Published on June 21, 2013
From Theory toImprovement: A conceptualframework for deliveringimprovements in healthcareJulie Reed, Cathal Doyle, Cathy Howe, Derek BellNIHR CLAHRC for Northwest London
Collaboration for Leadership in Applied HealthResearch and CareNational (~£90 million, 9 programmes)• Conduct high quality applied health research• Translate the findings from research into practice• Increase the capacity of NHS organisations and public,private and third sector partners to engage with and applyresearchNorthwest London (£10 million 2008-2013)• Systematic approach to delivering improvementsNIHR CLAHRC for Northwest London
Northwest LondonPopulation = 2 millionBudget = £3.4 billion400 GP practices14 different NHS TrustsMost ethnically diversepopulation in UKVery wealthy and verypoor = 17 years differencein life expectancy
CLAHRC NWL ApproachQualityImprovementQuality Improvement MethodsPatient and PublicInvolvementEngaging Patients and StaffResearchRigorous Design and Use ofDataEducationTraining, Support andCollaborationA collision of different worlds…NIHR CLAHRCFor Northwest LondonHealth OutcomesPatient ExperienceImprove health outcomes and patient experience through delivery ofclinically effective care.Primary aim:4 Rounds: 21 Projectsover 55 Sites engagingover 500 NHS staffsystematic approach
CLAHRC NWL AchievementsBeneficial impacts on care quality, outcomes, experience and costs• COPD discharge care bundle:– Improved compliance with „best care‟ (from 0% baseline - 70%)– reduced length of stay (e.g. by 2.5 days)– costs savings (e.g. estimated at £123,410/year)• Medicines Management:– ADR identification (e.g. 70% potential ADR)– medication reduction (e.g. 52% meds)– cost avoidance (e.g. estimated net £145,000/yr)– co-designed “My Medication Passport” (paper & app, c.9,000 copies)• Diabetes Improvement through Peer Led Education (DIMPLE):– Built capacity: 31 “community champions‟, 6 peer educators and 9 peer mentors– engaged over 9,182 people through 352 events inc BME groups,– Social return on investment estimated at £11 for every £1 invested.Demonstrated Patient & Public Engagement & Involvement benefitsInclude (3 examples):
Cycle forImprovement1.Patients &CarersExperience&Outcome2.Identifyneeds3.Priorities4.IdentifySolutions5.ImplementExperimentalMedicineRandomisedControlled TrialsBasicSciencesPublic HealthStatisticsSociologyPsychologyManagementEducationEpidemiologyHealthEconomicsEngineering
What did the literature say?• What, where, who & how?
What improvements should be made toimprove care?• Translating Medical Research into Practice• Multiple evidences need to be considered at once –continual growth of EBM• Evidence needs to be relevant to local contextconsiderations• Staff and patients are not passive recipients,individual, group perceptions affect uptake,acceptance & behaviour• Translation is not a linear process
Where does improvement take placeand who is involved?• Healthcare systems and context• Healthcare complex multi-level system• Healthcare is an organic/social system –relationships, identity, power, emotion (inc stress)• Quality of care is dependent on collaborationbetween multiple individuals as well as individualbehaviour• Care is delivered by many individuals andorganisations• Perpetually evolving and adapting, unpredictable
How should improvement take place?• Change management and high performingorganisations• Knowledge management and valuing knowledge –external and internal• Value staff and patients – necessary engagement• Political alignment (shifting political landscape)• Continued learning and feedback loops –responsive and dynamic
What? Where and who? How?3 separate perspectives on improvementWhat should be done to improve care/improvementsshould be made?Where does improvementtake place andwho is involvedHow changeandimprovementshould takeplaceConsidering 3perspectivestogether….
What should be done to improve care/improvements should be made?Where and whoHowUnderstand andutilise existingknowledgeCapture andProduce newknowledgeIterative developmentReveals the complexity and overlap/interdependency of these 3 different perspectives(shows the 12 objectives plus 4 extra concepts (internal knowledge, org memory, external knowledge, researchand evaluation) which help expand the knowledge/acting scientifically theme)InternalknowledgeExternalknowledgeOrganisationalmemoryResearch andevaluationUnderstand systemand servicesUnderstand VariationIdentify SystemicIssuesFreedom to act andlearnActive engagementFacilitate dialogueResourcesandHeadroomPoliticalandStrategicAlignmentInvest in ContinualImprovement
Conceptual Frameworkfor delivering improvement in healthcareAct scientificallyandpragmaticallyEngage andempowerEmbraceComplexitySupport for longterm successUnderstand and utilise existing knowledgeIterative DevelopmentCapture and produce new knowledgeActive engagementFacilitate dialogueFreedom to act and willingness to learnUnderstand services and processesUnderstand variationIdentify and act on systemic issuesProvide headroom and resourcesPolitical and Strategic AlignmentInvest in continual improvementValuesPrinciples
Implications• Recognition of the complexity of theproblem• Need to move the research agenda to the‘black box’ of improvement• Value (necessity?) of transdisciplinaryworking and multiple perspectives• A framework that is applicable in allsituations but it’s counter-cultural!
CLAHRC NWL QI tools and methodsSystematic andscientificapproach toimplementationusing qualityimprovementtools andtechniques
NIHR CLAHRCfor Northwest LondonFind us at…W: www.clahrc-northwestlondon.nihr.ac.uk/homeE: email@example.comT: @CLAHRC_NWLFind me at…W: www.cathyhowe.netE: firstname.lastname@example.orgT: @cathgreenhalgh
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