The role of context in successful improvement

Naomi Fulop, University College London

Glenn Robert, King’s College London13th March, 2014

Perspectiveson contextA selection of essays considering the role ofcontext in successful quality improvement

Original researchMarch 2014

Why this matters?

• Results of QI interventions across health care systems or within organizations - mixed, often disappointing

• Promising interventions implemented in one setting do not transfer to others, or not sustained

• With the benefit of hindsight, the usual explanation offered is ‘context’

What is ‘context’?

• ‘Context is everything’ (Gouldner, 1955)

• The gardening metaphor…..

• “Context refers to the ‘why’ and ‘when’ of change and concerns itself both with influence from the outer context (such as the prevailing economic, social, political environment) and influences internal to the focal organisation under study (for example, its resources, capabilities, structure, culture and politics).” (Pettigrew et al, 1992)

• Blurred boundaries between ‘context’ and the ‘intervention’?

Which contextual factors are associated with successful implementation of QI interventions in health care organisations: A systematic review

• which aspects of context have been found to be important in the implementation of quality improvement interventions?

• which aspects are modifiable? • what evidence is there that these aspects have

successfully been modified, and resulted in improvement to quality?

Receptive contexts for change (Pettigrew et al, 1992)

How emotional dynamics influence change dynamics (Huy, 1999)

Receptive context for change

Quality & coherence of policy

Key people leading change

Environmental pressure

Supportive culture

Effective managerial/clinical relations Co-operative inter- organisational networks

System level

Macro: national/regional healthcare system Domains

Structural (relating to the organization of a system)

Psychological (relating to mental phenomena)

Meso: healthcare organization

Simplicity & clarity of goals & priorities

Fit between change agenda and locale

Additional factors

Micro: front-lineline service/department

Dimensions of literature synthesis (Robert and Fulop, in press)

What we found• Majority of studies large-scale, cross-sectional

surveys• Mostly U.S.• Most common Pettigrew et al features

– Organisational culture– Quality and coherence of policy– Environmental pressures

• Most studies at meso (organisational) level• Majority studies ‘structural’ cf ‘psychological’

factors – esp at micro level• Very few studies looking at more than one level of

the system

Some examples of ‘modifiable’ factors

• Most studies not of ‘modifiable’ factors• Macro e.g. publication of surgeon’s and

hospital’s performance• Meso e.g. introduction of electronic patient

record• Micro e.g multi-faceted QI intervention incl

financial incentives improved adherence to guidelines

The way forward?• Some recent developments in the field e.g. MUSIQ• But attention now needed on psychological/emotional context

that facilitates QI • Piloting the acceptability, feasibility and value of reflective tools

that enable practitioners to take contextual factors into account before beginning - and during - future QI interventions

• Designers of future QI interventions need to consider all three levels of the healthcare system (macro, meso, micro)

• Framework for future research: longitudinal, process-based, organizational case studies

• QUASER 8 challenges of quality improvement

https://www.ucl.ac.uk/dahr/quaser/QUASER-GuideForHospitals

Source: Kaplan et al, 2012

Physical & technological:designing physical infrastructure and

technological systems supportive of quality

efforts

Structural: structuring,

planning and coordinating

quality efforts

Political:addressing the

politics and negotiating the

buy-in, conflict and relationships of

change Cultural:giving ‘quality’ a

shared, collective

meaning, value and significance

Educational:creating and nurturing a

learning process that supports

continuous improvement

Managing the external

environment:responding to broader social,

political & contextual factors

Emotional: inspiring,

energising and mobilising people

for quality improvement work

Leadership:providing clear,

strategic direction

QUASER: 8 challenges for QI

Physical & technological:designing physical infrastructure and

technological systems supportive of quality

efforts

Structural: structuring,

planning and coordinating

quality efforts

Political:addressing the

politics and negotiating the

buy-in, conflict and relationships of

change Cultural:giving ‘quality’ a

shared, collective

meaning, value and significance

Educational:creating and nurturing a

learning process that supports

continuous improvement

Managing the external

environment:responding to broader social,

political & contextual factors

Emotional: inspiring,

energising and mobilising people

for quality improvement work

Leadership:providing clear,

strategic direction

QUASER: 8 challenges for QI

Lessons from the Health Foundation Learning Communities Improvement Project: context and skills

John Gabbay & Andrée le May(and Jonathan H Klein & Con Connell)

17

Background– The Health Foundation– Quality improvement

• “Improvement science”

– Organisational learning

• Learning communities/ communities of practice

Improvement Science? = “proven” improvement methods (e.g:)

18

PDSA cycles Care bundles

Run charts

Driver diagrams

Benchmarking

process and outcome measures

Lean methodology

Process mapping

Statistical process control

Six sigma

• Working with the willing/early adopters

• Using clinicians’ own data

• Mutual problem-solving “improvement conversation”

• Focussing on one or two key agreed problems

• Doing small tests of change and adjust as you go

• Showing just enough evidence to make the point

• Developing ideas of improvement with the clinicians

• Getting buy-in through early wins and natural spread 

19

Underpinned by:

20

Methods

– Orientation visit (+topic selection) – Snowball samples (n=9-13 per “improvement group”) – SPIBACC (Systematic Prior Interview-Based Analysis of

“Claims & Concerns”)– Prioritisation of improvement tasks– “Learning Events” (to introduce “IS” techniques)– Further interviews (~ 35) + SPIBACC before Learning Events– (9 Learning Events in total) – Participant Observation – Follow up interviews (n=33)

21

Sites • Exemplary QI (?)

• 2011-12

• 2 x 2 “Improvement groups”

• Furnhills

– COPD– Dementia (memory clinic)

• Dansworth

– Elderly care– Dementia (hospital environment)

Furnhills

• COPD

• Dementia (memory clinic)

Dansworth

• Elderly care

• Dementia (hospital environment)

22

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Context • External environment

– Continuity

– Targets

• Internal organisational culture of improvement

• Resources, structures and processes

• Leadership

• Local politics

• Relationships: trust and communication

Successful Improvemen

t ?

Soft skills

Organisational

base

Lear

ning

Skill

s

Techn

ical skills

Wasted resource!Skills fall short

The Improvement Pyramid

Skills Fall Short

The Improvement Pyramid

Skills fall short

27

Implications• Organisational & personal skills are essential for handling context

• They are an essential precursor to the application of “hard” IS skills and must be well developed if the latter are to succeed

• Learning communities are an effective way to help meld those sets of skills

• Learning communities function more effectively when facilitated especially when community learning skills are weak

• Achieving sustained improvements with IS may require specific interventions

– for learning soft skills

– to systematically facilitate the QI process (SPIBACC) so as to get “inside” the contextual concerns and deal with them