Where in the world isimprovement science?

5th October 2012

G. Ross Baker, University of TorontoNaomi 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

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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:

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G. Ross BakerKaveh ShojaniaLisha Lo

Naomi FulopAngus Ramsay

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

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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

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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

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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

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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)

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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

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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

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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

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UK centres - summary

• Almost all UK centres located in university settings

• 1/3 represent formal partnership between academic and healthcare organisations

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UK centres - research• Key research themes include:

– Evaluation– Innovation– Patient Safety– Measurement– Organization and delivery of care– Public health– Implementation– Knowledge translation

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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

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UK example 1Institute 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

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UK example 2NIHR 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

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UK example 3Social 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 non-clinical 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

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UK example 4IMPLEMENT@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.

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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

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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

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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

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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

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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

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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

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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

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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.

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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?

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Continuing challenges

• Are long-term partnerships between academic and delivery organizations sustainable?

• What are the effective models for such units?

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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?

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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?

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Questions? Comments?

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