and will involve a change in healthcare culture and an understanding that improvement is the responsibility of all. Engagement of doctors early on and the involvement of parents and children at all stages of service design and delivery are essential. Rather than the seemingly token involvement of healthcare providers, this should include the development of true partnerships. Creative use of real-time data is required to drive change and transform clinical systems.24 CONCLUSION Quality improvement in paediatrics and child health is about putting the child at the centre of care and requires all of us to take the lead. It is not solely the responsibility of managers, executives or consultant paediatricians. However, change is challenging and there are often obstacles to introducing improvements in quality of care. This paper outlines Deming’s
Figure 1
Four key lenses of profound knowledge.
theory for change in healthcare, with practical examples for overcoming barriers to change. It is important for all paediatricians to become adept at change management and advocates for continual improvement (figure 1). Competing interests None. Provenance and peer review Commissioned; externally peer reviewed.
REFERENCES 1 Deming WE. The new economics. 2nd edn. MA: MIT Press, 2000. 2 Berwick DA. Promise to learn a commitment to act-improving the safety of patients in England. London: DOH, 2013. 3 Ronny C, Cheung LH, Muir Gray JA. Unwarranted variation in health care for children and young people. Arch Dis Child 2012;0:1–6. 4 Mountford J, Shojania KG. Refocusing quality measurement to best support quality improvement: local ownership of quality measurement by clinicians. BMJ Qual Saf 2012;21:519–23. 5 Oates K. The New Clinical Leader. J Paediatr Child Health 2012;48:472–5. 6 Berwick D, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Affairs 2008;27:759–69. 7 Lemer C, Cheung CR, Klaber RE. An introduction to quality improvement in paediatrics and child health. Arch Dis Child Educ Pract 2013;98:175–80. 8 Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington: Institute of Medicine, 2001. 9 Mohr J, Batalden P, Barach P. Integrating patient safety into the clinical micro system. Qual Saf Health Care 2004;13(Suppl 2): ii34–8. 10 Swensen S, Pugh M, McMullan C, et al. High-impact leadership: improve care, improve the health of populations, and reduce costs. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement, 2013. ihi.org 11 Kenney C. Transforming health care: virginia mason medical center’s pursuit of the perfect patient experience.New York, NY: Productivity Press, 2010. 12 Reinertsen JL, Gosfield AG, Rupp W, et al. Engaging physicians in a shared quality Agenda. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement, 2007. http://www.IHI.org 13 Kotter J. Leading change. Cambridge: Harvard Business Review Press, 2012. 14 Bevan H. From compliance to commitment. 2012. http://www. institute.nhs.uk/nhs_alert/article_of_the_month/from_ compliance_to_commitment/ 15 NHS Change Model. http://www.changemodel.nhs.uk/pg/ dashboard 16 NHS Change day. 2013. http://www.changemodel.nhs.uk/pg/ groups/33183/NHS+Change+Day/27?community=NHS +Change+Day 17 Dixon-Woods M, Leslie M, Tarrant C, et al. Explaining Matching Michigan: an ethnographic study of a patient safety program. Implementation Sci 2013;8:70–82. 18 Langley GJ, Moen R, Nolan K, et al. The improvement guide: a practical approach to enhancing organizational performance San Fransciso. Jossey-Bass, 2009.
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Quality improvement 19 Perla RJ, Provost LP, Murray SK. The run chart: a simple analytical tool for learning from variation in healthcare processes. BMJ Qual Saf 2011;20:46–51. 20 Insitute for Healthcare Improvement (IHI) Open School. 21 Runnacles J, Moult B, Lachman P. Developing future clinical leaders for quality improvement: experience from a London children’s hospital. BMJ Qual Saf 2013;22:956–63.
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22 Anstey MH, Gildfind SP, Litvak E. Sleep faster! (Somebody else needs your blanket...). Aust Health Rev 2012;36:244–7. 23 Amalberti R, Auroy Y, Berwick D, et al. Five system barriers to achieving Ultrasafe health care. Ann Intern Med 2005;142:756–64. 24 Best A, Greenhalgh T, Lewis S, et al. Large-system transformation in health care: a realist review. Milbank Q 2012;90:421–56.
Lachman P, et al. Arch Dis Child Educ Pract Ed 2014;0:1–6. doi:10.1136/archdischild-2013-305193
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Equipped: overcoming barriers to change to improve quality of care (theories of change) Peter Lachman, Jane Runnacles, Jan Dudley, et al. Arch Dis Child Educ Pract Ed published online June 2, 2014
doi: 10.1136/archdischild-2013-305193
Updated information and services can be found at: http://ep.bmj.com/content/early/2014/06/02/archdischild-2013-305193.full.html
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References
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Education & Practice Online First, published on June 2, 2014 as 10.1136/archdischild-2013-305193 QUALITY IMPROVEMENT
Equipped: overcoming barriers to change to improve quality of care (theories of change) Peter Lachman,1 Jane Runnacles,2 Jan Dudley,3 On behalf of RCPCH Clinical Standards Committee 1
Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK 2 Department of Paediatrics, Royal Free Hospital, London, UK 3 Department of Paediatric Nephrology, Bristol Royal Hospital for Children, Bristol, UK Correspondence to Dr Jan Dudley, Department of Paediatric Nephrology, Bristol Royal Hospital for Children, Bristol BS2 8BJ, UK; [email protected] Received 11 November 2013 Revised 7 March 2014 Accepted 5 May 2014
To cite: Lachman P, Runnacles J, Dudley J. Arch Dis Child Educ Pract Ed Published Online First: [ please include Day Month Year] doi:10.1136/archdischild2013-305193
INTRODUCTION Quality improvement is about the patient; the child who comes to us to be cared for. It is our obligation to meet the needs of the child in a reliable way, to get care right the first time every time. Yet we often fail to achieve this. The key is to develop systems of care that will more than meet the rising expectations of the population. This article explores the complexity of change in healthcare, based on Deming’s theories of change1 with practical ideas for introducing improvements in quality of care. BACKGROUND In his review of safety in NHS England post Mid Staffordshire, Berwick2 recommended that “Mastery of quality and patient safety sciences and practices should be part of initial preparation and lifelong education of all health care professionals, including managers and executives”. This places a requirement on all of us to take the lead in quality initiatives. To achieve this duty, we require an understanding of the science of improvement and of theories of change. Despite the impressive clinical gains in the past years, the problems of waits, delayed diagnosis, harm and lack of equity remain. Healthcare professionals do not always provide evidence-based care for a variety of reasons, including lack of awareness, or scepticism of the validity of the data, beliefs derived from our own experiences and a perception of the individuality of patients. In addition, healthcare has become unaffordable in terms of waste and cost. Although we may be aware of what needs to change and how to go about it, introducing change can be extremely challenging. It may be difficult to convince doctors or organisations to do things differently.
Clinical standards reflect the distillation of best evidence into guidelines that then are applied in the clinical environment. The National Institute for Health and Care Excellence (NICE), the American Academy of Pediatrics (AAP) and the RCPCH clinical standards committee all set high-quality standards for healthcare, but the implementation of these standards into practice is erratic. Professional autonomy and inherent conservatism may contribute to this. We need to understand how to overcome barriers to change. THE CHALLENGE OF CHANGE The need to transform the way healthcare is provided has become more pressing with the rise of consumer-oriented society and the demand for safe, reliable care. This change in expectations requires a focus on clinical outcomes to ensure we meet the needs of children and their families. The issues of quality and safety in healthcare are central to the future delivery of service: how care is delivered is now as important as what is delivered. Improvements in the understanding of the complexity of healthcare, changes in consumer demands for reliable care and the realisation that healthcare is often of variable quality are important drivers for change. It is now clear that there is widespread unwarranted variation that does not add value in the delivery of healthcare for children in the UK.3 A major problem is the lack of data and/or transparency when data are available. Clinicians should take local ownership of data quality measures in order to demonstrate responsibility for the delivery of high-quality care.4 The complexity of healthcare calls for a new type of leadership from paediatricians,5 who need to promote improvement and patient safety. In order to achieve this, paediatricians will need to understand how
Lachman P, et al. Arch Dis Child Educ Pract Ed 2014;0:1–6. doi:10.1136/archdischild-2013-305193 1 Copyright Article author (or their employer) 2014. Produced by BMJ Publishing Group Ltd under licence.
Downloaded from ep.bmj.com on October 17, 2014 - Published by group.bmj.com
Quality improvement to improve quality of care within their healthcare system. Changes should aim for reliability so that safe, effective and equitable care is always delivered. The real aim of quality is the integration of the Triple Aim6: ▸ good population outcomes ▸ increased patient satisfaction ▸ decreased cost.
This overall aim for a health system can be devolved to the clinical micro system—the consultation and care of the child, where we aim to deliver the best outcome for the child, at low cost and with excellent child and parental satisfaction. To achieve this, we need to continually improve. QUALITY AS THE FOUNDATION FOR CHANGE Lemer et al7 provided a basic introduction to the concept of how we define quality in the first of the EQUIPPED series. Quality is a dynamic concept involving continual improvement, which aims to achieve the outcomes desired and required by the person receiving care. Healthcare quality has six domains,8 all of which provide impact. Quality care is 1. 2. 3. 4. 5. 6.
safe (no harm) effective (evidenced-based care) equitable (available to all) timely (no delay) efficient (no waste) patient-centred.
Translated into practice, this means we have to provide reliable care at low cost, without any waste in the system. Increasing allocated resources is not the answer to the challenge. Instead, it requires a fundamental change in the way we deliver services, from a traditional reactive approach to a proactive and generative construct. THE UNDERLYING THEORY FOR CHANGE IN HEALTHCARE When we embark on a quality improvement programme, we start out on a journey that has a strong theoretical basis, as strong as the biomedical tradition of research. The key theories for continuous quality improvement emanate from a line of statisticians and theorists and can be summarised in the concepts of Profound Knowledge as postulated by Deming.1 Profound Knowledge consists of an understanding of four key lenses. Each lens is essential in order to develop an effective change improvement programme. LENS 1: SYSTEMS THEORY FOR CHANGE An understanding of systems is essential in order to improve processes. The interaction between the macro system (eg, the NHS), the meso system (the hospital) and micro system (the clinical team) is crucial in the way we deliver services. Improvement takes place at the level of the clinical micro system.9 The requirements for improvement include knowledge of change methodologies, commitment to continual
2
Box 1 Characteristics of effective micro systems9 ▸ Integration of information ▸ Measurement of outcomes ▸ Interdependence of the care team—multidisciplinary teams ▸ Supportiveness of the larger system ▸ Constancy of purpose—know where we want to go ▸ Connection to the community and parent involvement ▸ Investment in improvement—want to be better ▸ Alignment of role and training with the improvement methods.
improvement, understanding of ways to measure change and training aligned with the improvement aims (box 1). One of the most effective system changes in healthcare has been at Virginia Mason in Seattle (box 2). The total approach to solving healthcare challenges is one that can be replicated if there is the will to change. We all work in a clinical micro system, and therefore all have the power to improve within that system at all time. If all clinical micro systems could improve, the impact to the overall macro system would be immense. LENS 2: THE PSYCHOLOGY OF CHANGE Understanding the dynamics of people and how they interact is essential. To affect change, we need to understand the beliefs, values and assumptions of people working within the system. Particular attention needs to be placed on engagement of different professional groups. The culture of the different systems will impact on the performance at all levels. There is an extensive literature on how to achieve buy-in from clinicians to improve care. Key principles are 1. 2. 3. 4.
to engage clinicians at an early stage to make the change relevant to day-to-day work to reframe questions in an engaging manner to use data as a driver for change and improvement rather than for judgement.12
Rather than simply muddling along, making the process work in the current construct, we need to lead, and generate a vision of change. Kotter13 postulated eight steps needed to achieve change (box 3). In order for change to happen, front-line staff need to change. This is difficult and we have to constantly reframe the reasons for change and develop the desire for a new way to improve care. Ganz13 postulated that we should address both the rational and the emotional sides of the mind in order to mobilise people to change. This involves making the commitment to change and the clinicians’ own experience a unifying
Lachman P, et al. Arch Dis Child Educ Pract Ed 2014;0:1–6. doi:10.1136/archdischild-2013-305193
Downloaded from ep.bmj.com on October 17, 2014 - Published by group.bmj.com
Quality improvement Box 2 Systems thinking and collaboration across organisational boundaries—Virginia Mason Health system, Seattle, USA The Institute for Healthcare Improvement (IHI) High Impact Leadership framework10 describes five behaviours for healthcare leaders to consider when driving improvement and innovation in their organisation: 1. Person centredness; 2. Front-line engagement; 3. Relentless focus; 4. Transparency; 5. Boundarilessness. The latter concept encompasses both ‘mental boundarilessness’; asking open-ended questions and encouraging non-traditional approaches to problem-solving, which is therefore linked to innovation, and leadership across organisational boundaries. By achieving boundarilessness, leaders can ensure true collaboration, connecting colleagues on multidisciplinary teams and from different parts of the organisation, and with external partners including patients. They seek shared aims, harvest ideas, share resources and use systems-thinking to frame problems and challenges. Virginia Mason Health system in the USA is an exemplar of boundarilessness.11 It invests in training clinicians on idea-generating techniques so they learn and work to redesign care processes. Its leaders understand the necessity of innovation and use Lean methodology. This involves understanding the current processes by using value stream maps of all major processes. Value stream mapping is a method of analysing the current state and designing a future state for the series of events that take a product or service from its beginning through to the customer. An example of this is a joint replacement pathway, which starts in primary care. Value stream mapping encourages collaboration across organisational boundaries. Virginia Mason focuses on clinician engagement in rapid-cycle improvement workshops, and their metrics measure the total value stream map rather than its individual components, which further encourages collaboration and systemsthinking.
Box 3 Kotter’s steps to lead for change13 1. Establishing a sense of urgency of why change is needed; 2. Forming a powerful coalition of people who want to change; 3. Creating a vision for where we want staff to go; 4. Communicating the vision to the front line in a way they understand so that it is relevant to them; 5. Empowering those in the front line to act on the vision to achieve change by providing training in quality improvement and the data to change; 6. Ensuring that there are early short-term wins and achievements that demonstrate the purpose of the change; 7. Consolidating improvements to produce more change over time; 8. Sustaining the change by making it the way things are done.
Box 4 Engaging staff in change through commitment building
process so that there can be shared vision and understanding of the need to change (box 4, table 1). An example of how complex change can be is the Matching Michigan programme (box 5).
Healthcare organisations and systems are more likely to deliver sustained transformation change through commitment than compliance. Commitment approaches build motivation, proposed by Bevan,14 as the best possible starting point for mobilisation for change at scale. The NHS change model,15 created by senior leaders, clinicians, commissioners and providers to support the NHS to adopt a shared approach to leading change, emphasises ‘our shared purpose’ in building the energy for change.16 The first NHS change day in March 2013 illustrated how commitment building from all NHS staff can motivate and mobilise others in change, however small, to benefit patients. The concept of ‘connecting with hearts and minds’ is crucial in engaging staff in quality improvement efforts and overcoming barriers to change; clinicians are more likely to respond to real patient stories demonstrating why change is necessary than financial implications. During the course of a focused improvement effort, staff may modify their behaviour, but unless they emerge from the effort with new beliefs and a new sense of purpose associated with the change, old behaviours can return with lack of commitment.
LENS 3: A THEORY OF KNOWLEDGE TO TEST CHANGE The current theory used most widely is the Model for Improvement developed by Associates in Progress Improvement (API).18 Small tests of change, in which we are constantly predicting what will happen and then adjusting our actions, is the model used in most health settings. This concept of testing, predicting and
then adapting to changes, PDSA (Plan, Do, Study, Act) cycles, is the key for improvement. Data are on run charts and Statistical Process Control (SPC) charts, which are fundamental to the assessment of continual quality improvement.19 There are clear rules to assess when a change has become statistically significant, and this is a new language for most clinicians trained in biomedical statistics (boxes 6 and 7).
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Quality improvement Table 1
From compliance to commitment14
Compliance
Commitment
States a minimum performance standard that everyone must achieve
States a collective improvement goal that everyone can aspire to
Uses hierarchy, systems and standard procedures for coordination and control
Uses hierarchy, systems and standard procedures for coordination and control
Delivered through formal command and control structures
Delivered through voluntary connections and teams
Based on organisational accountability (“If I don’t deliver this, I fail to meet my performance objectives”)
Based on relational commitment (“If I don’t deliver this, I let the group and its purpose down”)
LENS 4: MANAGEMENT OF VARIATION TO IMPROVE CARE In all activities and all processes we see variation. The key to improvement is to understand variation to see if this (a) is common to the system process, (b) is to be expected or (c) has a special cause, for example, due to a specific factor that influences the process. An example might be in emergency care, where some event has an impact on the arrival of patients. Natural
Box 5 Matching Michigan: the challenge spreading change in different settings17 ‘Matching Michigan’ is a patient safety programme aimed at reducing central line infections in over 200 intensive care units (ICUs) in England. It followed the successful introduction of a checklist with evidence-based infection control practices in Michigan ICUs with a dramatic reduction in line infection rates. Introduction of such checklists or guidelines rarely directly impact upon practice without facilitating mechanisms. These were theorised post-programme to include the desire to conform to group norms, a networked community with regular communication between units, sharing of data and a culture of commitment. Interestingly, the success of this programme may not have been replicated in England, with improvements in line infections that could not confidently be attributed to programme participation. Dixon-Woods et al17 have explained this by describing outer and inner contexts, which strongly modified the programme’s effects. The outer context included “previous efforts to tackle central line infections superimposed on national infection control policies that were perceived by some as top-down and punitive”, undermining engagement in the programme. The local context was also ‘highly consequential’: past experience of QI, the quality of data collection and feedback systems, and the success of local leaders all influenced the programme’s impact.
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Box 6 Educating health professionals in improvement methodology—The Institute for Healthcare Improvement (IHI) open school for health professionals20 The IHI open school mission statement is “to advance healthcare improvement and patient safety competencies in the next generation of health professionals worldwide”. The Institute for Healthcare Improvement launched the open school in 2008 to provide all healthcare students with the opportunity to learn about quality improvement and patient safety at no charge. An online educational community has developed with e-learning courses, extensive resources and a network of local chapters worldwide. These ‘chapters’ are linked to universities and healthcare organisations, and organise events and activities locally to support improvement projects. They allow students, residents and faculty from all healthcare professions to connect. Resources online include case studies, podcasts, videos, improvement stories and toolkits to help implement quality and safety curricula across different health disciplines. The online courses, teaching the ‘Model for Improvement’ and its application, allow students and residents to obtain a basic certificate of completion and the opportunity to apply for continuing education contact hours. In the UK, local quality improvement education programmes, such as EQuIP at Great Ormond Street,21 use the online resources for their residents. The open school is now a popular and useful resource for young professionals through to experts worldwide. Such educational approaches focused on health professionals are crucial to ensure they have the skills to lead improvement efforts in their organisations.
Box 7 Overcoming barriers in healthcare Barriers in healthcare, which tend to increase the complexity of the process, need to be addressed early when introducing change. Often we need to simplify processes in order to ensure effective buy in. Amalberti et al23 considered the following key factors to achieve ultra safe systems: ▸ Accepting the inherent risk in all we do so that we plan for safety and quality; ▸ Eliminating unwarranted professional autonomy of doctors; ▸ Moving from the concept of being a craftsman to that of being an equivalent actor, where all members of the team are important; ▸ Promoting effective teamwork; ▸ Simplifying policies and processes by making it easy to do the right action.
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Quality improvement variability lies in the clinical conditions of patients. Artificial variability refers to the way we design and deliver services. It is this variability that needs to be eliminated where possible.22 We need to understand what causes variation, and learn which is good in the interests of patient care, and which is not. Variation can be in flow—and this needs to be eliminated, or in how we provide care in terms of clinical standards. This must be driven by the needs of the patient, not by the needs of the individual clinician. REQUIREMENTS FOR TRANSFORMATIONAL CHANGE Large-scale change requires that leadership is distributed to the front line, empowering these staff to change. This is a highly replicated feature of reliable organisations and will involve a change in healthcare culture and an understanding that improvement is the responsibility of all. Engagement of doctors early on and the involvement of parents and children at all stages of service design and delivery are essential. Rather than the seemingly token involvement of healthcare providers, this should include the development of true partnerships. Creative use of real-time data is required to drive change and transform clinical systems.24 CONCLUSION Quality improvement in paediatrics and child health is about putting the child at the centre of care and requires all of us to take the lead. It is not solely the responsibility of managers, executives or consultant paediatricians. However, change is challenging and there are often obstacles to introducing improvements in quality of care. This paper outlines Deming’s
Figure 1
Four key lenses of profound knowledge.
theory for change in healthcare, with practical examples for overcoming barriers to change. It is important for all paediatricians to become adept at change management and advocates for continual improvement (figure 1). Competing interests None. Provenance and peer review Commissioned; externally peer reviewed.
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Equipped: overcoming barriers to change to improve quality of care (theories of change) Peter Lachman, Jane Runnacles, Jan Dudley, et al. Arch Dis Child Educ Pract Ed published online June 2, 2014
doi: 10.1136/archdischild-2013-305193
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References
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