Improving improving pharmacy - .The Juran Trilogy From qihub.scot.nhs.uk . ... Review paper .

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Text of Improving improving pharmacy - .The Juran Trilogy From qihub.scot.nhs.uk . ... Review paper .

  • IMPROVING IMPROVEMENT

    Nick Barber

    Emeritus Professor of Pharmacy, UCL

  • The Victorian

    Pharmacy

    BBC2

    DVD; book

  • What is improvement?

    Change + value system = improvement

    Whos value system(s)?

  • Nothing is permanent except change

    No man ever

    steps in the

    same river

    twice, for it's

    not the same

    river and he's

    not the same

    man.

  • Improvement (Research?)

    Create

    Evaluate Understand

  • Improvement

    Where social science

    meets systems

    engineering?

  • Systems engineering

  • Juran

    Focus on quality

    management

    Popularised the

    Pareto principle

    (80% of problem

    caused by 20%

    causes)

    Anthropologists

    work influenced his

    resistance to

    change focus

    The Juran Trilogy By Source (WP:NFCC#4), Fair use, https://en.wikipedia.org/w/index.php?curid=50434936

  • The Juran Trilogy

    From qihub.scot.nhs.uk

  • Deming

    Developed PDSA

    cycle

    Helped Japanese

    industry

    regeneration

    Proposed System

    of Profound

    Knowledge

  • Demings System of Profound Knowledge

    Four lenses through which to view the world

    simultaneously

    1. Appreciating a System

    2. Understanding variation

    3. Psychology

    4. Epistemology the theory of knowledge

  • Three types of systems

    Ordered strong cause-effect linkage

    Complex emergent, unpredictable effects

    Chaotic random effects

  • Dave Snowden, Cognitive Edge

    Watch his

    YouTube

    videos. Start

    with the

    childrens

    party

    Read Harvard

    Business

    Review paper

  • Copyright Dave Snowden Cognitive Edge

  • The light bulb was not

    created by continuous

    improvement of the

    candle Source?

  • Two types of improvement

    Polish the cog

    Redesign the system

    (Complexity bites)

  • Dont over engineer!

    German Panzer III

    Russian T34

    Thanks to the Tank Museum, Bovingdon

  • Some of the best hospital systems in the USA use Quality Improvement Systems.

    Are they good because:

    QI systems make them really effective

    Or

    They have a range of systems approaches and QI is just

    an indicator that they take systems seriously?

    ? I have heard that the Mayo Clinic has more systems

    engineers than all English hospitals put together??

  • Social science can help

    Useable theories

    Behaviour change

    Adoption of new systems

    Understanding, sense making

    Spread

    context

    Evidence

    Economics

  • Theory can help

    Theory as reason giving. We all do it, better if we

    use a theory based on evidence!

    Demystifying theory and its use in improvement

    Davidoff et al BMJ Q+S 2015

    COM-B, Susan Michie Behavioural change

    NPT (normalization process theory) Carl May

    An Action Theory concerned with what people do

  • COM-B Michie et al Impl Sci 2011 6 42

  • Behaviour change wheel Michie et al Impl Sci 2011 6 42

  • Spread

    Obvious but tricky!

    Original innovation worked within one context will it

    work in another?

    Preconditions

    Resources

    Drive for change

    Matching Michigan

    New Medicines Service

  • Perspectives on Context

    www.health.

    org

  • Lining up Mary Dixon Woods Health Foundation

    Researchers found that not only

    were there differences in the

    design and implementation of

    the programmes, but also that

    an array of contextual

    influences, including local

    factors and the legacy of

    previous initiatives, had a major

    impact.

    Report on

    the

    Matching

    Michigan

    programme

    in the UK

  • Spread more likely to be

    successful if you can identify the

    successful core of the

    intervention

  • Picasso Bull Plate 1

  • Picasso Bull Plate 4

  • Picasso Bull Plate 7

  • Picasso Bull Plate 11

  • Evidence of effect?

    Need tools beyond RCTs; need formative evaluations

    Drug molecules do not vary, human systems do

    Need to use lower levels of evidence, like crown and civil courts

    Cause-effect assumptions very different in complex emergent

    systems

    Building a House on Shifting Sand. Takian et al 2012 BMC HSR

    reflections following national Electronic Health Record evaluation

  • Economics

    Think about them from the start it is unethical not to

    Understand how to capture cost data staff time, space, equipment etc

    Complex economics leave to the experts, but can be powerful New Medicines Service if it were a new drug NICE would recommend its use.

  • Summary

    The Health Service is already improving. This can be

    improved by

    Understanding systems

    Choose the right methods to improve the system you are

    working with

    Theories can help increase the chances of success

    Do not underestimate the importance of context in spread

    Evidence does not need to be from RCTs

    Keep cost effectiveness in mind