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Challenging Assumptions to Make Large-Scale Improvement

By Colleen Lampron | Tuesday, June 7, 2016

Challenging Assumptions to Make Large-Scale Improvement

If you’re like me and you’ve worked in quality improvement for many years, there is nothing better than seeing your hard work exceed your expectations. I lead two large-scale initiatives that focus on improving pediatric dental care. One focuses on improving oral outcomes for children ages five and under in Los Angeles County in California, and the other focuses on working with health centers across the US.

You might not suppose that this work leads to lasting changes in people’s lives, but it’s possible when you have dedicated professionals learning together. It starts with challenging people’s assumptions.

Learning to Lead Change

One assumption I had to challenge was some people’s definition of an “Improvement Advisor.” This got easier after I joined the IHI Breakthrough Series College (BTS College) four years ago.

I had been trying for about six months to get the first improvement project off the ground. I enrolled in the BTS College — a program that shows how to convene a large number of teams to work on a focused improvement initiative (what IHI calls a “Collaborative”) — because I needed more guidance.

In the improvement initiative I was leading, some project participants who called themselves Improvement Advisors seemed to think this meant they’d be working in an advisory capacity, instead of intensively coaching frontline teams. The Breakthrough Series College taught me how to sequence Learning Sessions, support my teams, and get the right people into the right roles to implement and spread improvement. I now use many of the BTS tools and methods, including how to continuously think about the participant’s perspective.

Reach Them While They’re Young

I’ve also sometimes had to challenge the assumptions of experienced health care providers: they don’t always know about the importance of focusing on oral health outcomes for kids ages five and under. The research shows that if you start early, you can prevent dental disease and other health problems, spare children from a lifetime of pain, improve educational outcomes, and save the health care system a lot of money.

When our project first started, we approached the CEO of a health center about this work. A nurse who had been in health care for more than 40 years, she was committed to her patients and to providing the best care possible to the community.

But when we asked her about taking part in a Collaborative to increase the number of young kids going to her dental clinic, she said, “Well, okay, but why? They have baby teeth. They’re just going to fall out.” She didn’t know about the wide-ranging negative consequences of dental caries (cavities) in baby teeth, including harm to the growth of future permanent teeth, interference with chewing and good nutrition, delays in proper speech development, and pain that makes it hard to sit in a classroom and learn.

Through participation in the pediatric dental care Collaborative and by working closely with her quality improvement team, she saw that early intervention makes a difference in families’ lives. This health center’s dental clinic went from serving no children ages zero to five to now seeing an average of 120 kids per month. Their team has embraced and applied the science of improvement and quality improvement tools as part of their day-to-day problem solving. The health center is now one of the Collaborative’s stars. 

The Collaborative has exceeded our outcome measure goal, which is the percent of kids zero to five who reduced their caries risk status. This couldn’t happen without amazing transformations and real system change.

Unexpected Heroes

The dentists in our Collaborative work in federally qualified health centers, caring for some of the people most at risk for dental disease in the US. These dentists have a lot of skill and expertise, but they don’t think of themselves as heroes.

Sometimes, though, patients challenge their dentists’ perceptions of themselves.

As part of our effort to encourage more teamwork between medical and dental care, a dentist in our Collaborative saw a four-year-old girl referred by a physician at his health center. The medical provider had looked in the girl’s mouth and determined that she needed to see a dentist right away, so she went directly from her well child visit to the dental clinic.

The dentist found that 17 of the girl’s 23 surfaces were decayed. The provider developed a plan, worked with the patient and her family, and helped get what was essentially a mouthful of disease under control.

Several months later, the girl’s mother returned to the clinic and asked to see the dentist. When she saw him, she said, “You’re my savior.” He was so surprised, he didn’t know how to react. “I’m not a savior,” he responded, “I’m just a dentist.”

The mother explained that her child had cried every night for the past year because she was in so much pain. “You took care of her,” she said, “and now she doesn’t cry anymore.”

This woman hadn’t known about early dental care, much less how to get access to it. The dentist, who thought he was just doing his job, made a big difference to a child about to start kindergarten and her entire family.

Commitment to Continuous Learning

The “all teach, all learn” spirit is one of the best things about a well-functioning Collaborative. It’s what allows us to challenge assumptions, including our own, without fear. When you create a culture of openness, you feel as though you’re continuously learning together.

Even though I’m running my own Collaboratives now, I still attend the BTS College monthly webinars as often as I can. Every time I attend, I learn from others who are doing all kinds of improvement work around the world, and take away two or three things that I can apply almost right away.

One of the most satisfying parts of the Collaborative experience is when you accept that nobody is perfect, and no one knows everything, but we’re all willing to learn for the sake of the populations we’re trying to help. Our commitment to them helps us drive improvement.

Colleen Lampron leads AFL Enterprises, LLC, and was a participant in IHI’s Breakthrough Series College.

 

You may also be interested in:

The Breakthrough Series Collaborative Method: Improving Health Care and a Whole Lot More

The Breakthrough Series: IHI’s Collaborative Model for Achieving Breakthrough Improvement

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