Addressing PMTCT Gaps through a Systematic Process Improvement (PI) Approach
A Systematic Narrative Review of Quality Improvement Models in Health Care
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Transcript of A Systematic Narrative Review of Quality Improvement Models in Health Care
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A Systematic Narrative Review of Quality Improvement Models in Health Care
Dr Alison PowellDr Rosemary Rushmer Professor Huw Davies Feb 2009 http://www.nhshealthquality.org/nhsqis/5658.html
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Presentation outline• Preamble: “quality”; quality improvement
“interventions”; and organisational challenges
• Five common QI approaches: alphabet soup of TQM, CQI, BPR, PDSAs and OWAs
• Making sense of the evidence…• Differences & similarities in the models• Drawing conclusions:
– some necessary but not sufficient conditions– strategies for over-arching support
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“Quality of care” is contested and complexTacit
understandings differ across various professional groups…
Common dimensions:
• Safety• Effectiveness• Patient-centredness• Timeliness• Efficiency• Equity IoM, 2001But these
dimensions can conflict…
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Levels of QI interventions• Macro policy choices:
e.g. Commissioning (World-Class?); Finance (Payment by Results?); “Choice”; Appraisal, oversight, inspection and regulation…
• A (micro) focus on individuals:e.g. continuing professional development;
(re)accredidation; encouragement to adopt evidence-based practice…
• Meso-level (organisational) change:– improvement and redesign at service
level…
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Organisational challenges (1)• Organisational & service complexity• Multiple stakeholders &
multiple/conflicting missions• Multiple – but poorly integrated –
standards and targets • Strong professional identities,
boundaries and autonomy… …limited professional engagement• Limited management control
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Organisational challenges (2)• Disconnect between resource decisions
and quality considerations• Patchy data/analytic capacity• Patchy / contested evidence-base• Education/socialisation focus on
individuals• Ongoing impacts of reorganisations,
organisational histories and major macro-level policy choices…CHURN
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• Models imported from industry• Some – diverse, but limited – evidence
(limited quantitative data, no cost-effectiveness data)
• Lack of clarity over “intervention”…indeed, growing hybridisation
• Complex interventions in ‘social worlds’• (Pawson & Tilley’s) “Realistic
Evaluation”:Context + mechanism influences outcomes “discerning what works, for whom, in what circumstances,
in what respects - and how”
Making sense of the evidence
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The approach…• Systematic searching (in health care)• Review within each ‘model’ – nature
of approach, evidence, experience…• Integration across the models –
– observations on similarity and difference– learning from system-wide experiences– identification of “necessary but not
sufficient” conditions– lessons learned from evidence to-date.
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Alphabet soup: common QI approaches
• Total Quality Management (TQM) &Continuous Quality Improvement (CQI)
• Business Process Reengineering (BPR)
• Practitioner-led rapid-cycle change (e.g. IHI’s PDSAs)
• LEAN thinking (Toyota)• Six Sigma
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TQM/CQI
• TQM/CQI approaches take as a focus the internal and external customers’ definitions of quality; see quality improvement as an ongoing activity that is part of everyday work rather than an isolated project; and focuses attention on systems rather than on individuals.
“Getting it right first time…”
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BPR
• BPR entails radical rethinking to design core processes from scratch; and emphasises the need for organisations to be designed around key processes and not around specialist functions.
• Less radical offshoots emphasise the importance of processes and pathways.“Why are we doing this at
all…?”
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Rapid-cycle change
• Rapid cycle change (e.g. the Plan-Do-Study-Act cycle) entails short-cycle small-scale tests of change followed by reflection on the results; emphasises close involvement of health care teams in defining the problem, suggesting potential solutions, and testing and refining these possible solutions.
“Practitioners are doing it for themselves…”
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BPR
• BPR entails radical rethinking to design core processes from scratch; and emphasises the need for organisations to be designed around key processes and not around specialist functions.
• Less radical offshoots emphasise the importance of processes and pathways.“Why are we doing this at
all…?”
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Lean thinking
• Lean thinking approaches emphasise examining the organisation’s processes to ensure that they are providing what the customer wants with minimal wasted time, effort and cost.
“Just-in-Time; Lean (and mean?)…”
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Six Sigma
• Six Sigma aims to increase the reliability of a process or system of care by using statistical tools and analysis to identify (and hence be able to address) the root cause of variation in the process or system (common cause vs. special cause variations).
“Define; Measure; Analyse; Improve; Control”
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System-wide experience
• Jonkoping County, Sweden
• Kaiser Permanente• The VA and QUERI• The “Organising for
Quality” cases• IHI’s 100,000 lives
campaign
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Difference & Similarity in Approach
• Differences (often) in: – Pace, place and scope of change– focus of change activities:
- processes or systems?- specific aspect(s) of quality?- (whose) perspective on quality?
- enabling or mandating improvement?• Similarities (often) in: objectives, tools
(esp. measurement – SPC), implementation
Clear-cut taxonomy neither feasible nor useful
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Conclusions
• Evidence limited, but not absent…• Although models vary in principle, in
practice much overlap, borrowing and hybridisation – no one model emerges as ‘best’
• Policing vs. enabling balance (i.e. data for judgment vs. data for learning)
• Context/model interactions are crucial…
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Necessary, but not sufficient…
• Active engagement of health professionals…(with training)
• Tailored, multi-faceted approaches to suit local need
• Sustained action at multiple levels…• Board-level support and follow-
through…• AND Active participation of managers
(organisational leaders) to…
Vital but do not guarantee success
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…managerial attention especially to…
• Communicate alignment with wider objectives (and protect from overload)…
• Provide local resourcing/tools, including external linkage…
• Help address local system consequences and barriers…
• Embed new practices into routine service.
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Consider over-arching support• Identify useful tools – provide training
in their use• Help local organisations identify their
quality improvement needs (data/analysis)
• Provide central support/training for local data gathering/analysis
• Support Boards to develop as quality champions
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Sharing the Findings
• Downloadable PDF from QIS website A Systematic Narrative Review of Quality Improvement
Models in Health Care. Powell, Rushmer and Davies http://www.nhshealthquality.org/nhsqis/5658.html
• Series of papers in Br J Healthcare Management(monthly: January – August 2009)
• See also: Quality Improvement: Theory and Practice in Healthcare
Boaden, Harvey, Moxham, Proudlove and Bevan http://www.institute.nhs.uk