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Where in the world is improvement science? 5 th October 2012 G. Ross Baker, Where in the world is improvement science? 5 th 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 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 – full view http: //tinyurl. com/ISCworld

Map of IS Centres – zoom on London Map of IS Centres – zoom on London

Map of IS Centres – obtaining details Map of IS Centres – obtaining details

Improvement Science Environmental Scan • Commissioned by the Health Foundation to inform – their 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 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 – 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 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 – 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 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 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 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 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 • 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 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 • 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 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 Ph. Ds 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 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: c 15 Ph. D students; 30 staff who can support Ph. Ds. – 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 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 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 North American centres • Improvement science centres in the US and Canada also vary in scope & activities • Period of origin important in foci – Early centres (1980 s, early 1990 s) 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 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: – – – – – 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 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 2000 s – 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 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 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 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; 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? • 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 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 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 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 Questions? Comments? 34