Pierre Barker MD
Senior Vice President IHI
Improving Quality: Theories of Change
Basic
science
Proof of
concept
Large
scale
efficacy
Study
What are we trying to solve?
The “What”
Reliable
“real-life”
implement-
ation
Scale-up to
populations
The “How”
Guidelines, Training & Resources,
Adaptive Designs that are context
sensitive
Designs that can be scaled-
up with the resources at
hand
Quality Improvement: Bringing Together
Two Types of Knowledge – (Deming)
Implementation
Knowledge Common view of the System
Motivation/Leadership
Accurate Reflective Data
“Learning by Doing”
Evidence
Based Subject
Matter
Knowledge Protocols/Guidelines,
Physical resources,
Clinical Training
the “what”
the “how”
Implementation
Knowledge
Evidence-based Subject
Matter Knowledge
Improvement
Improvement: Bringing Together Two
Types of Knowledge
Dr. Joseph M. Juran’s “Quality Trilogy” 5
QUALITY PLANNING
QUALITY IMPROVEMENT
QUALITY CONTROL
Juran Trilogy: All three elements are
needed
6
PERFORMANCE SHIFT
Chronic waste (opportunity for improvement)
Sporadic spike
Source: Juran J, Godfrey AB, eds. Juran’s Quality
Handbook: Fifth Edition. New York: McGraw-Hill, 1999.
Juran Trilogy: All three elements are
needed
7
PERFORMANCE SHIFT
Chronic waste (opportunity for improvement)
Sporadic spike
Source: Juran J, Godfrey AB, eds. Juran’s Quality
Handbook: Fifth Edition. New York: McGraw-Hill, 1999.
Juran Trilogy: All three elements are
needed
8
PERFORMANCE SHIFT
Chronic waste (opportunity for improvement)
Sporadic spike
Source: Juran J, Godfrey AB, eds. Juran’s Quality
Handbook: Fifth Edition. New York: McGraw-Hill, 1999.
Juran Trilogy: All three elements are
needed
9
PERFORMANCE SHIFT
Chronic waste (opportunity for improvement)
Sporadic spike
Source: Juran J, Godfrey AB, eds. Juran’s Quality
Handbook: Fifth Edition. New York: McGraw-Hill, 1999.
Policy, resources, coordination, accountability, mandates, etc.
Quality Planning
Components of quality: structure,
quality control and quality improvement
10
Quality
Improvement Rapid cycle
improvement
Motivation
Building knowledge
Continuous data
Standards/ Guidelines/
protocols
Professional oversight
Accreditation
Checklists
Quality Control
(Assurance)
IMPROVED
OUTCOMES
Quality Planning
11
Quality
Improvement Aims
Measures
Changes
Quality Control
IMPROVED
OUTCOMES
QA and “QI” confusion: both can/should
use Model for Improvement
Aims
Measures
Changes
QA Approach
IMPLEMENT STANDARDS
PROBLEM
SOLUTION (DEVELOP
STANDARDS)
Review (Succeed/Fail)
SYSTEM BARRIERS
Context & Local Knowledge
QI Approach
GREAT IDEAS
SYSTEM ANALYSIS
IMPLEMENT
SUCCEED/ FAIL
PROBLEM
Context & Local Knowledge
Rapid Test System
Where do approaches fit on the QA/QI
Spectrum
QA QI Accreditation
COPE
SBM-R
IHI Breakthrough Series
Standards based approaches
Preterm mortality ~60/1000 births
Theory of Change: Drivers of Maternal
and Newborn Survival
Decrease Maternal and
newborn mortality by
50%
Motivation for change
Knowledgeable health workers ready to use their
skills
Immediate access to essential commodities
Data systems in real time
A Learning System Cross-professional teams meet regularly, review data, test changes, report progress
Progress celebrated, challenges supported
Informed/activated patients & communities
Drills, mentoring
Decision support, checklists
Key suppliers part of QI team
Data for improvement vs data for reporting
Data “owned” at every level
Multi-level leaders promote change
Supportive Supervision
Essential QI methods
Data-driven process
improvement
SCREEN TREAT RELIABLE
MEASURES
AVAILABLE DRUGS & SUPPLIES
Systems approach The Gap
% m
oth
ers
rece
ivin
g A
CS
Rapid cycle testing of local ideas
% eligible women received at least one
dose of corticosteroids
2
1
Sustainability
February 2014
June 2014
December 2014
% eligible women received at least one
dose of corticosteroids
Zone of control/assurance QI
Essential QI methods
Phased Scale up
methods
Local leadership
Context-sensitive learning systems
Summary
1. What is the problem we are trying to solve? Context-sensitive implementation and scale up, using
adaptive designs
2. How do you change system performance? Deming – the “what” and the “how” (common systems,
psychology/motivation, reflective data, learning while
doing)
3. A balanced view of quality Juran Trilogy (planning, assurance/control, improvement)