I’ve been thinking of a few things lately. One of those things has been the idea that ‘QI is the right way to do things’. You might be thinking, well yeah, else why else might you read this blog? But then you might be thinking, well no, QI isn’t the only way to do things, there are other ways too. Why am I thinking this you might ask?… Good question.
The ‘one best way’ thing is bothering me a lot. There is often something in improvement communities that perhaps goes a little unsaid, or isn’t talked about enough. During my thesis, one of the things that interested me, was the idea that there were lots of different ways of improving. That’s sounds obvious now, of course there is, isn’t there? But then I had been an ‘improver’ for so long, I think that maybe I had gotten a little blinkered that it was the ‘only way to improve’ and other ways to improve were just not as good. ‘QI group think’ if you like. QI: my one best way.
A book I read, talked about different theories of performance, and this intrigued me as a different way of thinking about improvement. (I had to get past the bias in my head telling me that quality is different to performance btw). In this particular book, the author (Talbot, 2010), describes four categories of performance interventions ways (at that time) in use in the English public sector. These are: managerial-contractual interventions; the market/quasi-market systemic change; user choice and voice; and capability interventions. Each can be argued to be underpinned by differing theoretical perspectives and involve different actions by organisational actors. However, these interventions, are often used concurrently, in silos and in a disconnected way, with little design or deliberation as to how they interconnect. In addition, it is argued that whilst these interventions are used for performance improvement, the interventions often have other purposes such as providing assurance to service users or stakeholders, or to identify areas of poor practice.
Taking each in turn. Managerial-contractual interventions typically include direct and top down management control and the use of contractual levels, with the use of performance management and targets. Not a difficult intervention to spot in healthcare in England. And with arguably some success, there were lots of downsides to targets in the late 2000s, but waiting times, where target were imposed, did fall. This approach can be argued to be understood as an application of institutional theory, emphasising the formal and legal aspects of structures.
Market or quasi market interventions try to stimulate competition between organisations and disrupt as a way of stimulating improvement and innovation. Leagues tables and transparency approaches feature heavily here to encourage all to want to be top of the pack. A data rich approach, needing someone to produce and publish the league tables or to ‘referee’. Perhaps a regulator of some sorts, such Monitor during the 2000s. These types of interventions can be argued to be underpinned by public choice theory, where individuals try to maximise for public good*.
User choice and voice interventions can also be argued to have this theoretical base. These types of interventions try to empower service users through ‘formal’ rights and entitlements and through choice of service providers for example. Again we can think of examples of this in healthcare such as policies such as ‘any qualified provider’ and the ‘right to be treated in 18 weeks’ within the NHS constitution.
Finally, capability interventions. This is for me where improvement falls in. This type of intervention focuses on support to organisations such as funding, people, time, air cover and the encouraging of approaches such as QI and Lean, helping organisations improve for themselves by strengthening their resources and capabilities, as many in healthcare have been encouraged to do over the past 20 years, yet still this can be critiqued as overly complicated. QI can be argued to be based on resource based theories of performance. And I drew heavily on this theory in my research on improvement capability.
What is striking about these four categories of interventions is that the final one, that includes QI, is the only category that is driven by organisations delivering services or care themselves. It is an ‘inside-out’ approach to change, rather than the other three which can be described as ‘outside-in’ (Lillis and Lane, 2007). During my thesis, it was noted in the literature that much research as been conducted on outside-in approaches but little on inside-out ones or their interaction, including in the conditions that support flourishing improvement interventions (or hinder them). It is why I focused my doctoral research on the relationship between regulation and improvement… (spoiler: can be helpful, but not always). (Extra side note… It does make me wonder if that is sometimes why QI seems to struggle to gain traction at regional and national levels, as by definition it’s hard for national/regional bodies to lead the inside-out stuff… whereas the rest, especially with all those added bonuses of assurances etc…).
We have learnt a lot more about improvement now, especially in healthcare and what works in what circumstances and what doesn’t. Still more to learn. We have also learnt much more about regulation, the market, user choice and targets. Lots worked, and lots didn’t or at least, seemed not to. As we move into covid recovery, I’m wondering have we learnt enough though to move away from our favourite ‘one best way of improving’ , whether we made our careers in performance management, regulation or improvement and move towards a more integrated way of improving? What if we can improve QI by being more inclusive and tolerant of other ways of improving? Can we build and draw deliberately on some of the best aspects of all, be vulnerable enough to say ‘I don’t know enough about how QI or performance management or user voice could help here’? Maybe you already do that. For me though, I’m wondering what else, how can QI approaches be seem as complementary rather than sometimes competing/an alternative, too complicated and ‘the only way’ and, if so, would that be helpful?
Still thinking. Love to hear what others are thinking.
* massively over simplified explanation, but enough for this blog
Healthcare Quality Improvement 