Where in the world is improvement science? 5 th October 2012

1. Where in the world isimprovement science?5th October 2012 G. Ross Baker, University of Toronto Naomi Fulop, University College London

2. 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

3. Map of IS Centres – full view http://tinyurl.com/ISCworld

4. Map of IS Centres – zoom on London

5. Map of IS Centres – obtaining details

6. 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:

7. 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

8. 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

9. 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

10. 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

11. 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)

12. 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

13. 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

14. 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

15. UK centres - summary • Almost all UK centres located in university settings • 1/3 represent formal partnership between academic and healthcare organisations

16. UK centres - research • Key research themes include: • Evaluation • Innovation • Patient Safety • Measurement • Organization and delivery of care • Public health • Implementation • Knowledge translation

17. 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

18. 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

19. 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

20. 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

21. 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.

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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.

30. 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?

31. Continuing challenges • Are long-term partnerships between academic and delivery organizations sustainable? • What are the effective models for such units?

32. 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?

33. 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?

34. Questions? Comments?