Although the debate about what exactly constitutes Improvement Science research continues, The Health Foundation, a leading funder, proposed three distinct categories, providing a helpful way of understanding Improvement Science and the research that is being undertaken in this emerging field:
- Research about improvement science – the study of how improvement work is undertaken;
- Research using improvement science methods – studies that assess the use of specific quality improvement methods or approaches;
- Research to create frameworks, models and concepts related to improvement science – the development and exploration of concepts in Improvement Science.
At CLAHRC Northwest London, quality improvement (QI) projects within the local NHS are our vehicles for testing and exploring the use of QI methods and approaches. Data generated from these projects offers CLAHRC Northwest London the unique opportunity to undertaken research across all three areas. Research provides valuable insights into how improvement work is undertaken, the roles of different QI tools, methods and approaches and also the development conceptual frameworks and models to support future improvement endeavours.
At our February research partners meeting we heard from two researchers about Improvement Science research that had been undertaken at CLAHRC Northwest London.
Planning Measurement for Improvement: Getting the most out of your data
Yewande Adeleke, from the Public Health and Information Intelligence team, reported on a Health Foundation funded study led by Dr Tom Woodcock. The study aims to create a web-based tool to help healthcare quality improvement teams to effectively plan measurement strategies, which are crucial in supporting and evaluating improvement endeavours. As part of the development of this tool, the team undertook a two-round modified Delphi survey to establish consensus on the content of the tool by engaging experts in the field.
The survey enabled the team to scale back the number of items that were initially identified for inclusion in the tool by one third and identified 5 overarching concepts:
- The design of measures;
- Data collection and management;
Like with many tools designed for use by practitioners, not just researchers, the development of the new tool needs to be carefully balanced, to ensure it is comprehensive but also pragmatic to support use in the field. This tool aims to offer an important contribution to QI planning, especially in supporting improvement teams to develop good measurement plans.
Although the next step for the team is the creation of the web-based tool, this has also provided an opportunity to reflect on the rigorous measurement planning approach CLAHRC Northwest London has developed over the last 8 years. The CLAHRC approach to working with NHS staff to support them to engage with improvement data, especially through the use of the Web Improvement Support for Healthcare (WISH), could provide some real insight that may be useful in developing the tool.
Future plans include testing the tool with current improvement projects that CLAHRC Northwest London support, introducing a further level of rigour to data collection and analysis and providing an opportunity to gather feedback about its utility.
Furthermore, there may also be future opportunities to influence how organisations collect data for QI, which is currently achieved predominantly through CQUIN (Commissioning for Quality and Innovation) or NCA (National Clinical Audit) mechanisms.
Exploring the use of Process Mapping in practice in the healthcare sector
Dr Grazia Antonacci, from the Quality Improvement and Improvement Science team, presented on the work she recently undertook at CLAHRC Northwest London for her PhD that was supervised by Dr Julie Reed and Professor James Barlow in collaboration with the University of Rome Tor Vergata. Dr Antonacci’s work explored the role of process mapping in healthcare, first through a systematic review, then followed by a qualitative study of QI project in the NHS that are supported by CLAHRC Northwest London.
Process mapping can be defined as a methodology to analyse and better understand the systems and processes in which improvement interventions may be introduced. The origins of process mapping can be ascribed to Frank Gilbreth (American Society of Mechanical Engineers – 1921). The use of mapping techniques then rapidly increased in the manufacturing field as well as in service industries and included application in many domains (quality improvement, business engineering, development of information technologies etc.). The popularity of the use of process mapping in healthcare is undoubtedly linked to the need for an approach to share knowledge and experience of processes across a wide range of stakeholders, especially in increasingly complex healthcare systems. Despite the widespread use of process mapping there are no systematic reviews of its use in healthcare, as such Dr Antonacci identified and reviewed more than 60 empirical studies that used process mapping in healthcare, of which nearly two thirds were published since 2010. This review offers a novel contribution to the literature on process mapping and identified several deficiencies, especially related to the poor involvement of stakeholders (particularly patients) and poor training in process mapping techniques.
The findings of the systematic review were subsequently used to inform a qualitative study to explore the use of process mapping by QI projects supported by CLAHRC Northwest London. Interviews were undertaken with NHS staff and identified that process mapping was undertaken in a wide variety of settings for numerous reasons, with a particular emphasis on the need to:
- Improve communication between different professional groups or organisations;
- Develop consensus and a shared understanding of how processes actually occur in complex systems;
- Promote patient-centred care by supporting dialogue between healthcare professionals, patients, and their families.
As this study outlines, whilst there is no single consistent approach to process mapping, the need to involve stakeholders across professional and organisational boundaries are crucial and often require leadership to achieve this. So despite the potential benefits of using process mapping, a more structured and informed approach is required.
Both researchers eloquently outlined the need for Improvement Science research. CLAHRC Northwest London recognises that despite the wide use of many QI methods and approaches, such as process mapping and measurement strategies, there are still gaps in our understanding of how these methods are currently used and what contribution they make to improvements. Furthermore, it is necessary to identify ways in which the methods and tools can be enhanced to be more effective whilst remaining practical.