[MUSIC] Hi, I'm Tom Woodcock, module lead for Quality Improvement in Healthcare and this is Dominique Allwood. Dominique do you want to just introduce yourself, remind people who you are? >> All right, so hello again everyone. My name is Dominique Allwood I'm a consultant in public health medicine by background and I have two roles. One is working in the in NHS as a Deputy Director of Strategy and Improvement where I lead the quality improvement team. and I'm Associate Medical Director here at Imperial College Healthcare Trust, and I also work outside the NHS but in health care at the Health Foundation a large UK based charity. >> Great, thanks so much and thanks for joining us today. I'd like to ask you some questions about quality improvement and public health. After all this of course is a public health and quality driven course, but most quality improvement initiatives that I hear about and read about seem to be focused on improving the quality of care that people receive once they are already in the healthcare system. Rather than trying to delay or prevent onset of disease or address people's health related behaviors, or wider determinants of health. But does that mean that we can't use quality improvement approaches to tackle these kind of problems. >> Thanks, Tom. I think it's a really interesting question and one that I've been thinking about for a while, given my background in public health and improvement, and it's sort of colliding of two worlds that I'm really keen to understand more about. And I think you've hit a really interesting question in that there's many approaches to improvement that go on or change that aren't always badged as quality improvement, and those do happen outside of healthcare. But in healthcare we've taken on this mantle of QI, and that approach has been very much borrowed from other industries including manufacturing where you have quite a process orientated way of delivering your service, and so many parts of healthcare align themselves really well to that. In terms of things like elective surgery, planned surgery, and care or treatment through a clinic setting where you have a finite number of people and you know what you need to deliver. So QI is really successful in doing change and improvement using those types of methods. But I think there are ways in which you can apply it to these bigger population health challenges. You talked a bit about prevention or social determinants, and actually if you think about some of the different definitions of quality they are around need and they're around equity. And so I think it's important that we do apply similar thinking and approaches to try and make improvements using some of the same methods, but I do think some of them need adapting. I've seen some really successful examples of how quality improvement method, and improvement approaches have been applied to these broader challenges. A couple of brief ones being one where a fire service work very closely with the NHS to broaden its roles from just tackling fires, to thinking more about health care prevention and prevention of falls. And that was really helpful to have a common set of method across both the fire service and the NHS. And then I've seen other examples of clinicians working in the NHS wanting to tackle some quite big health challenges like poverty and thinking about how might they boil that down to some smaller or more tangible improvement type projects, and use Qi methods and approaches driver diagrams and process mapping to do that, so I think it is possible. >> Thank you, those are some really interesting examples. So how do you set about doing that? How do you set about using a quality improvement approach? And you've mentioned some of the commonly used tools there to work, kind of beyond the healthcare system and make an impact in communities and populations. >> I think that one of the biggest things I've learned from QI is this mantra of think big, but start small. So whilst we might have a huge challenge like obesity or poverty that we want to tackle, you can't do all of that once. And actually if you look at the complexity that there is within that, you need to focus in on a piece of what you want to try and access and work on and try and impact. So acknowledging that the area is very large, but actually what's within your sphere of influence and control might be quite specific. So I think thinking about understanding the complexity of the system and accepting that uncertainty and that complexity is really important. I think that the framework that I've often drawn myself too recently is something called pico, which I think people may have already learned about on this module. Which is about population, intervention, comparator and the outcome. And I think it's really helpful here, because actually what we're trying to do is start with the population so often with quality improvement in healthcare we start with the service. And we say things like how do we reduce the number of did not attend or cancelled appointments? Rather than let's understand our population group, that might be the main group that are finding it difficult to come to our surgeries and clinics. So if you start with a population group like homelessness or some other kind of characteristics, I think that really helps you start to focus on the population rather than the service. The second thing is about the intervention and recognizing that when you're looking at QI with a typical healthcare lens, the interventions are often evidence based they're structured they're bounded. We have things like bundles and they're well described so the change ideas are very obvious, whereas within population health challenges they're often complex, multifaceted, not always known or have a robust evidence base for them so being clear about the interventions and recognizing there might be some limitations on what you're looking at. The third area is around the 'c' the comparator. So in healthcare we often look at benchmarking over time or compared to other people, but I would urge people when they're thinking about more of the population health challenges to think about their comparators being other populations with inequalities or looking at equity. So what's the comparator about comparing population groups and the final one is about the outcome, and so within healthcare we collect a lot of administrative data, so it's very easy to look at proxy measures and process measures to be able to demonstrate our impact and we need to think about what the equivalent is with population health as well, because often these outcomes are quite far down the line in the future and it's very hard to measure those. >> But that sounds that's really helpful. I mean 'cause we often talk in quality improvement about that, the relationship between process and outcome. But it's a real challenge, isn't it when these are so separated in time? So absolutely trying to get some process measures in there. So what do you think the main challenges are then in taking this approach and using it to tackle these big public health issues? And how can we kind of overcome those challenges and get the results that we need to get? >> I think part of it is about understanding that this is a blended approach to taking quality improvement into population health. So, whilst driver diagrams might work really well for some specific problems actually, that's often quite a reductionist approach to be able to say that do these things and they will lead to this, which will lead to that. And as we've mentioned, public health and population health problems are a lot bigger than that, so it might be the driver diagram is appropriate for this project or approach, but it might not be, but equally a process map might be. So I think it's about understanding. which of the tools in the QI toolbox are helpful and useful at this point. And then there are some other disciplines that you can draw into that may not be typically in the QI sphere, but often QI people draw out from people that work in public health, so some of the more community engagement measures and thinking about how you involve people and listen and understand and do the stakeholder analysis work. So I think it's about having a blended approach to improvement, so improvement science is really helpful, but there are wider approaches that you can take to think about your Public health and population health challenges and I've already talked about that mantra of Think Big but Start Small so have some bounded scope and be prepared to take a small chunk or a bite off to start with. Do some rapid tests of change and also be prepared to fail and I think sometimes we get slightly caught up and confused with the difference around improvement and research. And actually within this wider sphere we need to be accepting that we can't have big sample sizes and we aren't here to do big rigorous research projects we're here to do improvement test and fail and move through quickly and that can feel quite uncomfortable, particularly at the level of population health. So I think it's about understanding what's appropriate for that project and drawing on the best parts of quality improvement to do that. >> Having said all that, and you've given us some fantastic examples of where this can work. Why is it then, do you think that there are fewer QI projects tackling these big important health problems? >> Well, I think part of it might be the labeling, so people might be doing improvement or change work, but they might not necessarily call it QI, and so it may be that lots of that's going on. It's just not under the label that we recognize. For some of it, it's about developing those skills and knowledge and capability in quality improvement. There is a specific mindset and toolbox and not everybody has the benefit of being able to have some of that training, and so I think that's really important to develop that and coach and lead others. And in health care in particular we're quite good at starting to think about that capability building. And I think, particularly when you're working across sectors, it's really important to recognize that people have those different approaches to leading change and we're there to sort of help span the boundaries of those things across kind of health care into population health and public health. And I guess the final thing is that not everybody is comfortable with ambiguity and uncertainty, and sometimes find these problems just too big and don't really know where to start, and I often talk about the difference between quality as a navigation versus an exploration. Well, I mean by that is in healthcare it's often a well known challenge with a well known solution, the gap there is about the actual implementation of it. So, for example, we know that ventilator acquired pneumonias have a specific treatment, it's just that we're not always doing it. So, the issue there is that we can put checklists in place, and then if people follow them we will potentially make improvements. Whereas in population health challenges we don't always know huge amount about the problem and/or the solution is quite complex. So, we can't just put checklists in place or navigate our way through a recipe to take us to the end point. We have to explore, and it's not always as defined. And so, not everybody feels comfortable with that uncertainty and the complexity. And it takes a bit of system thinking to think more broadly about what's needed, a bit like some of the work of Deming and others, which I'm sure you will have heard about. So, I guess these challenges feel quite big and wicked, and that's not for everybody, I guess. >> I guess the hope is that some of these tools and frameworks, whether it be from quality improvement or from another field can help us get some traction, help us make some progress to improve health for the populations. >> Yeah, I think it's about just having a systematic approach and thinking about what you want to achieve ultimately, how you're going to get there, how you might know the typical questions and mindset of an improver. And then, the tools will sort of fall from that, but I think it's always worth trying to take an improvement approach for lots of problems that you want to tackle. Irrespective how big or small they are and whether they're more healthcare facing or population health facing, because I think the improvement tool kit and mindset is so wide ranging that it can be really helpful. >> Great, thank you so much, Dominique. That's been really useful and fascinating conversation. So, thank you. >> Thank you. [MUSIC]
