IMPROVING IMPROVEMENT

Nick Barber

Emeritus Professor of Pharmacy, UCL

The Victorian

Pharmacy

BBC2

DVD; book

What is improvement?

◦Change + value system = improvement

◦Who’s 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)

Anthropologist’s

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

Deming’s 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)

Don’t 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