How do we learn about improving health care: a call for a new epistemological paradigm

Abstract

Purpose: The field of improving health care has been achieving more significant results in outcomes at scale in recent years. This has raised legitimate questions regarding the rigor, attribution, generalizability and replicability of the results. This paper describes the issue and outlines questions to be addressed in order to develop an epistemological paradigm that responds to these questions.

Questions: We need to consider the following questions: (i) Did the improvements work? (ii) Why did they work? (iii) How do we know that the results can be attributed to the changes made? (iv) How can we replicate them? (Note, the goal is not to copy what was done, but to affect factors that can yield similar results in a different context.)

Next steps: Answers to these questions will help improvers find ways to increase the rigor of their improvements, attribute the results to the changes made and better understand what is context specific and what is generalizable about the improvement.

Keywords: complex adaptive systems; delivery; implementation; improvement; learning.

Figure 1

Codifying improvement.

Figure 2

The aim of the improvement was to increase the proportion of HIV patients who received middle-upper arm circumference (MUAC) measurement in order to identify malnourished patients, and improve their nutritional status. The initial changes were to have nurses and physicians complete a nutrition-assessment training, provide them with the MUAC tapes, and ask them to measure and record the MUAC. However, these did not result in any improvement for the first few weeks (Graph 1). Then they achieved nearly 100% during the week of an external visit from the Ministry of Health, but this was not sustained. At this point, the health center engaged an improvement advisor to work with them. He set up a team comprised of the individuals who played roles in the process of care for HIV patients: receptionist, nurse, physician, pharmacist, and patient representative. They decided they would assess their progress on a weekly basis, using a time-series chart. The team decided to implement another change: to appoint one nurse to be in charge of performing MUAC right after registration. This led to an improvement of approximately 70%. The team discovered that patients skipped the MUAC station to be seen by the physician, or missed the nurse while she was out for a break. The team decided to test another change: involve expert patients in MUAC at the registration desk, including training them in MUAC measurement. This led to an improvement of approximately 90%. [Example from USAID Health Care Improvement Project (2007–2014)].