The role of context in
successful improvement
Naomi Fulop, University College London
Glenn Robert, King’s College London
13th March, 2014
Perspectives
on context
A selection of essays considering the role of
context in successful quality improvement
Original research
March 2014
Why this matters?
• Results of QI interventions across health
care systems or within organizations mixed, often disappointing
• Promising interventions implemented in
one setting do not transfer to others, or not
sustained
• With the benefit of hindsight, the usual
explanation offered is ‘context’
What is ‘context’?
• ‘Context is everything’ (Gouldner, 1955)
• The gardening metaphor…..
• “Context refers to the ‘why’ and ‘when’
of change and concerns itself both with
influence from the outer context (such
as the prevailing economic, social,
political environment) and influences
internal to the focal organisation under
study (for example, its resources,
capabilities, structure, culture and
politics).” (Pettigrew et al, 1992)
• Blurred boundaries between ‘context’
and the ‘intervention’?
Which contextual factors are associated with
successful implementation of QI interventions in
health care organisations: A systematic review
• which aspects of context have been found to be
important in the implementation of quality
improvement interventions?
• which aspects are modifiable?
• what evidence is there that these aspects have
successfully been modified, and resulted in
improvement to quality?
Receptive contexts for change (Pettigrew et al, 1992)
How emotional dynamics influence change dynamics (Huy, 1999)
Receptive context for change
Quality & coherence
of policy
Key people leading
change
System level
Environmental
pressure
Supportive culture
Effective
managerial/clinical
relations
Co-operative interorganisational
networks
Macro:
national/regional
healthcare system
Meso: healthcare
organization
Simplicity & clarity
of goals & priorities
Fit between change
agenda and locale
Micro: front-lineline
service/department
Domains
Structural
Psychological
(relating to the
organization of a system)
(relating to mental
phenomena)
Additional factors
Dimensions of literature synthesis (Robert and Fulop, in press)
What we found
• Majority of studies large-scale, crosssectional surveys
• Mostly U.S.
• Most common Pettigrew et al features
– Organisational culture
– Quality and coherence of policy
– Environmental pressures
• Most studies at meso (organisational) level
• Majority studies ‘structural’ cf ‘psychological’
factors – esp at micro level
• Very few studies looking at more than one
level of the system
Some examples of ‘modifiable’
factors
• Most studies not of ‘modifiable’ factors
• Macro e.g. publication of surgeon’s and
hospital’s performance
• Meso e.g. introduction of electronic patient
record
• Micro e.g multi-faceted QI intervention incl
financial incentives improved adherence to
guidelines
The way forward?
• Some recent developments in the field e.g. MUSIQ
• But attention now needed on psychological/emotional context
that facilitates QI
• Piloting the acceptability, feasibility and value of reflective
tools that enable practitioners to take contextual factors into
account before beginning - and during - future QI
interventions
• Designers of future QI interventions need to consider all three
levels of the healthcare system (macro, meso, micro)
• Framework for future research: longitudinal, process-based,
organizational case studies
• QUASER 8 challenges of quality improvement
https://www.ucl.ac.uk/dahr/quaser/QUASER-GuideForHospitals
Source: Kaplan et al, 2012
Structural:
structuring,
planning and
coordinating
quality efforts
Political:
addressing the
politics and
negotiating the
buy-in, conflict
and relationships
of change
designing physical
infrastructure and
technological systems
supportive of quality
efforts
Cultural:
giving ‘quality’ a
shared,
collective
meaning, value
and significance
Emotional:
Educational:
inspiring,
energising and
mobilising people
for quality
improvement
work
creating and
nurturing a
learning process
that supports
continuous
improvement
Physical &
technological:
Leadership:
providing clear,
strategic direction
QUASER: 8 challenges for QI
Managing the
external
environment:
responding to
broader social,
political &
contextual factors
Structural:
structuring,
planning and
coordinating
quality efforts
Political:
addressing the
politics and
negotiating the
buy-in, conflict
and relationships
of change
designing physical
infrastructure and
technological systems
supportive of quality
efforts
Cultural:
giving ‘quality’ a
shared,
collective
meaning, value
and significance
Emotional:
Educational:
inspiring,
energising and
mobilising people
for quality
improvement
work
creating and
nurturing a
learning process
that supports
continuous
improvement
Physical &
technological:
Leadership:
providing clear,
strategic direction
QUASER: 8 challenges for QI
Managing the
external
environment:
responding to
broader social,
political &
contextual factors
Lessons from the Health Foundation
Learning Communities Improvement
Project: context and skills
John Gabbay & Andrée le May
(and Jonathan H Klein & Con Connell)
Background
– The Health Foundation
– Quality improvement
• “Improvement science”
– Organisational learning
• Learning communities/ communities of
practice
17
Improvement Science?
= “proven” improvement methods (e.g:)
18
Underpinned by:
• Working with the willing/early adopters
• Using clinicians’ own data
• Mutual problem-solving “improvement conversation”
• Focussing on one or two key agreed problems
• Doing small tests of change and adjust as you go
• Showing just enough evidence to make the point
• Developing ideas of improvement with the clinicians
• Getting buy-in through early wins and natural spread
19
Methods
– Orientation visit (+topic selection)
– Snowball samples (n=9-13 per “improvement group”)
– SPIBACC (Systematic Prior Interview-Based Analysis of
“Claims & Concerns”)
– Prioritisation of improvement tasks
– “Learning Events” (to introduce “IS” techniques)
– Further interviews (~ 35) + SPIBACC before Learning Events
– (9 Learning Events in total)
– Participant Observation
– Follow up interviews (n=33)
20
Sites
• Exemplary QI (?)
• 2011-12
• 2 x 2 “Improvement groups”
• Furnhills
– COPD
– Dementia (memory clinic)
• Dansworth
– Elderly care
– Dementia (hospital environment)
21
Furnhills
• COPD
• Dementia (memory clinic)
Dansworth
• Elderly care
• Dementia (hospital environment)
22
Context
• External environment
– Continuity
– Targets
• Internal organisational culture of improvement
• Resources, structures and processes
• Leadership
• Local politics
• Relationships: trust and communication
23
Successful
Improvement
?
The Improvement Pyramid
Wasted
Skills fall
resource!
short
The Improvement Pyramid
Skills Fall
fall short
Skills
Short
Implications
• Organisational & personal skills are essential for handling context
• They are an essential precursor to the application of “hard” IS skills and
must be well developed if the latter are to succeed
• Learning communities are an effective way to help meld those sets of
skills
• Learning communities function more effectively when facilitated
especially when community learning skills are weak
• Achieving sustained improvements with IS may require specific
interventions
– for learning soft skills
– to systematically facilitate the QI process (SPIBACC) so as to get
“inside” the contextual concerns and deal with them
27