Quality Improvement and Health Inequalities

Health inequalities are a major public health concern. Some differences in health status are caused by pressures entirely out with a person, or group’s, control. Despite the scope for gain, Health Inequalities work and Quality Improvement work have tended to be two separate islands of activity.

There are examples of application of QI techniques to public health processes. You can find an office example from our own work at this link. The techniques have also been applied to help the delivery of meals after a disaster, coached by Toyota staff, demonstrating the wide applicability of the methods.

Work in Scotland, involving the Q Community, QI Hub and Scottish Improvement Science Collaborating Centre among others, has found fewer examples of work targeting QI methods on inequalities.  One of the best examples they have found is work by Graham Mackenzie, Angela Dougall and colleagues. You can see details of the work in a brief video, and in a paper published in BMJ Open Quality.

The work starts from a clear problem: poverty affects health. There is a UK government programme, Healthy Start, that offers vouchers to obtain food and vitamins to pregnant women and women with children under four years of age, living in poverty. The  project described by Mackenzie and Dougall aimed to increase the value of the scheme to women and their children. To do this, women had to know about the vouchers, had to apply, and had to be successful in their application.

The authors started working with one midwife in one location as this was the route of access to the scheme for many women. This is in line with the approach of the Institute of Healthcare Improvement (IHI). (IHI have excellent QI resources – their website is well worth a look if you haven’t come across them before.)

In Lean terms, the team identified over-processing and changed the process to remove waste – additional steps that the midwife had added, with the best of intentions. In a second cycle of change, they identified that changes had not had the desired effect, and quantified the reasons for this, using a Pareto diagram. In the video linked above, Dr Mackenzie relates this to Dr Deming’s Theory of Profound Knowledge.

On their third cycle, the team began to look for spread. They checked out the applicability of their findings to a wider group of midwives and identified a lack of Standard Work and considerable variation. New Standard Work was created and shared. The extent to which this was co-produced Standard Work was not explicit from the published report.

There was limited improvement, so the team ran a fourth improvement cycle in which they fed back information on uptake to the teams. Some improvement happened, but there were problems with sustainability. Further investigation, supported by the use of driver diagrams, found that some of the challenges were in nurses having the time to help eligible women to complete the form, and the  team then moved to increase access to people able to offer welfare advice, which would include Healthy Start vouchers.

There is a good discussion in the paper about the impact of contextual factors, including the type of areas covered by the teams, and the proportion of income deprived people in their particular population.

The project, after impressive gains, ran in to some problems related to a change by the national team processing the applications. In a classic example of a team optimising their own efficiency, while worsening the overall performance of the system, the national team decided to discard applications received before the 10 week pregnancy eligibility date, rather than store them before processing them when that date was reached, as they had done previously. This type of problem in an overall value stream will be familiar to everyone who has worked on processes that cross different teams, and who focus on process measures rather than outcomes.

Despite this late problem, the project resulted in a substantial amount of resource received by mothers and children in need.

Would there have been any method differences if it had been run as a Lean project? Results may not have differed, and the necessarily brief description in the paper and video make it hazardous to make assumptions about what did or did not happen. In a Lean project, there may have been more focus on the initial state, and probably earlier value stream review. Staff and patient involvement in the design solution would be explicit, and daily management methods may have been profitably applied in the fourth stage, by linking data to local action and a focus on Standard Work.

This is nit picking, however – this is a valuable example of improvement methods applied to a programme which aims to reduce inequities, and it is well worth reading. The current Scottish work on inequalities and quality improvement methods may produce more examples of this, and will be worth watching. There is scope for shared international learning – everyone wants to reduce poverty, and the adverse effects of living in poverty.

Image Source: NHS Health Scotland https://www.nhshisa.net/2017/08/13/nhs-scotland-can-help-reduce-inequalities/

One thought on “Quality Improvement and Health Inequalities

  1. Thanks Cameron, that’s a great summary and further interpretation of the work. Lots more to do in this area, but also considerable challenges with “reforms” to welfare system. All the best, Graham

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