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