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					Where in the world is
improvement science?
5th 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
  encompasses quality improvement, patient safety and
  related approaches
• Studies improvement and supporting efforts to improve
  care, translating evidence of effective practice into daily
• Roots in methods developed in industry, as well as new
  approaches to the assessment and application of

Map of IS Centres – full view
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:

   G. Ross Baker           Naomi Fulop
   Kaveh Shojania          Angus Ramsay
   Lisha Lo

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

Methods - database development
• Development of a database of Improvement Science
   – 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

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
   – 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
   – establish research and educational trends
   – identify the current state of improvement science centres in
     England, North American and Europe and opportunities for
     future development


• 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)

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

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
• Little consistency in terms used for “improvement
  science” and related disciplines & methods

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

UK centres - summary

• Almost all UK centres located in university settings

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

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

UK centres - education
• Strong focus at master’s, doctoral, and post-doctoral
• 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

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 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

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: 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
– 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
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 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

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.
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

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
• More recent ISCs driven by interest and funding in clinical
  effectiveness and translational research

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

North American centres – education (1)
• Between 1990 and 2000 many US centres developed
  educational programmes concurrent with their research
   – Short programs on QI/patient safety knowledge and skills relevant
     to clinical practice
• Very few dedicated Master’s programs developed in early
   – Graduate studies in patient safety and QI were part of broader HSR
     programs, often strongly influenced by interests of key personnel

North American centres – education (2)
• However, new Master’s programs have been launched in
  recent years in the US and Canada, with more in
   – 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

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

Summary of Findings
• ISCs increasing in number in UK, Europe and North
• 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

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.

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?

           Continuing challenges

• Are long-term partnerships
  between academic and
  delivery organizations

• What are the effective
  models for such units?

             Continuing challenges
• How can ISCs balance
  institutional imperatives of
  academic and practice based

• How can capacity of IS
  researchers be increased, with
  capabilities required to work
  across disciplinary &
  organisational boundaries?

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?

Questions? Comments?


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