1. The role of context in successful improvement
Naomi Fulop, University College London
Glenn Robert, King’s College London
13th March, 2014

2. Original research Perspectives on context March 2014
A selection of essays considering the role of
context in successful quality improvement
Original research
March 2014

3. Why this matters?
Results of QI interventions across health care systems or within organizations - mixed, often disappointing
Promising interventions implemented in one setting do not transfer to others, or not sustained
With the benefit of hindsight, the usual explanation offered is ‘context’

4. What is ‘context’? ‘Context is everything’ (Gouldner, 1955)
The gardening metaphor…..
“Context refers to the ‘why’ and ‘when’ of change and concerns itself both with influence from the outer context (such as the prevailing economic, social, political environment) and influences internal to the focal organisation under study (for example, its resources, capabilities, structure, culture and politics).” (Pettigrew et al, 1992)
Blurred boundaries between ‘context’ and the ‘intervention’?

5. Which contextual factors are associated with successful implementation of QI interventions in health care organisations: A systematic review
which aspects of context have been found to be important in the implementation of quality improvement interventions?
which aspects are modifiable?
what evidence is there that these aspects have successfully been modified, and resulted in improvement to quality?

6. Receptive contexts for change (Pettigrew et al, 1992)

7. How emotional dynamics influence change dynamics (Huy, 1999)

9. Dimensions of literature synthesis (Robert and Fulop, in press)

10. What we found Majority of studies large-scale, cross-sectional surveys
Mostly U.S.
Most common Pettigrew et al features
Organisational culture
Quality and coherence of policy
Environmental pressures
Most studies at meso (organisational) level
Majority studies ‘structural’ cf ‘psychological’ factors – esp at micro level
Very few studies looking at more than one level of the system

11. Some examples of ‘modifiable’ factors
Most studies not of ‘modifiable’ factors
Macro e.g. publication of surgeon’s and hospital’s performance
Meso e.g. introduction of electronic patient record
Micro e.g multi-faceted QI intervention incl financial incentives improved adherence to guidelines

12. The way forward? Some recent developments in the field e.g. MUSIQ
But attention now needed on psychological/emotional context that facilitates QI
Piloting the acceptability, feasibility and value of reflective tools that enable practitioners to take contextual factors into account before beginning - and during - future QI interventions
Designers of future QI interventions need to consider all three levels of the healthcare system (macro, meso, micro)
Framework for future research: longitudinal, process-based, organizational case studies
QUASER 8 challenges of quality improvement

13. Source: Kaplan et al, 2012

14. Physical & technological: Managing the external environment:
Structural:
structuring, planning and coordinating quality efforts
Political:
addressing the politics and negotiating the buy-in, conflict and relationships of change
Physical & technological:
designing physical infrastructure and technological systems supportive of quality efforts
Cultural:
giving ‘quality’ a shared, collective meaning, value and significance
Emotional:
inspiring, energising and mobilising people for quality improvement work
Educational:
creating and nurturing a learning process that supports continuous improvement
Leadership:
providing clear, strategic direction
Managing the external environment:
responding to broader social, political & contextual factors
QUASER: 8 challenges for QI

15. Physical & technological: Managing the external environment:
Structural:
structuring, planning and coordinating quality efforts
Political:
addressing the politics and negotiating the buy-in, conflict and relationships of change
Physical & technological:
designing physical infrastructure and technological systems supportive of quality efforts
Cultural:
giving ‘quality’ a shared, collective meaning, value and significance
Emotional:
inspiring, energising and mobilising people for quality improvement work
Educational:
creating and nurturing a learning process that supports continuous improvement
Leadership:
providing clear, strategic direction
Managing the external environment:
responding to broader social, political & contextual factors
QUASER: 8 challenges for QI

16. John Gabbay & Andrée le May (and Jonathan H Klein & Con Connell)
Lessons from the Health Foundation Learning Communities Improvement Project: context and skills
John Gabbay & Andrée le May (and Jonathan H Klein & Con Connell)

17. Background The Health Foundation Quality improvement
“Improvement science”
Organisational learning
Learning communities/ communities of practice

18. Improvement Science? = “proven” improvement methods (e.g:)
Care bundles
PDSA cycles
Run charts
Statistical process control
Benchmarking
Driver diagrams
Process mapping
Six sigma
process and outcome measures
Lean methodology

19. Underpinned by: Working with the willing/early adopters
Using clinicians’ own data
Mutual problem-solving “improvement conversation”
Focussing on one or two key agreed problems
Doing small tests of change and adjust as you go
Showing just enough evidence to make the point
Developing ideas of improvement with the clinicians
Getting buy-in through early wins and natural spread 

20. Methods Orientation visit (+topic selection)
Snowball samples (n=9-13 per “improvement group”)
SPIBACC (Systematic Prior Interview-Based Analysis of “Claims & Concerns”)
Prioritisation of improvement tasks
“Learning Events” (to introduce “IS” techniques)
Further interviews (~ 35) + SPIBACC before Learning Events
(9 Learning Events in total)
Participant Observation
Follow up interviews (n=33)

21. Sites Exemplary QI (?) 2011-12 2 x 2 “Improvement groups” Furnhills
COPD
Dementia (memory clinic)
Dansworth
Elderly care
Dementia (hospital environment)

22. Furnhills
COPD
Dementia (memory clinic)
Dansworth
Elderly care
Dementia (hospital environment)

23. Context External environment Continuity Targets
Internal organisational culture of improvement
Resources, structures and processes
Leadership
Local politics
Relationships: trust and communication

24. Successful Improvement ?
Learning Skills
Soft skills
Technical skills
Organisational base

25. The Improvement Pyramid
Skills fall short
Wasted resource!

26. The Improvement Pyramid
Skills fall short
Skills Fall Short

27. Implications
Organisational & personal skills are essential for handling context
They are an essential precursor to the application of “hard” IS skills and must be well developed if the latter are to succeed
Learning communities are an effective way to help meld those sets of skills
Learning communities function more effectively when facilitated especially when community learning skills are weak
Achieving sustained improvements with IS may require specific interventions
for learning soft skills
to systematically facilitate the QI process (SPIBACC) so as to get “inside” the contextual concerns and deal with them