Science of Improvement

in the Healthcare Setting

QI Training 1
Enabling Objectives
• Explain the Science of Improvement
 Discuss the change and improvement
 Describe the two types of knowledge to develop
effective change
 Explain the four components of Deming’s System of
Profound Knowledge and their uses to understand
the current problems
 Explain the interplay between the four components
of profound knowledge
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Outline
• Introduction
• Change and improvement in healthcare
• Deming’s “System of Profound Knowledge”
• Four components of profound knowledge
• Interaction of the four components
• Summary
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“Science” of “Improvement”

Science:
“knowledge attained through
study or practice”
Improvement:
“increase in value or in
excellence of quality or
condition”
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Science of Improvement
• Science of improvement is a problem-solving
approach centered on continuous inquiry and
learning.
• It promotes the organization,
 To explore new ways of working in small
incremental improvement steps
 In more innovative ways and
 how improvements are achieved and sustained
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Why Improvement?
• To Transforming Healthcare (Improve patient outcomes & experience, Lower
costs, workforce satisfaction)

• “Healthcare....is a moral and scientific enterprise, but not

fundamentally a commercial one. We are not selling a product.
We don't have a customer who understands everything and
make rational choices - and I include myself here’’
 ‘’Ultimately the secret of quality is love. You have to love your patient, you have to love your
profession, and you have to love your God. If you have love, you can then work to monitor and
improve the system’’
(Health Affairs-2001)

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Two Types of Change
• Reactive Change (1st order Change)
 Response to sudden problem in the system
 Returns the system to prior condition
 Impact only a few parts of the system
 Short term impact
• Fundamental Change (2nd order Change)
 Create a new system of performance
 Redesign processes
 Impacts various part of the system
 Long term impact
Designed byThe Improvement
Alemu Guide, 2nd Edition – p111-116
Kejela Feb 2021 7
Change for Improvement
When choosing changes avoid:

“Every improvement 1) More of the same

needs change, but • Don’t reinvent the wheel
not every change is 2) Utopia syndrome
an improvement”
3) The perfect solution to the
wrong problem
The Improvement Guide, 2nd Edition – p110-111
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Which is Improvement?

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 Types of Knowledge to Develop
Effective Changes
Types of Knowledge

Subject Matter
Knowledge Profound Knowledge

•Knowledge acquired Profound: Deep insight of

through formal and this knowledge
informal learning and The interplay of the theories
reinforced with experience. of systems, variation,
•Professional knowledge. knowledge, and psychology.

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 Knowledge for Improvement
• The ability to make beneficial changes or improvements is enhanced by
combining subject matter knowledge and profound knowledge in creative
ways

Subject Matter Knowledge

Learn to combine the two

Increased capability knowledges in creative way

to make
to develop effective change
Improvement
for improvement

Profound Knowledge

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The Improvement Guide, 2nd edition – p75c
Kejela Feb 2021
 Knowledge
Deming’s System for Improvement
of Profound Knowledge
• The System of Profound Knowledge
provides a lens. Looking through
this lens allows us to better
understand and optimize our
organizations.

• Describes the System of Profound

Knowledge,
 Four elements of organizations

 That should work together to

become more effective in
leading improvement Dr. W. Edwards Deming(1900-1993)
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The Improvement Guide, 2nd edition – p75c Source : Improvement Guide, Introduction, p xxiv-xxvi
Kejela Feb 2021
Lenses of Profound Knowledge

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The Improvement Guide, 2nd2021
Kejela Feb edition – p76
Appreciation of the System
• Interdependent group of items,
peoples, processes working
together towards a common goal.
 Process: a sequence of
steps/actions through which
inputs from suppliers are ~~~Edwards Deming~~~
converted into outputs for
customers
 System: the sum of all the
part (including processes) that “If you can’t describe what
interact together to produce a you are doing as a process,
common goal you don’t know what you
are doing”
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Appreciation for the System
• Understand the properties of a system .

 Identify elements/units in the system

“If each part of a
you want to improve. system, considered
 Understand functions of each units and separately, is made
to operate as
who know what to do.
efficiently as
 Understand interactions of possible, then the
interdependent units, groups of people, system as a whole
will not operate as
procedures and items in your system
effectively as
 Know how to communicate and possible.”
coordinate Ackoff, 1981
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Do they Appreciated their System?

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Appreciation for the System
• System’s performance is the
results of :
 Its design and operation
 Not simply a result of individuals’
efforts within the system
• Technical tools to understand
a system
 Fishbone
 Process map

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“Every System
Complete is of
each Perfectly Designed
the steps in this to Get the Results
process
it Gets”
NO

Step 3: Do
Step 1: Step 2:
Add 12 to the you have
Pick any number Multiply your
number from step 2 a 2-digit
from 3 to 9 number by 9
number?
YES

Step 6:
Step 7:
Step 4: Step 5: Convert your
Write the name of a
Add your 2 Divide # from step 4 Number to a letter:
the fastest mammal
digits together by 4 to get a 1 1=A 2=B 3=C
in the world that
digit number 4=D 5=E 6=F
begins with your letter
7=G 8=H 9 = I

Step 10: Step 11:

Step 8: Convert your
Step 9: Write down the name
Write down Number to a letter:
Add 8 to your of a country in Africa,
the color of 1=A 2=B 3=C
# from step 5 beginning with the
your animal 4=D 5=E 6=F letter from step 10
7=G 8=H 9 = I

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A “brown-dotted” Cheetah in Kenya

“Every
system is
perfectly
designed
to get
the
results it
gets”
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Large Group Exercise
Appreciation of the System
 In group of 3-5 members
 Considering ER length of stay >24hrs at your facility
 List units involved in this system.
 List functions of each units
 Does each unit know what to do
 Understand interactions of interdependent units,
 How can you communicate and coordinate better in the future

Time: 15 minutes
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Understanding Variation
• Variation exist with the
performance data
• Variation is the voice of the
process
 Learn to Listen, understand it
through data overtime and use
data for improvement
• Example
 How does the number of daily outpatient
visits vary over the days of the week?
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Understanding Variation - Exercise

• Write with your dominant hand, the small

letter “a” ten times on a paper
• Do the same with your non-dominant hand

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Understanding Variation

• Variation is unavoidable
• Common and special
cause variation
 Common cause: inherent in
the process or system
 Special cause: not inherent
in the process or system
The Improvement Guide, 2nd edition – p79-81
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Common and Special Cause Variation
46
Body Temp._ Individual chart
Measure
44

42

40

38
Temp.

Subgroup
Center
UCL
LCL
36

34

32

30
1

10

11

12

13

14

15

16

17
Time

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Theory of Knowledge
2
1 This prediction needs to
The theory of change be tested to learn how
that you introduce is it is influencing the
predicted to lead to
system you are trying
improvement
to improve.

3 4
The application
of plan, do, study, act Comparing predictions to
results is a key source of
(PDSA) cycles help us learning
better learn, innovate
and improve.
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Theory of knowledge cont’d

• A change is a
prediction

• Learning from theory

and practice

• Testing of change –
Plan-Do-Study-Act
cycles

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PSYCHOLOGY – HUMAN SIDE OF CHANGE

• The rate at which improvements spread

relies on people implementing the change in
practice.
• Improvement leaders frequently experience
resistance and struggle to overcome
resistance to change
• When introducing change, it should be made
attractive,
 aiming for something better and
 motivate people
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Psychology of Change

• Reflection
 How do you respond to change in your facility?

 Pair and Share experience with your neighbor

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Psychology of Change
“A square man cannot
be expected to fit in a
round hole right away.
He must have time to
modify his shape.”
- Mark Twain

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Psychology of Change
• Helps to,
 Predict how people will react to change
 Understand behaviors that drive people’s
motivation
 intrinsic and extrinsic motivation

 Avoid blaming the people for the poor outcome,

rather review the process design and its operation.
 Fundamental attribution error
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Psychology in Improvement
• People want to create value
when doing something
• When introducing change focus
on intrinsic motivators rather
than fear and extrinsic
motivators.
• Creating a culture that respects
people and treats them as What drives the fishes to jump to
the bigger containers?
partners galvanizes commitment
to act
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Psychology: Resistance to
Change
• Must I suffer resistance?
• Yes! Resistance is what we want!
 Resistance to change in not a problem—it’s
expected
 Resistance indicates engagement with change
and poses a dilemma about how we will work
together to address it

Source: The Science Behind Resistance to Change: What the Research Says & How it Can Help You, KaiNexus
Presentation by Mark Graban and Mark Jaben

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Psychology: Resistance to Change
• People’s resistance to change comes from
fear.
 Fear of failure, of losing control, of moving from
habit to uncertainty
 Fear of loss: of attachments, structure, future,
meaning & identity

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 N
Resistance to Change-Pyramid
o
t
N w
o il Lack of Motivation to enact the change

N t l Performance Management
o i
n
t a g
Lack of skills to execute the change

b Training
K l
n e Lack of understanding regarding

o
the change
Communication
w Adapted from “The Resistance Pyramid” elaborated from Nieder and Zimmerman by Galpin (The Human Side of Change 1996)

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Interaction of the Four Components

• Improvement is derived mainly

from the interaction of the four
components

• Example:
 You cannot appreciate the
system without considering the
impact on variation

 Including the human side of

change is critical for effectively
building knowledge about
change for improvement

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Kejela Feb 2021 QI Training January 17, 2025 35
Small Group Exercise
• Tena Lehulu Hospital has a long elective surgical cases waiting list which has led to
significant complaints. The hospital has two well-equipped operating rooms
functioning twice a week for elective surgeries. The hospital has 4 surgeons who
alternate to operate on elective cases as per their schedule.

• The hospital director regularly communicates the complaints on the prolonged time
patients are waiting to get a scheduled for the elective surgery. The surgeons justify
the high case load the hospital is accommodating and how busy they are in their
day-to-day activities.

• One day the hospital director wants to discuss the problem with the surgical
department and came up with his regular monthly KPI report. The KPI report states
that, the previous month, the delay for elective surgical admissions was 145 days
while major surgeries per surgeon were only 20. He explained to the surgeons that
they did not even operate 1 case a day while the waiting list is so long.

• Finally, he told them his subsequent expectations of at least 3 surgeries a day from
each of the surgeons which ended the agreement.
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Small Group Exercise

• Work in groups of 4 participants

• Read the scenario in the participant manual
• Answer the following questions
 Describe how the components of profound knowledge were applied in
this scenario
 What did the hospital director do well?
 What could the hospital director have done better, if he had had
knowledge of profound knowledge?
• Time: 35 minutes
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 Case: Long elective surgical backlog
Appreciation of the System Understanding Variation
• concerning the long elective surgical backlog, in the Hospital…
• Concerning the long elective surgical backlog, in the Hospital…
• What are the key processes?
• What data do you have already?
• Functions of each element/process

• Interconnection b/n each element • What is it telling you about the long elective surgical
backlog?

Theory of knowledge
Knowledge of Human Psychology
• Theory of change that will help you overcome the problem • How ready do you think people in your system are for change?

• Knowledge and prediction • Are some people more ready for change than others? -Motivation

Applying PDSA framework • How do you think people feel about the issue you are going to work on?
•
• Is there anything else external that might be influencing the surgical
team?

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Summary
• To be an effective leader of improvement
 Apply the central principles of improvement
 Combine subject matter knowledge with profound
knowledge
 Understand the four components of profound
knowledge and their interactions
 Appreciate differences in people, value teams
 Know that we have poor systems and not poor
performing people

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Thank
you!
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