“Do not seek to follow in the footsteps of the old masters. Seek instead what the old masters sought.” – Basho (1644-1694)
In her 2012 keynote presentation at the Institute for Healthcare Improvement (IHI) National Forum on Quality Improvement in Health Care, IHI CEO Maureen Bisognano said that everyone in health care should have two jobs: to do the work and to improve how the work is done.
In that simple statement, Bisognano posed a transformational challenge to health care organizations struggling to meet the increasing demands of the marketplace to provide excellent patient experience, and make a meaningful impact on the health of the patients they serve. Following in the footsteps of other industries, they must somehow figure out ways to define the work — of everyone, including senior executives, point-of-care staff, clinicians, and those in support roles — to deliver excellent care and services (“doing the work”), while simultaneously designing systems and processes that build in continuous improvement (“improving how the work is done”).
How can this be accomplished?
IHI’s Comparing Lean and Quality Improvement white paper describes two distinct but related approaches to Bisognano’s challenge. We refer to these approaches as the “IHI approach” to quality improvement (“IHI-QI”) and “Lean.” We take “IHI-QI” to mean the approach to quality improvement developed by Associates in Process Improvement and promulgated by IHI, grounded in the work of Walter Shewhart, W. Edwards Deming, and Joseph Juran. IHI-QI emphasizes rapid-cycle testing in the field in order to learn which interventions, in which contexts, can predictably produce improvements. By “Lean” we mean the integrated principles, methods, and tools that have developed from the Toyota Production System to optimize the performance and management of value-producing systems.
The effort to improve quality in US health care has spread well beyond the “early adopter” phase of the 1990s. At that time, the Institute for Healthcare Improvement took the lead in promoting and translating industrial quality improvement methods to health care practitioners in a determined effort to close the “chasm” between unreliable common care practices and the evidence-based guidelines emanating from medical science. In the 25 years since the seminal book Curing Health Care was published, health care quality improvement has become a worldwide movement, and in the US has gained urgency from policy reforms by payers, governments, and professional standards bodies that increasingly insist on management of outcomes and documented efforts to constrain costs and improve value. These trends show every indication of accelerating in coming years.
IHI has been guided by a close relationship with Tom Nolan, Ron Moen, Lloyd Provost, and their colleagues at Associates in Process Improvement (API) that began in 1992. That collaboration has resulted in wide-scale application of IHI-QI in health care worldwide. The IHI approach is informed by the work of Shewhart and Juran and is based on the application of Deming’s System of Profound Knowledge. The specific methods of IHI-QI have evolved, based on learning from their application within health care by API, Improvement Advisors, IHI Fellows, faculty and staff, strategic partners, as well as thousands of participants in IHI projects and initiatives. IHI’s clinical and technical leaders learned quality improvement from API, who in their turn worked closely with Deming.
IHI-QI is a vibrant discipline. It has not ossified into dogma, thanks in good measure to the diversity, energy, and idealism of its adherents, and to the “open source” approach that IHI has promoted with regard to methods and content. IHI faculty have been encouraged to candidly share their best ideas, in the belief that the field can most rapidly and effectively advance health care quality through collaboration. Together, the IHI community has grown in an atmosphere of transparency and a spirit of “all teach, all learn.”
IHI-QI is often confused with one of its core elements, the Model for Improvement. The Model — three clarifying questions and the Plan-Do-Study-Act (PDSA) cycle — has formed the mainstay of IHI’s teaching and improvement methodology over the years. But despite its fame, and despite its manifest utility in almost any life situation, the Model for Improvement is not synonymous with IHI-QI.
The Model for Improvement, developed by Associates in Process Improvement, is a general-purpose heuristic for learning from experience and guiding purposeful action. More simply, it is an “algorithm for achieving an aim” at any scale. As a tool for gaining practical knowledge, it represents a radical distillation of pragmatic epistemology into a habit of immediate, sequential testing of changes. One objective of the Comparing Lean and Quality Improvement white paper is to reconsider the Model for Improvement in its proper place, as a pervasive guide for action within the larger context of IHI-QI.
At present, Lean tools and methods are rapidly gaining adherents among aspiring health care improvers. As health care leaders have embraced the results-oriented discipline of industrial quality improvement, interest in more effective management systems has increased. The Toyota Production System (TPS), in particular, has received much attention. TPS is rooted in the innovations of Taiichi Ohno and colleagues in Toyota factories starting soon after the end of World War II. Adaptations of TPS are widely known by reference to one of its key principles of practice, “Lean” — the drive to devise nimble tasks, processes, and enterprises that maximize value and minimize waste in all its forms. Leading health care organizations, notably Virginia Mason Medical Center in Seattle, ThedaCare in Wisconsin, and the Pittsburgh Regional Health Initiative in Pennsylvania, have adopted TPS as their model for management and improvement, with widely recognized success.
To learn more about how practitioners of both Lean and IHI-QI can use the principles and methods of the other to extend their capabilities, download Comparing Lean and Quality Improvement.
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Moving from Volume to Value is a featured track at this year's National Forum on Quality Improvement in Health Care (December 10–13, 2017 | Orlando, FL, USA)