the role of context in successful improvement naomi fulop, university college london glenn robert,...
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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 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
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)
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Background– The Health Foundation– Quality improvement
• “Improvement science”
– Organisational learning
• Learning communities/ communities of practice
Improvement Science? = “proven” improvement methods (e.g:)
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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
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Underpinned by:
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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)
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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)
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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
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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