We are awash with improvement methodologies, frameworks, models and toolkits aimed at embedding quality improvement in healthcare. Everywhere I turn I am bumping shoulders with Kaizen, Lean, the Model for Improvement Six Sigma, the NHS Change Model…and the list goes on. In an effort to make pragmatic choices within such abundance I often hear advice along the lines of “It doesn’t matter which methodology you choose, just choose one and use it consistently.” And this is reasonable advice based on the principle that following an evidence-based improvement methodology is better than following none at all. Each methodology takes a very different ideological approach towards improvement (e.g. Lean focuses on reducing system waste; MfI on small scale iterative improvement) but at the core of all is the ethos of continuous learning. (As it happens the terms ‘learning’ and ‘improvement’ are often used interchangeably in the quality improvement (QI) arena. To say we have improved implies that we have learnt and the implications of this subsummation is something I would like to explore further in another blog).
I have been involved in designing quality improvement learning for over six years and during that time there has been some (but not enough) discussion and reflection on how learners learn within the context of improvement. The focus upon the ‘what’ of QI – What methodology should our organisation use? What is the content of the QI curriculum? What tools and techniques can we package to assist with the implementation of improvement projects? – Has not always been extended by a dialogue around the ‘How’ – How do we become continuous learners? How do we enact improvement? How do we teach improvement in such a way that it is transferred effectively into healthcare organisations? How do we develop a pedagogy for improvement?
It is therefore very encouraging to see the work of Bill Lucas (Centre for Real-World Learning at the University of Winchester) with Hadjer Nacer (The Health Foundation) which presents some weighty challenges to the QI community and in doing so raises the profile of teaching and learning as a key disciplinary function for improvement. Lucas’s thought piece The habits of an improver: Thinking about learning for improvement in health care and the webinar, Getting into the Improvement Habit, details efforts both to understand the current learning landscape for QI and start a dialogue about new ways of conceiving QI teaching, learning and assessment. Within the context of Mid Staffs and Don Berwick’s imperative that the NHS must become a ‘learning organisation’ Bill Lucas asks
“So why is it apparently so hard for the NHS to take learning seriously and for improvement to become the watchword of everyone in the service when it has so explicitly been linked to reducing harm? There are many reasons. Lack of time, lack of resources, lack of understanding and lack of confidence are just four typically given. But we wonder whether there is something else of note going on here. Perhaps ‘improvement’, like ‘learning’, is just too big a concept for people to comprehend? As a consequence, therefore, improvement tends to become ‘an improvement project’. Or, at an even more precise level, a single plan-do-study-act (PDSA) cycle.”
Often there is an unintended disembodiment in which the lived experience of the improver does not synchronise with the way in which QI is taught and learnt. It is unarguably valuable (to an extent) for an improvement practitioner to understand the underpinning theory and have a set of tools and techniques with which to implement change. But in focussing on these more tangible aspects of QI, and in trying to reduce the complexity inherent in improvement, we often sidestep thinking on what it means to be an improver; to actually embody improvement.
Lucas suggests a tilting of the current axis of thinking in which the habits of an improver (aligned with the knowledge and skills they need) become the conduit into QI teaching and learning. He details five habits (Learning; Influencing; Resilience; Creativity; Systems Thinking) and goes onto suggest that improvement develop its own signature pedagogy (a distinctive pedagogical approach which signals specific ways of thinking about a profession). This might then be combined with “better matching of method to desired learning outcome and better use of evidence of effectiveness in selection of teaching and learning methods”. This last point is crucial and, I think, has yet to be fully explored in the context of QI. There is an opportunity to foreground the practice of teaching and learning to co-produce new curriculum and experiment with different modes of teaching and assessment. In so doing we might consider how we reflect the ethos of ‘improvement’ and not ‘judgement’ in the way we design assessment (e.g. can we think creatively about iterative assessment?). There are a plethora of evidence-based and innovative teaching and learning methods to experiment with. The affordances of blended and networked learning should be a part of the conversation alongside approaches such as games-based learning and a consideration of digital literacies.
Lucas’s report has been framed as the start of a conversation –and it is an essential conversation. It provides opportunity to align the subject expertise within the field of QI with the rigour of evidence-based educative approaches. I will listen, observe and contribute with great interest.