Advances in application of the Science of Improvement: Past, present, and future Lloyd P. Provost...
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Advances in application of the Science of Improvement: Past, present, and future Lloyd P. Provost Associates in Process Improvement Senior Fellow, Institute for Healthcare Improvement [email protected] 1 API- 2014
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Transcript of Advances in application of the Science of Improvement: Past, present, and future Lloyd P. Provost...
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Advances in applicationof the Science of Improvement:Past, present, and futureLloyd P. ProvostAssociates in Process ImprovementSenior Fellow, Institute for Healthcare [email protected]
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Advances in application of the Science of Improvement:Past, present, and future
PastA brief history of the Science of Improvement
PresentApplying the Science of Improvement today in healthcare
FutureSome conjectures and hopes for the future of the Science of Improvement
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Walter Shewhart
(1891 – 1967) Joseph Juran(1904 - 2008)
W. Edwards Deming(1900 - 1993)
The Pioneers of Quality Improvement
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Appreciation of a system
Understanding Variation
Theory of Knowledge Psychology
Values
Deming’s System of Profound Knowledge
The Foundation of the Science of Improvement
Systems
Understanding Variation
Theory of Knowledge
Psychology
History of the System of Profound Knowledge
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VARIATION
Walter Shewhart
R A Fisher
W Edwards Deming
PSYCHOLOGY
Eric Trist
Abraham Maslow
Kurt Lewin
Fredrick Herzberg
Elton Mayo
Douglas McGregor
KNOWLEDGE
Chris Argyris
John Dewey
C. I. Lewis
SYSTEMS
Russell Ackoff
Ludwig von Bertalanffy
Jay Forrester
Peter Senge
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Deming’s System of Profound Knowledge
"One need not be eminent in any part of profound knowledge in order to understand it and to apply it. The various segments of the system of profound knowledge cannot be separated. They interact with each other. For example knowledge about psychology is incomplete without knowledge of variation.“
W. E. Deming, The New Economics, 1994
Two Types of Knowledge
Subject Matter Knowledge
Subject Matter Knowledge: professional knowledge, basic to the things we do in life
Profound Knowledge: The interaction of the theories of systems, variation, knowledge, and psychology.
Profound Knowledge
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Making Improvements
Profound Knowledge
Subject Matter Knowledge
Increased capability to
makeimprovements
Learn to combine subject matter knowledge and profound knowledge in creative ways to develop effective changes for improvement
Intrinsic versus Extrinsic
Motivation
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PsychologyThe Human Side of the Science of Improvement
Shewhart’s Theory of Variation (1931)
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Common Causes—those causes inherent in the system over time, affect everyone working in the system, and affect all outcomes of the system
Special Causes—those causes not part of the system all the time or do not affect everyone, but arise because of specific circumstances
Berwick, Donald M., Controlling Variation in Health Care: A Consultation with Walter Shewhart, Medical Care, December 1991, Vol. 29, No 12, pp 1212-1225.
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W. Edwards Deming - Teaching, 1951Photo from The Deming Institute
Appreciation of a System
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Change in a system:First-order Change: A change that occurs within a given
system. The system remains the same.
Second-order Change: A change whose occurrence changes the system (discontinuity, logical jump).
Change Concepts in the Grouping
Eliminate Waste 11Improve Work Flow 12Optimize Inventory 4Change the Work Environment 11Producer/Customer Interface 8Focus on Time 5Focus on Variation 8Mistake Proofing 4Focus on a Product/Service 9
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ConceptAn opportunity to create
a new connection
Thoughtprocess
Specificidea B
Specificidea A
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BreakthroughResults
Theories, hunches,& best practices
A P
S D
Evidence & Data
A P
S D
A P
S D
A P
S D
Develop a change
Test a change
Test new conditions
Implement a change
Theory of Knowledge
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Gold Standard for Evidence in QI:
“Satisfactory prediction of the results of tests conducted over a wide range of conditions is the means to increase the degree of belief that the change will result in improvement.”
The Improvement Guide, 2nd Edition, 2009
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“Predictionis the problem”
– W. Edwards Deming
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Advances in Application of the Science of Improvement:Past, present, and future
PastA brief history of the Science of Improvement
PresentApplying the Science of Improvement today in healthcare
FutureSome conjectures and hopes for the future of the Science of Improvement
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The National Demonstration Project on Quality Improvement in Health Care (NDP)
• 20 Hospitals• 21 Quality Improvement Experts• September 1986 to June 1987• Initial and Summary Conferences• Founding of IHI
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Health Care Quality Improvement: Key characteristics
o Multiple experimental cycles (PDSA’s) for quick feedback and learning – (not just one study design)
o The initial intervention (changes to the system) are adapted and modified as study progresses
o Measuring over time (improvement is temporal)o Graphical analysis and presentation of data (SPC)o Learning from special causes and sub-group analysis are
key strategieso Involvement of local expertise in conducting project
(passion and possible bias)
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o Multi-factor study designs to learn from complex systems with non-linear and dynamic cause and effect relationships
o Contextual factors (background variables or confounders in research) are sometimes the major focus of the QI study
o Building reliability of the interventions can be a major part of the effort
o Sustainability of the changes is a consideration from the beginning of the project
Health Care Quality Improvement: Key characteristics (continued)
Greg Ogrinc, Kaveh G Shojania, “Building knowledge, asking questions”, BMJ Qual Saf 2014;23:265–267.
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Selection
Measurement
Confounding
Chance
Conclusion
Sample
Sample
Internal Validity
Traditional Enumerative Statistics Apply
Environment in an Enumerative Study
???
Perspective: Enumerative and Analytic Studies
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Clinical EpidemiologyFletcher, Fletcher, Wagner
Sample
Environment in an Analytic Study (QI)
Prediction is the Issue. Need different analytical
methods
Sample
Provost, Lloyd P. “Analytical studies: a framework for quality improvement design and analysis”, The British Medical Journal Quality and Safety, 2011, 20 (Supplement 1):i92-i96.
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Research and Improvement in Health Care
“The story could end here happily with two great streams of endeavor merging into a framework for conjoint action: improving clinical evidence and improving the process of care. Instead, the two endeavors are often in unhappy tension...”
Berwick, Donald M The Science of Improvement, JAMA. 2008;299(10):1182-1184
1950-1980’s Formal Evaluation of
Medical Practice,
Randomized Control Trials,
and Levels of Evidence
1980’s
Industrial Q
uality
Improvement Methods
applied to Health
care
Processes, I
OM Reports
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Another Possibility
LinearCause-and
-Effect Relationships
ComplexNon-Linear
Chaotic Systems
“Rigorous” Learning
Poor Learning
Learning from Experience
Randomized Controlled Trials
RCT’s
RCTs to Study Health Care Systems
What Methods ofLearning Go Here?
Adapted from Donald M. Berwick, MD – Eating Soup with a Fork, IHI Forum, 2008
API- 2014 23http://www.nytimes.com/2014/02/03/health/effort-to-test-health-policies-is-criticized-for-study-tactics.html?_r=0
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Advances in Application of the Science of Improvement:Past, present, and future
PastA brief history of the Science of Improvement
Present Applying the Science of Improvement today in healthcare
Future Some conjectures and hopes for the future of the Science of Improvement
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PREFACEDeveloping a continuously learning health
care system is critical for the future of health care, as well as for the future physical and financial health of the nation.
There is no simple path forward; rather, actions need to be taken by every stakeholder if this vision is to become a reality.
Mark D. Smith, Chair
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Five Methods to Support a System of Learning for Health Care
Moen, Nolan, ProvostMcGraw-Hill 2013, p. 346-347
1. Recognition and investigation of special causes using Shewhart charts.
2. Study of informative cases.
3. Observational studies of relationships between factors and responses.
4. Natural experiments (with factorial thinking).
5. Planned Experiments including the use of replication blocking, randomization, and experimental patterns.
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Context!
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“Orchestrated” Testing: Coordinate sophisticated PDSA testing in a
collaborative or network using Factorial DesignsAPI- 2014
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Time Series Analysis as the Standard for QI Studies
Webster, P. et al, “Using quality improvement to accelerate highly active antiretroviral treatment coverage in South Africa”, BMJ Quality and Safety, 2012;21:315e324.
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Integration of Quantitative and Qualitative Research
What Happened?Why?
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Reverend Thomas Bayes, 1701 - 1761
Learning to use Bayesian Statistics to support quality improvement
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Patient Focused Care: “Personalized Learning Systems”
“A Personalized Learning System is designed to make possible a more rigorous, collaborative, and individualized approach to care. Enable patients, families, clinicians, and researchers to work together to accelerate innovation, discovery, and the application of new knowledge…”
HBR Blog Network: A Personalized Learning System
for Improving Patient-Physician Collaboration,
Heather C. Kaplan, Jeremy Adler, Shehzad A. Saeed, Ian
Eslick, and Peter A. Margolis | 12:27 PM October 2, 2013
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A growing appreciation of complex systems
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The Need to Understand the Whole System…
When you are confronted by any complex social system, such as an urban center or a hamster, with things about it that you’re dissatisfied with and anxious to fix, you cannot just step in and set about fixing with much hope of helping.
This realization is one of the sore discouragements of our century… You cannot meddle with one part of a complex system from the outside without the almost certain risk of setting off disastrous events that you hadn’t counted on in other, remote parts.
If you want to fix something you are first obliged to understand…the whole system… Intervening is a way of causing trouble.
Lewis Thomas, 1974Biologist and EssayistFrom Business Dynamics by John Sterman, p.8
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Advances in applicationof the Science of Improvement:Past, present, and future
Continue to add rigor to the methods of improvement.
Continue to develop the Science of Improvement on the foundation prepared by Deming.
Appreciation of a system
Understanding Variation
Theory of Knowledge Psychology
Values
