SCIENCE OF

IMPROVEMENT

Federal Ministry of Health of

Ethiopia
 Outlines
• Principles of improvement
• Basis for science of improvement
• Appreciation of a system
• Classification of a system
• Causal web in health care systems
• Knowledge for improvement
• Building knowledge
• Human side of change
 PRINCIPLES OF
IMPROVEMENT
 Change and improvement are tied concepts
• Improvement requires change, but not all change leads to
improvement
• Improvement should be characterized based on a given criteria

 Types of change
o First order change
o Second order change

Federal Ministry of Health Health Service Quality Directorate

PRINCIPLES OF IMPROVEMENT
 Knowledge is essential for QI
 What kind of knowledge?

 Dr. Deming stressed the importance of studying four

areas to become more effective in leading
improvement:
1. Appreciation of a system
2. Theory of knowledge
3. Understanding variation
4. Psychology
Federal Ministry of Health Health Service Quality Directorate
 The Basis for the Science of
Improvement
Appreciation
of a system
Profound
knowledge
gives us a Building
Human
Knowledge
lens to view (Theory of
Side
of Change
our Knowledge)
(Psychology)
organizatio
n Based on
differently Deming’s
Understanding
Variation System of
Profound
Knowledge
Federal Ministry of Health Health Service Quality Directorate
 Appreciation of a
system
 Process vs system

 A process is sets of causes and conditions that repeatedly

come together in a series of steps to transfer input to
outcomes

 A system is an interaction of interdependent group of

items/people/process with a common purpose
 Not only parts but also relation ship b/n parts is important

Federal Ministry of Health Health Service Quality Directorate

 SYSTEMS THINKING
“If you pit a good performer against a
bad system, the system will win almost
every time. We spend too much time
fixing people who are not broken, and
not enough time fixing organizational
W. Edwards
Deming
systems...”
Federal Ministry of Health Health Service Quality Directorate
 Understanding systems

“Every system is perfectly designed to achieve the outcomes it gets”

Ascribed to Edwards Deming

• Organizations are made of departments, people, equipment,

facilities and functions
• Their interaction matters – parts separate efficiency may
not operate the system to its maximum effectiveness
• Management role is to optimize the system

Federal Ministry of Health Health Service Quality Directorate

 How we interpret under-
performance
• Very often when we have under-performance
and failure ,there is an underlying process or
processes that are the cause.

• But usually we try to blame the people involved

and fail to address the underlying processes
9

Federal Ministry of Health Health Service Quality Directorate

 Sheikh et al, 2011,
Federal Ministry of Health PLoSMed Health Service Quality Directorate
 SYSTEMS “HARDWARE” VS.
“SOFTWARE”
Stephanie Topp, 2013
• We often focus on hardware because it is:
• Easier to identify
• Somewhat easier to change
• Significantly easier to measure

• But some of the enduring barriers to quality occur in the

software domain:
• Professional norms and habits
• Lack of a “culture of data”

• Planning for quality improvement should include mapping of

both hardware and software components
Federal Ministry of Health Health Service Quality Directorate
 Group EXERCISE for
hospital teams
• Select a quality challenge and describe
to your partner:
1. Examples of the specific “hardware”
barriers you face
2. Examples of the specific “software” barriers
3. How is the current culture in your
institution address such issues?
Federal
Federal Ministry
Ministry of
of Health
Health Health Service Quality Directorate
 QUALITY “DRIVERS”

Aragon 2010
Federal Ministry of Health Health Service Quality Directorate
 THE IMPACT OF QUALITY -
EXAMPLE
• In 2005, India implemented the JSY program in
response to persistently high maternal
mortality
• JSY was a large-scale conditional cash transfer
program in 9 states, in which women were
incentivized to deliver in health facilities

Federal Ministry of Health Health Service Quality Directorate

 Rates of
facility-based
deliveries
increased
markedly

Randive B, Diwan V, De Costa A (2013) India’s Conditional Cash Transfer Programme (the
JSY) to Promote Institutional Birth: Is There an Association between Institutional Birth
Proportion and Maternal Mortality?. PLoS ONE 8(6): e67452.
doi:10.1371/journal.pone.0067452
http://www.plosone.org/article/info:doi/10.1371/journal.pone.0067452

Federal Ministry of Health Health Service Quality Directorate

 • But there was
MMR no detectable
change in
MMR

Randive B, Diwan V, De Costa A (2013) India’s Conditional Cash Transfer Programme (the
JSY) to Promote Institutional Birth: Is There an Association between Institutional Birth
Proportion and Maternal Mortality?. PLoS ONE 8(6): e67452.
doi:10.1371/journal.pone.0067452
http://www.plosone.org/article/info:doi/10.1371/journal.pone.0067452

Federal Ministry of Health Health Service Quality Directorate

 Thinking about
Systems
We can classify systems according to
• the degree of certainty about the link between cause
and effect
• the degree of agreement about the best course of
action in a situation.
• Simple
• Complicated
• Complex
Federal Ministry of Health Health Service Quality Directorate
 Simple Systems

Federal Ministry of Health Health Service Quality Directorate

 Complex Systems

• Formulae have only limited

application
• Raising one child gives no
assurance of success with
the next
• Every child is unique
• Uncertainty of outcome
remains
Federal Ministry of Health Health Service Quality Directorate
 Complex Systems

Federal Ministry of Health Health Service Quality Directorate

 Health Systems are Complex
Adaptive Systems

• Web-like; No linear causality

• Feedback loops
• Change over time
• Context-specific

Federal Ministry of Health Health Service Quality Directorate

 Causal chain

MANAGEM PATIENT
STRUCT CLINICAL
ENT OUTCOME
URE PROCESS
PROCESS S

Federal Ministry of Health Health Service Quality Directorate

Federal Ministry of Health Health Service Quality Directorate
 Complex Adaptive
Systems:
Context-Specific

• History
matters
• Culture
matters
• People
matter
Federal Ministry of Health
• Relationsh
Health Service Quality Directorate
 How can we get the system to
work better?
Building
Will

 Financing
 Workforce
 Governance
 Drugs and supplies
Methods for  Information systems
 Delivery systems Executing and
Systems
spreading change
Improvement
Federal Ministry of Health Health Service Quality Directorate
 Appreciation of a system

 Key ideas in system theory

 Parts of a system are aligned by a common purpose and
interdependent
 Boundaries of a system
 Temporal effects
 Leverage
 Constraints/bottlenecks
 Unintended consequences
Federal Ministry of Health Health Service Quality Directorate
 Process Analysis and
Improvement

 Eliminate unnecessary steps, or duplication, or steps that do

not add value to the customer
 Identify waste
 Re-order steps
 Reduce hand-offs
 Look for opportunities to run steps in parallel
 Identify and take pressure off bottlenecks

Federal Ministry of Health Health Service Quality Directorate

Bottlenecks
500/30 secs

270/30 secs

170/30 secs

270/30 secs
Federal Ministry of Health
Health Service Quality Directorate
 Bottlenecks

• A bottleneck or constraint is any part of a process

which restricts how quickly things pass through
the process
• Patients can only move through a process at the
pace of the bottleneck or constraint.
• They are typically found where backlogs of work
pile up or people are waiting

Federal Ministry of Health Health Service Quality Directorate

 Knowledge for
Improvement
Improvement: Learn to combine subject matter knowledge and profound
knowledge in creative ways to develop effective changes for improvement.

Subject Matter
Knowledge
Improvement
Profound
Knowledge

Federal Ministry of Health Health Service Quality Directorate

Two Types of Knowledge
Subject Matter Knowledge:
Knowledge basic to the things
Subject we do in life.
Matter Professional knowledge
Knowledge

Profound Knowledge: Profound

The interplay of the theories of
systems, variation, knowledge, Knowledge
and psychology

Federal Ministry of Health Health Service Quality Directorate

 Mental Model:
Individual

Federal Ministry of Health Health Service Quality Directorate

 Building knowledge

 Iterative nature of learning and

improvement (PDSA cycle)
1. Deductive approach (D of PDSA)
 Predictions are made based on the basis of theories,
hypotheses or assumptions
 Rational prediction need theory which is our current
knowledge on how the system works

2. Inductive approach (S of PDSA)

 Foundation of improvement is skillfully
Federal Ministry of Health building
Health Service Qualityknowledge
Directorate
 Human side of change
(psychology)

 Most changes will not happen

without support of people

 People will some reaction to a

change
Federal Ministry of Health Health Service Quality Directorate

Federal Ministry of Health Health Service Quality Directorate
 Human side of change
(psychology)
 Good leaders make  Attracting people to change
people part of solution  Relative advantages
 Difference in people  Compatibility

 Behavior is driven by  Minimal complexity

motivation  Opportunity to try and test
 Fundamental attribution  Opportunity to observe success
errors
Federal Ministry of Health Health Service Quality Directorate
 Understanding variation
 Knowledge of variation needed to take appropriate action
 My malaria medicine starts working
 My new diet works for my child
 My new sport is bringing change
 Importance of plotting data and look for patterns
 Statistical theories needed to differentiate predictable and
unpredictable patterns
 Common cause variation
 Special cause variation

Federal Ministry of Health Health Service Quality Directorate

 Understanding variation
 Need of methods and tools to understand
variation
 Usually using data display and interpret if there are special cause
variations
 Data over time
 Distribution (shape, spread) of data
 Relation ship b/n characteristics
 Location of data
 Multiple measures display

Federal Ministry of Health Health Service Quality Directorate

 Summary – profound
knowledge
 Their importance is derived mainly from
the interaction of components
 Looking all as a whole not separately

 Leaders of QI
 Look for fundamental assumptions and beliefs behind decisions and actions
 Appreciated people difference
 Understand value of team and cooperation, not competition
 Understand that we have bad systems and not bad people

Federal Ministry of Health Health Service Quality Directorate

 Thanks!

Federal Ministry of Health Health Service Quality Directorate