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

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

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’

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’?

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?

Receptive contexts for change (Pettigrew et al, 1992)

How emotional dynamics influence change dynamics (Huy, 1999)

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

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

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

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 https://www.ucl.ac.uk/dahr/quaser/QUASER-GuideForHospitals

Source: Kaplan et al, 2012

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

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

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)

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

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

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 

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)

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

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

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

Successful Improvement ? Learning Skills Soft skills Technical skills Organisational base

The Improvement Pyramid Skills fall short Wasted resource!

The Improvement Pyramid Skills fall short Skills Fall Short

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