Where in the world is
improvement science?
5th October 2012
G. Ross Baker, University of Toronto
Naomi Fulop, University College London
Improvement Science – what is it?
• Improvement science is an umbrella term that
encompasses quality improvement, patient safety and
related approaches
• Studies improvement and supporting efforts to improve
care, translating evidence of effective practice into daily
work
• Roots in methods developed in industry, as well as new
approaches to the assessment and application of
evidence
2
Map of IS Centres – full view
http://tinyurl.com/ISCworld
Map of IS Centres – zoom on London
Map of IS Centres – obtaining details
Improvement Science Environmental Scan
• Commissioned by the Health Foundation to inform
– their support of improvement science programmes
– the work of the Improvement Science Development Group
• Carried out by:
G. Ross Baker
Kaveh Shojania
Lisha Lo
Naomi Fulop
Angus Ramsay
6
Rationale and goal
• Aims
– identify centres of excellence in healthcare improvement
science in academia/elsewhere
– Identify programmes of research, graduate and post graduate
study, and development and service demonstration projects
– inform HF’s support of improvement science and serve as a
resource to others
7
Methods - database development
• Development of a database of Improvement Science
Centres
– Online search using terms including “healthcare quality”,
“patient safety” and related concepts
– Inquiries also made with contacts in universities and healthcare
organizations in England, Europe, and North America
• Additional information gathered from journals and other
publicly available sources
8
Methods - interviews
• Interviews with representatives of ISCs where
– Improvement science was a central focus
– At least three externally supported grants or a defined program of
teaching
– Moderate to high level of engagement with local health providers
– At least two identified faculty
• Interview topics
– Defining ‘improvement science’
– ISC activity: aims, research, education, collaboration
– Achievements and obstacles
Ethics approval obtained at King’s College London and the University of
Toronto
9
Methods - analysis
• Data analysed to
– produce descriptive profiles of ISCs
– establish research and educational trends
– identify the current state of improvement science centres in
England, North American and Europe and opportunities for
future development
10
Results
• 100 Centres identified through initial on line search
• 82 met inclusion criteria and contacted for interviews
• 43 interviews carried out (18 UK, 18 North America, 5
Mainland Europe and 2 Australia)
11
Core findings
• Centres quite heterogeneous in focus & activities
• Foci often linked to
– interests of lead faculty
– patterns of funding from research councils and similar bodies
• Current funding sources are not secure for many centres,
although some centres have prospered on large
endowments
12
Centres are quite heterogeneous
• Centres have a wide range of foci
– “patient safety”, “quality improvement”, “comparative
effectiveness” and other interests
• Most centres combine research and educational
activities, but a broad continuum in their involvement in
both
• Little consistency in terms used for “improvement
science” and related disciplines & methods
13
UK centres - context
• Prioritisation of “translational research” has spurred
investment in improvement science to address the gap
between evidence and healthcare delivery
• Several initiatives have contributed to ISC development –
e.g. through NIHR
– Collaborations in Leadership in Applied Health Research Centres
– Patient Safety and Service Quality Research Centres
– Programme Grants for Applied Research
14
UK centres - summary
• Almost all UK centres located in university settings
• 1/3 represent formal partnership between academic and
healthcare organisations
15
UK centres - research
• Key research themes include:
–
–
–
–
–
–
–
–
Evaluation
Innovation
Patient Safety
Measurement
Organization and delivery of care
Public health
Implementation
Knowledge translation
16
UK centres - education
• Strong focus at master’s, doctoral, and post-doctoral
levels
• Many centres support large numbers of Ph.D. students
• Many willing to support further doctoral level education
contingent on funding
• Mechanisms developed to build IS knowledge between
university and healthcare environments:
– NIHR CLAHRC diffusion fellows
– NIHR King’s PSSQ Secondee Programme
– Education programmes, e.g. short courses, professional
doctorates
17
UK example 1
Institute of Health & Society, Newcastle University
– Research on patient safety, health economics, behaviour change
– Various contexts, e.g. public health, applied health interventions,
decision making & organisation of care
– Education: many PhDs and Post-doc fellowships (ESRC, MRC, NIHR)
– Also, Health Foundation internships to support promising
undergraduates in continuing education
– Collaboration: partners with local NHS organisations & shares a
joint research with local NHS trust
– FUSE – Centre for Translational research in public health – with 5
universities in North East England
– Has supported a new campus of Newcastle University in Malaysia
18
UK example 2
NIHR CLAHRC for the South West Peninsula
– Research: primary research on clinical uncertainties and how to most
effectively improve services.
– Topics include health conditions (e.g. stroke & hypertension) and
technology (online networks and SMS support groups for teenagers).
– Education: c15 PhD students; 30 staff who can support PhDs.
– short tailored training programmes, e.g. on evidence based practice
– International course on designing and evaluating complex
interventions.
– Collaboration: formal partnership of local NHS organisations and
universities in Devon and Cornwall.
– Involvement of end users and service users prioritised, e.g. groups
covering local approach to drugs and health tech, and public involvement
19
UK example 3
Social Dimensions of Healthcare Institute
– Demonstrates how two organisations can collaborate to build on
each others’ strengths
– Research focuses on patient safety and quality improvement
• social science disciplines in St Andrews (e.g. sociology & anthropology)
• strong clinical focus in Dundee
– Post-graduate education covers students from clinical and nonclinical backgrounds; shared clinical & academic supervisors
– Collaboration: institute is founded on collaboration between two
universities. Further academic collaboration occurs in the UK and
internationally (e.g. UK and US); and there is strong local
collaboration with NHS partners in Tayside and Fife
20
UK example 4
IMPLEMENT@BU, University of Bangor
– Research themes: collaboration, evaluation, service improvement and
methodological innovation, carried out in acute care and care homes
– Considers changes at process and organisational levels.
– Theory development around PARIHS framework.
– Education: professional doctorate for senior health service managers
– Master’s level training on research methods, implementation science
and evidence synthesis. Co-led by the local health board.
– Collaboration: international academic partners, NHS organisations
focusing on acute and long term healthcare.
– Also recently worked with the local police force to translate learning
from healthcare to their setting.
21
North American centres
• Improvement science centres in the US and Canada also
vary in scope & activities
• Period of origin important in foci
– Early centres (1980s, early 1990s) were developed by pioneers
with specific interests in improvement (e.g., University of
Wisconsin and Dartmouth Medical School)
– Much work in this era centered in large healthcare systems and
work by IHI
– Driven largely by immediate practical issues and thus very
applied in focus
22
North American centres, continued
• Following pivotal IOM reports (1999 and 2001), AHRQ
funded centres focused on patient safety
– often collaborations between medical and other professional
schools and academic medical centres (e.g., The Brigham
Center)
• More recent ISCs driven by interest and funding in clinical
effectiveness and translational research
23
North American centres: research
• Key research themes include:
–
–
–
–
–
–
–
–
–
Informatics
Patient safety (broadly)
Medication safety
Safety in specific settings (e.g., primary care)
Policy
Hospital-acquired infection prevention
Design
Measurement of outcomes, performance, quality and safety
Team work and communications
24
North American centres – education (1)
• Between 1990 and 2000 many US centres developed
educational programmes concurrent with their research
programmes
– Short programs on QI/patient safety knowledge and skills relevant
to clinical practice
• Very few dedicated Master’s programs developed in early
2000s
– Graduate studies in patient safety and QI were part of broader HSR
programs, often strongly influenced by interests of key personnel
25
North American centres – education (2)
• However, new Master’s programs have been launched in
recent years in the US and Canada, with more in
development
– Increasing capacity for graduate education, and provide
opportunities to review such curricula
• Other innovative programs, e.g. VA Quality Scholars and the
Harvard Fellowship in Patient Safety and Quality, have
created new educational opportunities
26
Improvement Science in Mainland Europe
• Interviews carried out with 5 ISCs in Europe
• Centres developed in response to local interests and
emerging opportunities
– Chalmers University in Gothenburg developed a Centre for
Healthcare Improvement to support local organisations’ interest in a
more scientific approach to QI
– UMC Utrecht Patient Safety Centre developed due to CEO’s
prioritisation of safety research
– Institute of Health Policy and Management (Erasmus) & IQ Scientific
Institute (Radboud) prioritise new challenges, e.g. global health,
consultancy work and e-communications
27
Summary of Findings
• ISCs increasing in number in UK, Europe and North
America
• ISCs are heterogeneous in scope, activities and size
– Some are “nested” within larger units, with improvement
science only a limited part of the agenda
– BUT such centres have scale to support expanded teaching and
research programs
28
Summary of Findings
• ISCs increasingly focus on specific foci, e.g. patient safety;
thus vulnerable to shifts in funding and research interests
of key faculty
– Support for patient safety research in the US has ebbed, leading
to retrenchment or refocus on supporting health system
education and practice development
– New funding for comparative effectiveness research in the US
will stimulate a focus on outcomes research
– This may result in strong shifts in focus by many centres.
29
Continuing challenges
• Can ISCs develop sustainable revenues to support
research and education?
• Can a graduate curriculum linking improvement science
to underlying disciplinary knowledge (e.g. health
sciences, social sciences, engineering) be developed?
30
Continuing challenges
• Are long-term partnerships
between academic and
delivery organizations
sustainable?
• What are the effective
models for such units?
31
Continuing challenges
• How can ISCs balance
institutional imperatives of
academic and practice based
units?
• How can capacity of IS
researchers be increased, with
capabilities required to work
across disciplinary &
organisational boundaries?
32
Continuing challenges
• How can fruitful epistemological debate be encouraged
that helps identify useful methods and theories to
advance the debate?
• What could be the role of the ISDG in addressing some of
these challenges?
33
Questions? Comments?
34