When I worked nationally for NHS Improvement (NHSI) a few years ago, I remember a Finance Director once asking me when NHSI was going to mandate an improvement approach nationally, because then he would get on with it in his organisation. He didn’t want to start off investing in one approach only for the regulator later to say a different improvement approach was ‘the’ one to use. I didn’t know quite how to answer at the time, and didn’t really, suggesting that perhaps that wasn’t really the point and it didn’t matter too much, to avoid answering the question.
I have written about this topic of ‘which improvement approach’ a few times over the last few years in these blogs (improvement brands; which QI approach is the best?), and my reflections keep evolving overtime. I suppose I’m curious about two things with the constant refrain of ‘which QI approach?’ These are, why and who benefits by this question, and I reflect on these in this blog.
My whole career has been in this improvement space, first as a technical improvement specialist in safety critical engineering sectors and then leading improvement programmes across healthcare…. using that same technical specialism. Earlier in my career, I reflect I thought what I did as a professional engineer is how improvement ‘should’ be done. My professional expertise needed to count (I needed to count). And as I was in undergraduate education at the time of publication of ‘Lean Thinking’ and around academics working in the research of automotive productivity with Tier 1 and 2 suppliers in the NE of England. This way of improving then, to me was ‘how’ improvement ‘should be done’. As Lean. Else, why would I have been taught it and for it to form the basis of much of why I got my first job and the start of my professional knowledge?
When I moved into healthcare, some 10 years or so later, Lean was a brand new shiny idea. I went to the first Lean healthcare conference at the national motorcycle museum in Coventry. Brilliant for me, right?, Just up my street, with 10 years of professional experience in just that area. I worked with national programmes drawing on Lean thinking with the productive ward in Liverpool and then led the Bolton Improving Care System and used Lean across England with NHS Blood and Transplant. My identity in healthcare as an (isolated) improvement engineer working in healthcare became wrapped up in Lean, the improvement approach. My identity was so wrapped up in it, one of my Generation Q colleagues profoundly asked me, ‘who are you without Lean?’ Which was quite a shock to me at the time and it was a question I wasn’t ready to process or wanted to answer then. For me, then, I reflect because of the expert power and identity Lean healthcare gave me, Lean was ‘my one best way’ of doing improvement, why would I not ‘be’ Lean? I reflect I possibly treated it for a while with the arrogance of a magic bullet that could work for everything. To me it mattered then that Lean was the approach.
The IHI and the Model for Improvement, what the hell is that? Was never in my professional training, and was certainly not part of my professional communities of practice (still isn’t outside of healthcare), that made me very sceptical and it seemed a bit of a threat perhaps to my expert power from Lean. Nevertheless, I have learnt more of it and assimilated it with my existing improvement knowledge, along side lots of other ways of learning and improving. Another string to my bow.
Overtime, and especially during my PhD, I have understood more about lots more different improvement approaches, theories and conceptual models, many from outside the narrow field of ‘QI in healthcare’, each with pros and cons, often sharing the same roots in the work of Deming, Shewhart and others. There is so much commonality across improvement approaches, it is easy to understand why is often advocated that it doesn’t really matter which QI approach you take, just pick one and get going. I have done it myself when working with beginners, anxious about doing things ‘right’. This messaging helps to remove anxiety, particularly about improvement jargon and to help people find their initial way through the complexity of improvement brands and consultancy snake oil. Nevertheless, whilst this message does seem to simplify improvement for beginners, for me there are so many ways of improving, I’m no longer of the view that there is ‘one best way’, and no ‘one improvement approach’ (goodbye to that identity). Yet, indicating that all improvement approaches are interchangeable so it doesn’t really matter which one you pick isn’t really a better message in the long run, any more than there is one best approach, imho. I am not arguing for no approach at all as an alternative, an approach is needed in my view. So the question ‘which one then?’, recurs.
Many improvement approaches have shared roots and much in common (except the jargon) they are still diverse with different strengths and weaknesses we can learn from in different contexts. The diversity of approaches is improvement practice’ strength as well as its weakness. Study after study indicate that use of even basic improvement approaches such as PDSA cycles have low fidelity in practice in healthcare, and that this may account for some of the reason why improvement doesn’t always deliver on the goals set out. High fidelity improvement practice deliberately chooses the approach to fit the problem, rather than just picking any approach and suggesting it works in every context for every problem. By articulating ‘it doesn’t matter which improvement approach is used’ as a simple response to ‘which one should we use?’, inadvertently perhaps this suggests that approach doesn’t matter, yet fidelity of approach does seem to matter if we want better outcomes from our improvement practise.
For me, having an improvement approach is important and being choiceful in which one is probably helpful. Just as choosing an appropriate research method is important when answering a particular research question, as this depends on the research design, the epistemological and ontological perspective and pragmatic considerations. Thus it follows that having an appropriate improvement approach in particular circumstances for an improvement problem is important too. No simple answers to the question of ‘which one?’.
I do wonder a little given my own experience if this question of ‘which one?’, layers upon professional identities about ‘how to’ improve, priorities, soft power, organisational hierarchies, resources, differing ideas and world views and thousand of other things, that might all seem to fall in to the mix here. Is the question really about the approach choice or is it just the visible artefact of something else going on? Is the response of ‘it doesn’t matter which one’ a way of trying to not surface some of those issues?, and like I did with the Finance Director, an attempt to avoid answering. Or at least to try to not let those concerns stall any improvement from happening.
For me ‘science’ of improvement is to some extent the technical know-how for the improvement approach which then needs to be combined with the ‘art’ of improvement – that is the understanding of what circumstances, and what types of problems and issues each approach might be suited, and for whom improvement matters. For me, it matters why, where, who and how we improve, and how we keep learning to do that better, to improve, improvement, for all our patients, carers and families.
Healthcare Quality Improvement 