Taking models from industry is always controversial in health care. It is now uncommon to come across people who feel there is no role for quality improvement in health and social care. Anyone who works with Lean methods, however, regularly meets people who feel that ‘it’s all about cars’, and ‘you’re treating people like mechanical objects’ and other variations of these concerns.
These worries are genuinely held and are probably best addressed by encouraging people to come to see some Lean work, or to meet people who have been involved in Lean improvement work. Anyone who attends RPIWs will have had the experience of staff who are worried, or even mildly hostile, who have become engaged by day three, and positive enthusiasts by the end of the week. Seeing improvement second hand will not convince everyone, but at least it starts to set the scene and to at least raise the possibility that the staff member might not be wasting their time by becoming involved in Lean work.
Dr Alison Powell and colleagues reviewed the use of improvement methods in health care for NHS Scotland. Their report is available at this link.
They quote Walsh and Freeman as saying,
“in a sense we should view every quality improvement programme as a kind of experiment, and design it to be ‘auto-evaluative’ so that the programme itself produces information about its own effectiveness.”
This makes sense. It is easy to ‘write up’ the successful projects, but the most useful learning often comes from understanding what did not work, and having the opportunity to reflect on the failure. The organisation in which I work encourages staff to enter all improvement projects on to an on-line database at the time of instigation of the project. There are several reasons for this, including helping people to know who is working in the same area. The main point of it, however, is to gather information on all of the projects, not simply the successful projects that become those that are widely disseminated. Understanding which projects stalled, and why that happened, is of enormous potential value for any organisation.
Powell and colleagues review some of the usual suspects in quality improvement – Total Quality Management (TQM), Continuous Quality Improvement (CQI); Business Process Reengineering (BPR); rapid cycle change; Lean and Six Sigma. They note, correctly, that there is considerable overlap between processes. They also make a better attempt than some other papers at describing in what way these overlaps occur, although given the length of their report, they do not pursue this in detail.
They make a good point about understanding the context of an intervention, a point touched on in a previous post. Powell and colleagues suggest:
‘…the types of research methods used to understand and evaluate quality improvement initiatives need to shed light on the interaction between the intervention and its context. Traditional experimental research methods like randomised controlled trials have a limited role in this respect but the review was able to draw on a wide range of studies of quality improvement in health care …These studies provide informative explanatory analysis ‘discerning what works for whom, in what circumstances, in what respects and how’.
In doing this, they come to remarkably similar conclusions to some previous work, concluding that health care organisations need to look at improvement models and:
- decide on the best fit for them
- apply it locally in a ‘programmed and sustained way’
- engage front line clinical staff, who have an essential role in leading improvement
- acknowledge that managers at all levels have a key supporting role
- ensure that the quality improvement activities are aligned with the priorities and aims of the organisation
- embed the work in normal practice
- take advantage of external sources of advice and expertise
This suggests that health care is not different in kind – if you replaced ‘clinicians’ with ‘skilled, expert staff’, then all of these considerations would apply to quality improvement in any organisation. It does mean that every health care organisation is slightly different from the one next door, and that no matter what the context, careful preparation, support, perseverance and commitment will be required to embed change.
Illustration courtesy of njaj at freedigitalphotos.net