Improving Improvement

The pressures facing the health and social care system are considerable and the complexity of the system makes improvement challenging. In recent years there have been numerous calls for the use of a systems approach in efforts to transform health and care. However, until the publication of the Engineering Better Care report by the Royal Academy of Engineering, there had been a lack of a clear definition of what this might mean in a health and care context.

The Engineering Better Care report aimed to describe the engineering systems approach and explore, in partnership with healthcare leaders, whether such an approach could be applied to health and care. While healthcare professionals know intuitively that there is a need to involve stakeholders in decisions and think across pathways, and many people working to improve health and care are aware of and use systems techniques, lessons could be learned from the different perspectives of the engineering sector and the analysis and rigour applied in engineering systems. The Engineering Better Care report was based on an extended conversation within a unique forum of experts, in collaboration with the Royal College of Physicians and the Academy of Medical Sciences. It brought together systems engineers, health and care professionals, quality improvement experts, and patient representatives to develop a new and integrated systems approach for health and care service design and improvement.

The framework and tools described in the Engineering Better Care report aimed to stimulate conversations with funders, healthcare provider leaders, teams and individuals delivering quality improvement and service design. This toolkit is the direct result of these ongoing conversations and work continues with the Royal Academy of Engineering, the Royal College of Physicians, the Royal College of Anesthetists, the Academy of Medical Sciences and the Health Foundation, led by the University of Cambridge Engineering Design Centre, on its development and application to improvement practice.

Engineering Better Care describes the development of a systems approach to health and care design and continuous improvement, taking inspiration from both the healthcare and engineering sectors. It takes a broad view of systems (or systems of systems) as a set of elements that include people, processes, information, organisations and services, as well as software, hardware and other systems that, when combined, have qualities that are not present in any of the elements themselves. It then proposes that a systems approach is a process that integrates four key and complementary perspectives:

• People: understanding of interactions among people, at the personal, group and organisational levels, and other elements of a system in order to improve overall system performance
• Systems: addressing complex and uncertain real world problems, involving highly interconnected technical and social elements that typically produce emergent properties and behaviour
• Design: focusing on improvement by identifying the right problem to solve, creating a range of possible solutions and refining the best of these to deliver appropriate outcomes
• Risk: managing risk, based on the timely identification of threats and opportunities in the system, assessment of their associated risks and management of necessary change.

Each of the four perspectives of people, systems, design and risk can be seen as individual components within an overall improvement process. However, while each uniquely contributes to a systems approach, they are inextricably linked and the challenge is to integrate them within a useful, versatile and systematic process that repeatedly delivers results. The Engineering Better Care report presents the improvement process as an ordered set of questions, based on the individual perspectives, that should be asked until the current system is improved to delivered something measurably better into service. That sequence of questions has been extended to introduce questions related to the management of the improvement process. More details are provided in the Engineering Better Care section of this toolkit.

Engineering Better Care is complimentary to many other improvement approaches and an improvement programme may include elements from any or all of these models:

• IHI Model for Improvement: adopted by the Institute of Healthcare Improvement as its primary framework for accelerating improvement in healthcare
• Lean Thinking: developed at Toyota in the 1950s to create the Toyota Production System, a strategic approach that focuses on dramatically improving flow in the value stream and eliminating waste
• Six Sigma: developed at Motorola in the 1980s, to focus on removing the causes of defects and reducing variation in processes
• Flow Coaching Academy: a virtual/digital action-learning approach to delivering meaningful change within the UK National Health Service
• Quality, Service, Improvement and Redesign: a service improvement programme that has been delivered over many years to hundreds of staff involved in healthcare
• Improving Improvement: a pragmatic systems approach to health and care design and continuous improvement based on the Engineering Better Care report.

The questions that emerged from Engineering Better Care were always intended to complement other approaches to improvement and transformation already prevalent in health and care, adding new perspectives and value to existing expertise. The original report also captured the strengths and weaknesses of a number of exiting healthcare and engineering improvement tools and, while the list of tools included was not exhaustive, highlighted the benefit of drawing such methods together¹.

The following sections briefly introduce a number of the better known improvement approaches, illustrating their key features. This is preceded by a summary of Engineering Better Care and an introduction to the Improving Improvement Toolkit which is based on this report and a Quick Start Guide to use the approach. The purpose here is to show potential synergies between these approaches, rather than to advocate the use of a particular framework or method. More detailed analysis of the IHI Model of Improvement, Lean Thinking and Six Sigma also shows the potential of using a systems approach to enhance the power of these tools in the improvement and transformation of complex systems. A number of important topics of relevance to all improvement approaches is also presented.