I read a tweet recently asking for more non-clinical involvement in healthcare quality improvement (QI) work. That, for me – ‘a non-clinician’, is a pretty shocking indictment of where the QI ‘movement’ seems to have gotten to. To a point where some perceive that QI can be seen as being for clinical staff, rather than for all. It made me stop and think, what? Why is that? How did that happen? Why is it seen as elitist and exclusive?
But then, I remembered reading an article by Prof. John Ovretveit who, way back in 1997, described the ‘battleground’ for power and change in healthcare, between clinicians and ‘non-clinicians’. In that article, Ovretveit argued how there seems to be a perpetual power battle over what constitutes quality, and thus what constitutes improvement. When in many ways, both ‘quality’ and ‘improvement’ are ambiguous concepts and can be conceptualised in multiple and diverse ways. When viewed like this ‘QI’ can be argued to be a form of value judgements from those with power seeking to make things better (for themselves or others they deem as worthy). And what ‘better’ is, is likely to be determined by those with the power. Perhaps, if I reflect on the tweet, rather like the view it contained, ‘QI is for clinical staff’ rather than other staff, or indeed patient groups.
This reflection makes me think about why there is so many different forms of improvement in use in health and care, some of which seem to be perceived as for some groups more than others. Are they some kind of gesture or response within this battleground for power? I wonder if thinking about improvement though this perspective might help to explain the many and varied versions and brands of improvement, that may or may not be accessible to different groups.
When I say ‘improvement brands’ what I mean is the many different ‘ways’ and improvement approaches that are often touted. Such as: TQM (total quality management), BPR (business process reengineering), continuous improvement, service improvement, operational improvement, training within industry, IHI-QI (using mostly the Model for Improvement), Kaizen, lean, six sigma, theory of constraints, agile, lean six sigma, Toyota Production System, Toyota kata, Deming system of profound knowledge, complexity theory, Microsystems coaching, clinical systems engineering, patient experience based design, organisational development/human led methods, statistical process control, audit, guidelines and standards and design thinking. Not to mention the consultancy/bespoke offerings that repackage these, such as listening into action, QSIR, the Virginia Mason lean approach, the Intermountain approach, productive ward, flow coaching, 15s30m, and so on, and on, and on. [11 lines just to list those, and still stuff will be missing]. All different improvement ‘brands’ arguably vying for ‘audience’ attention and reputation [at least by someone], and widespread application to generate the oxygen of case studies, and perhaps funding and resources, and maybe even fame and fortune and growing legitimacy, and with that perhaps also power.
Multiple improvement brands that can confuse and create barriers to collaboration through language. I have also seen cases where the plethora of approaches has stifled improvement by improvement beginners whom are unsure of which improvement approach to take, for fear of not choosing ‘the best’. I have also witnessed some organisations and leaders worrying they will pick an approach that is ‘not approved’ by the regulatory agency or region and they may invest in learning one ‘way’ to only discover they need to jettison it later, stifling adoption of an improvement approach. Or worse, abandoning their investment and learning in one improvement approach if or when the regulatory agency picks ‘the right one’ or suggests [or requires] an alternative. Arguably Pseudo innovating yet another way of improving within that organisation.
In addition, as we noted at the beginning, there are leaders, organisations and teams that somehow seem to perpetuate the view that specific improvement ‘types’ are for some groups (staff, patient or both) more than others, perhaps strengthening the power of some groups over others. Further, a view has sometimes been given by some that some improvement approaches are for specific priorities that are ‘obviously’ more important than the perceived priority of a different improvement approach [perhaps like this stereotypical, and imho wrong, argument that I come across: lean for waste vs IHI-QI for quality]. These stereotypes and perceptions seem to me to be reinforced by the different branding, and channels to ‘market’, (application), that seem to inadvertently exclude some groups more than others and perhaps add to a view of improvement as elitist and exclusive.
I mean just how many brands of improvement do we need? How many can we come up with to try to differentiate what we do, or to say this is special for our ‘tribe’ only, or to make it really clear this chosen approach is the ‘good one’. [e.g. this isn’t about *cross out unneeded answers*: a policy objective that no one likes, cost savings, targets, reconfiguration, rebanding jobs, stuff that’s hard that no one wants to do, weekend working/7days, or a regulation thing or accountability].
It is my view, and I have argued this before on this blog, (re OD and QI and which improvement approach is best?), that most improvement approaches have shared roots and provenance and have much more in common than they have differences. Further, many improvement approaches are iterations of previous approaches (TQM is arguably an earlier iteration of what we now call lean) or have developed further in one sector more than another (such as six sigma in electronics). Many describe the shared roots in the post WW2 era, with the work of Deming, Juran, Feigenbaum and Lewin; and there are even earlier roots from from the first few decades of the 20th Century just after Taylor, with the work of Codman, Shewhart, Box, the Hawthorne experiments, the Gilbreths, Training within Industry and Morris Motors to name just a few examples. This makes me think of just all the different ways that knowledge can grow and evolve and how knowledge builds on what has gone before.
It remains my view that whilst the branding packaging, terminology and presentation of improvement approaches can differ substantially, the core content is very similar. Improvement approaches (of whatever label) don’t just have shared history, and core content, they also have much more in common. Such as taking a process view, a focus on value for the user/consumer/patient, a focus on flow and reduced variation and importantly the importance of those doing the work in supporting team based improvement (Boaden & Furnival, 2016).
This blog now might now sound as though I am making an argument for ‘one best way’ of doing improvement, eliminating the branding, the eliteness and exclusivity, the jargon differences, the subtle and not so subtle tool differences, the emphasis on different elements, the value judgements as to priorities made based on the selected improvement approach and so on. Yet, I am not. Whilst there are obvious advantages for beginner improvers to learn and practice one improvement approach, rather than several at one time, and gain some mastery; the power for me of using improvement approaches, comes exactly from the diversity of so many ‘ways’ of improving.
This diversity, to me, means improvers can select the ‘best’ way for the challenge at hand, contingent on the circumstances such as the existing knowledge, skills, prevailing culture, ease, the challenge itself and crucially ‘for whom’ the improvement is for. And experienced improvers of several ‘brands’, can then change their approach and terminology, with the multi-disciplinary teams whom with which they are working and co-designing, as needed to suit new problems, new challenges and new circumstances.
This flexibility of improvement approach, in my view, can help to solve challenges by adding diversity through plural perspectives, each with a different view of a challenge, and by being more inclusive in who can take part by achieving challenges in multi-disciplinary, and more accessible ways. Allowing even more new ways of improvement to emerge as we learn together to solve problems and deliver improvement across all dimensions of quality, be that safety, delivery, equity, morale, experience or cost.
For me, to ensure the very best for patient care and population health, we need this diversity and multi-disciplinary way of improving, to ensure the constant evolution and improvement of improvement approaches, to prevent the ossification of improvement practice. We also need this diversity and inclusivity of both people and improvement approach, to help guard against elitism, where some groups can ‘do’ improvement yet others are excluded. We need the diversity and inclusivity to help us see old problems afresh, to achieve new challenges and to help us keep moving ‘Improvement’ forward with new thinking to help us achieve the breakthroughs we need in health and care. To improve improvement: we improvers too have ‘two’ jobs. We need to ensure the high quality application of improvement approaches across and between health and care organisations, now and for the future.
Improvement is everybody’s job.