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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
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