Sustainably Improving Health Care

Creatively Linking Care Outcomes, System Performance and Professional Development

Paul Batalden, Tina Foster

• Publisher: CRC Press
• Year: 2022
• ISBN:
  9781000605006
• Edition: 1
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

Culture, Context and Quality in Health Sciences Research, Education, Leadership and Patient Care (Second book in a series of five) Sustainably Improving Health Care promotes the importance of integrating improved care outcomes, system performance, and professional development so that the future of health-care advancement is creative and sustainable. It addresses the challenge of creating and nurturing a culture of continuous improvement that is able to sustain and generate creative professional work for the improvement of health care. Using real-world examples, the book succinctly reveals how the model can be practically applied from a variety of different perspectives. "This book makes the persuasive argument that well-intended efforts to redesign and reform health care will enjoy only short lives without the full commitment and engagement of the health-care worker - the product of the sustainability- and capacity-building engine of professional development." Dave Davis MD, CCFP, FCFP, in the Foreword "This book is about a model that has emerged from our own work, our observations of the work of colleagues and others, and our refl ections about the requirements for the future of the continual improvement of health care. We explore its origins, its content and manifestations, and its implications, particularly for health professional leaders interested in the ongoing improvement of health care. Form and vitality develop in the model as it engages reality - the reality of trying to create cultures of sustainable, generative approaches to the ongoing improvement of health care." From the Preface

1

The Evolutionary Beginnings of the Model

Paul Batalden

The presenters at a recent improvement conference were describing all the improvement teams in their organization and the challenges of actually improving outcomes for patients. They were getting more and more animated as they described the growing maze of logistics needed to support their efforts. I had just met some well-motivated mid-career physicians and nurses who were trying to improve their care and they were frustrated, finding it hard to get the interest and attention of colleagues that everyone respected. Something clicked as I considered these two “conversations” and I began to listen with different ears, suddenly able to hear and see the fatigue induced by improvement exhortations and endless measurement. I had new insights into the burnout of the good doctors and nurses I met. I heard about the limited successes and frustrations of leaders trying to “incentivize” participation in improvement efforts in a new way. I realized that our invitations to participate in the improvement of care were adding one more thing to already over-full health professionals’ lives. We were coming at this from the social and organizational need, bringing real excitement about ever-new ways of doing this work. But we were not engaging professionals in the improvement of health care from within their own efforts to have a meaningful professional life. I realized we needed to rethink what we were doing, if we hoped to create a sustainable, generative process of improvement.

During the twentieth century, new ways of creating better quality, safety, and value were developed in both manufacturing and service sectors of the economy. As the leaders of these changes advocated new ways of measuring and new ways of analyzing and changing work, generalizable notions and theories of work, workplace, worker, and beneficiaries of work emerged.^{1, 2, 3, 4, 5, 6}

At the seminar I attended in Atlanta, GA, in 1981, W. Edwards Deming was talking about ball bearings, manufacturing processes, and measurement. I began to wonder why my physician colleague and I had come. The room was full of engineers, some of whom were smoking. We seemed to be the only health professionals. What did all this have to do with health care? That night, my colleague and I took Dr. Deming to dinner. He talked of his experience with his wife’s Alzheimer’s care and the health professionals and the care settings. The next day, I realized his message was not about ball bearings, manufacturing processes, and measurement: it was about an underlying theory of work, worker, and workplace. Ball bearings and manufacturing were only the language being used.

For these quality pioneers, the phenomenon “quality” included the quality, safety, and value of services and products, and when all of these were at stake, it was clear that it was a matter of design. These key characteristics of the product or service were central to the creation and production of the work itself. Quality was no longer just the concern of inspectors and regulators. Because “quality” connected to every aspect of an organization, it became increasingly clear that it was part of the work of top leadership and the way entire organizations functioned.

As these phenomena became manifest in health care, new approaches to improve and change were connected to new ways of measuring outcomes in individuals and in populations. New roles and processes for accrediting, regulating, and standard-setting bodies emerged.^{7, 8, 9} Exploring the “usual” ways of work in these new ways revealed nearly infinite opportunities for change and redesign.

One day my nurse colleague Connie said, “You know you draw the same pictures about the anatomy and about your recommendations for surveillance for the parents of these little girls with their first urinary tract infection and I stand outside at the desk and complete the same lab forms and instructions for collecting urine cultures … What if we printed some of this out ahead and asked the parents to fill in the demographic information on the slips – so we could use our time to have more complete, more effective, and more efficient conversations with them?” She was inviting me to explore and change the process I used in my professional work as a physician.

By the closing decades of the last century, these new ways of making improvement were exploding. Methods for teaching about health care as process and system, about measurement for learning and for reducing unwanted variation, and about facilitating and leading the work of small, multidisciplinary groups working at the front lines of health care became widely available.

Early-adopter leaders realized the possibilities and committed themselves and their organizations to action. Gradually “Flowcharting 101” became process literacy; “Meeting Management 102” became more effective work teams; “Customer Expectations and Satisfaction Measurement 103” became better focus on patient outcomes. Work on the “processes-as-they-were” made people realize the inherent unreliability, undependability, and unwanted variation that was rampant in health care. It was fun to see the discovery and satisfaction that came from being able to make a change and learn from it.

Connecting this newfound local process literacy with generalizable science and the improvement of clinical outcomes began to push our understandings of the complexity of it all.

In 1984, we started with improving the care for patients who were having hip replacements. The process of selecting the patients, anticipating the rehabilitation and recovery processes, selecting the most appropriate prosthesis, and so forth revealed how interwoven and how many choices were a part of routine patient care. As we moved to other conditions and mapped those processes we began to recognize patterns of changes that could be considered for any clinical process.¹⁰ We also began to recognize the emerging cacophony around outcome measurement, leading us to think of a generalizable frame for these measurements we called a “value compass.”¹¹

We were realizing that designing and testing changes that attracted local energy and resources was an almost infinitely creative challenge. The love of the challenge attracted wonderful colleagues … and their excitement and enthusiasm helped their local communities join in the early change-creating work.

Networks of early adopters emerged to facilitate exchanges of learning. Sharing occurred at all levels in health-care service settings: chief executive officers, chief medical officers, chief nursing officers, and those in quality improvement resource jobs – “coaches” and facilitators of the changes. People were proud of what they were learning and were eager to share their insights with others. Consultants were busy at work – with few in health care initially. In a relatively short time, that changed and soon there were consultants of every kind available.

National and international forums were started. Soon there were established connections within and across organizations, local communities, and countries. A common spirit of cooperation and discovery characterized the emerging community of practice. Presentations of the “best local work” were given with pride and received with gratitude … soon to be adapted and tried elsewhere. By many measures, it was an impressive first decade or so. People really seemed to understand by the systems and processes at work in producing the results caused (in part) health-care outcomes.

These new ways of understanding complex work were almost endless. One top leader team in a hospital got so interested in understanding the process of getting a snack for patients in the middle of the night that they spent 9 months flowcharting all the possibilities! Once we understood how profound our “process illiteracy” was and how much variation there was from day to day and patient to patient, we began to get curious about all the “special cause” contributors and to the myriad “common cause” contributors of that observed variation. The people with the most insight were usually those closest to the work – but they were busy health professionals, many of who were in voluntary organizations. None of this was yet being taught in undergraduate or graduate health professional education. How was this going to remain vital for the long term?

In local settings, the first invitation to health professionals to participate was met with some skepticism, but the allure of “new knowledge” and “new ways of looking at familiar issues and problems” attracted the curiosity and creativity of the health professional community that knew change was needed but had struggled to make it happen. The second invitation to participate in the work of improvement was more focused and sophisticated. The third was recognizable as “one of the interesting ways we do things here.” The fourth and fifth began to feel like all-too-familiar exhortations to do more and more. People were beginning to wonder how many invitations they should accept for their lunch hours, their days, and their shifts off. Soon it became possible to discern signs of “improvement fatigue.” Slowly it became more difficult to get the right people involved, teams took longer to get their meetings scheduled, intervals between team meetings got so long that it became hard to remember exactly what had happened at the last meeting. In some places, “forming an improvement team/project” became code-talk for slowing things down, or for eventually letting things die of process-correct exploration.

A colleague had just gotten an example of this new way of looking at the work and successfully introducing a change in a high-impact journal! As he debriefed the experience, he described how none of the peer reviewers thought he should mention anything about the process analysis, nor should he mention anything about iterative cycles of change that he had actually used, nor should he use so many time-ordered data sets and analytic statistics to explain the variation he encountered, nor should he talk about the multidisciplinary teams he had assembled to work on the overall process, nor should he describe anything about the context in which these changes were brought about. The “quality” journals wanted examples of “audits” or “medical care evaluation studies” or other “assessment” reports. How was this activity going to develop as a form of science? The usual peer-reviewed scientific health-care literature was not yet very helpful.

Realizing that differences in outcome in differing settings came from differences in systems and processes in differing and particular local contexts challenged our dominant ways of reporting about improvement – as a science. Peer reviewers and editors wanted reports of controlled experiments – but each setting had its own identity and that identity was often in a reflexive interaction with the interventions that were being tested! We were confronting the paradox of seeking the development of this new work as science in an epistemological tradition that seemed inimical to that development! Peer-reviewed publications were the language of the professional education community. The high-impact journals were set up to screen out the early reports, but a few health professional educators were beginning to take notice and had begun to explore teaching these ideas despite already over-stuffed curricula. Those teachers began to network and to work as a community of practice.

The first time that the Dartmouth–Institute fo...

Table of contents

• Cover
• Title Page
• Copyright Page
• Table of Contents
• Foreword
• Preface
• About the Editors
• List of Contributors
• 1 The Evolutionary Beginnings of the Model
• 2 Better Patient and Population Outcome: Practical Approaches that Health Systems Can Adopt for Measuring the Health of Patients and Populations
• 3 Better System Performance: Approaches to Improving Care by Addressing Different Levels of Systems
• 4 Better Professional Development: Competence, Mastery, Pride, and Joy
• 5 Teaching the Triangle: The Dartmouth-Hitchcock Leadership Preventive Medicine Residency Program
• 6 Simple, Complicated, and Complex Phenomena in Health Care: Using the Triangle to Improve Reliability and Resiliency in Health-Care Systems
• 7 Faculty as Coaches: Their Development and Their Work
• 8 Governance, Leadership, Management, Organizational Structure, and Oversight Principles and Practices
• 9 The Triangle and Undergraduate Medical Education
• 10 Triangle Synergies in a National Quality and Safety Education Initiative in Nursing
• 11 Collaborative Improvement of Cancer Services in Southeastern Sweden: Striving for Better Patient and Population Health, Better Care, and Better Professional Development
• 12 Contributing Authors' Reflections
• Index