Dr. Amar Shah, Associate Medical Director and Consultant Forensic Psychiatrist at East London NHS Foundation Trust, and Dr. Robert Lloyd, Vice President at the Institute for Healthcare Improvement, make a case for bringing the best of quality improvement and traditional research together.
We have a wonderful richness of research expertise and quality improvement (QI) expertise in health care, across many of our organisations. This puts us in a great position to be able to bring the best of both of these fields together, in our vision and strategies to improve the health and health care for the populations we serve.
As many organisations develop and apply skills in improvement across the workforce, many people often question how this new way of making changes to services sits alongside the use of academic or traditional research and evidence-based medical practice.
There are many similarities between research and QI:
- Both generate new knowledge. Research helps us understand what works (efficacy), often by comparing an intervention against a control or placebo. Improvement helps us test these interventions in the real-world setting, making adaptations if necessary, and understanding how to effectively and efficiently implement them across a variety of settings.
- Both methods are grounded in the basic scientific method of starting with a hypothesis, designing an experiment to test it, and then collecting data to see whether the hypothesis held true. In QI, a properly designed PDSA (Plan-Do-Study-Act) cycle will go through the exact same steps. Academic research is often referred to as “pure science” where we try to control for the confounding factors and biases that might influence the outcome. Academic research can therefore be more definitive about making cause-and-effect linkages. Improvement, on the other hand, is “applied science” (sometimes referred to as implementation science) where we acknowledge that improving services in the real world is complex, with multiple variables involved that cannot always be controlled or held constant. So, whilst we can show a relationship in time between an intervention and an outcome, we cannot necessarily demonstrate a definitive causal link. Also note that in improvement science we modify our hypotheses as we gain new knowledge. In academic research a null hypothesis is established at the beginning of a study, and this hypothesis does not get modified during the course of the study.
- Both rely on data to guide practice. Research helps us demonstrate which interventions have evidence to justify their use in a given setting. Improvement helps us demonstrate which changes lead to improvement in a given setting, using data and testing to build our degree of belief that an idea has merit.
So, how can we bring research and QI together?
- A well-designed quality improvement project should bring together knowledge – from within the team (of what ideas might make a difference based on their experience of working within the system), from outside the team (from other places that may have tackled a similar problem), and from the evidence base (where it has been shown in pure science that a particular intervention has efficacy). All of this knowledge should be brought together in a single theory of change, illustrated in the team’s driver diagram.
Here are a couple of examples to illustrate:
- At East London NHS Foundation Trust (ELFT) we currently have many teams working to reduce non-attendance at appointments. These teams are testing a number of interventions, developed by staff and service users in the services. They are also testing SMS messaging, which has been shown in research studies to be efficacious in reducing missed appointments. The teams are also using the knowledge from research about what form of wording has the greatest impact on behaviour, to inform the tests being run in these services.
- Many of the inpatient wards at ELFT have been working on violence reduction. At the very start of this work, we looked to the evidence base to identify interventions that had been shown by researchers to reduce inpatient violence on mental health wards. We presented these findings to the project teams, who utilised them in building their theory of change.
- Research findings can help us find opportunities for improvement work. Thematic analysis of complaints, serious incidents, or service user feedback can help us identify areas of concern for possible improvement interventions. For example, an analysis of the feedback captured from a year of Executive WalkRounds at ELFT identified two big areas of opportunity – the IT helpdesk and estates repairs – which have now led to the design of two corporate QI projects on these topics.
- The sequential testing and scale-up of ideas through quality improvement can build an increasing degree of belief that a change can lead to improvement in multiple settings and contexts. This could then lead into designing a formal research study, using more rigorous study design to examine the efficacy of the intervention once all other known confounders have been controlled.
In summary, while a majority of health care professionals are not engaged in pure academic research, we should constantly be reviewing and discussing the results that come from research endeavours. Ideas that have been shown to be efficacious provide the input for improvement research that tests how these ideas can be applied efficiently and effectively in everyday situations.
Follow Dr. Amar Shah (@DrAmarShah) and Dr. Robert Lloyd (@rlloyd66) on Twitter.
You may also be interested in:
Building a Culture of Improvement at East London NHS Foundation Trust
Video: What’s the Difference Between Research and QI?