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"It’s essential to create space for the process of shared discovery. You’re helping [improvement] teams look at their own data with fresh eyes."
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Lessons for Improvement Leaders in Any Setting

By Nana Twum-Danso | Friday, November 12, 2021
Lessons for Improvement Leaders in Any Setting
Photo by Okan AKGÜL | Pixabay

Nana Twum-Danso, MD, MPH, FACPM, understands that some improvement lessons know no geographic boundaries. The Institute for Healthcare Improvement (IHI) Senior Vice President, Global, draws upon her years of experience building improvement capability around the world as she leads IHI’s efforts to improve health and health care worldwide. During a recent interview, she shared some of the advice she gives improvement leaders about how to work with teams in any setting:

  • Let the data be your guide. When IHI is invited by a new organization to help them improve health outcomes, we look at the data to determine where to start. I recall a situation in which I was working with a team on reducing infant mortality. [The IHI team] encouraged the internal people to look at their data with us and then brainstorm. We asked a key question: Where is the data telling us to start this improvement work? The doctors in the system said, “It looks like most of the infants who die in our system are dying on the first day.” I think it was more than 50 percent of the infants were dying within the first 24 hours of arrival. Remarkably, this was the first time they were gaining that important insight as a team. Various people in the hospital may have known intuitively that this was a problem, but they hadn’t delved into their data to help them decide that this was a critical area in need of improvement. We facilitated this learning by using a Pareto chart [a type of bar chart in which the factors that contribute to an overall effect are arranged in order according to the magnitude of their effect]. This led to more questions: What are we doing in our system that leads people to do poorly so soon after they come here? Are the problems in our system? Are they outside our system? They were able to explore enough of the data to realize that the challenge was their triage system. Triage wasn’t working the way it should have to save lives. Though the country had a triage policy in place, the people in this hospital were essentially providing care on a first-come, first-served basis, so some of the sickest children were attended to later than those whose clinical condition was not as life-threatening. Changing the triage system to focus on acuity of illness allowed them to detect and treat those who were sicker more quickly.

  • Identify the true experts. When we come into a system — as change agents or improvement advisors — there’s an expectation and assumption that we know best. We are the experts, right? We have experience. We have the theories. There is some truth in that, but [those closest to the problems we’re trying to solve] are the experts in their system. When I was working on Project Fives Alive! in Ghana, we tried to identify best practices, highlight the lessons learned, and bring attention to those who were doing notable work within the system during this nationwide project. We shared those stories wherever we found them to show that people throughout the system have pearls of wisdom to offer, and we need to learn from them and help them spread what they are doing to other parts of the system. Change ideas don’t have to come from experts or from other institutions; many of them are already in our system. They may simply be underappreciated or the people leading improvement efforts may not be empowered enough to share and spread the ideas.
  • Put aside your assumptions. We never know a priori what change idea or what solution is going to work in a particular context. We may have a general sense of a change concept that could work, but we’re not the ones most familiar with the local situation. For example, we know reminder systems often work to improve processes, but will they work for a particular population? If so, what channels should we use to send the reminders, and how often? We may not know, but the people closest to the problem will have a better sense.
  • Improvement is a way of seeing and not just a set of methods. What [improvement leaders] bring is an improvement lens. Over time, we teach others to see through that lens. It’s the lens through which we ask questions and the lens through which we surface data. That’s the way we start building improvement capabilities. So much of what change agents do is coaching. It’s essential to create space for the process of shared discovery. You’re helping teams look at their own data with fresh eyes. If you can challenge improvement teams to come up with change ideas they are willing and able to test consistently and at scale, you’re changing mindsets. Learning improvement is like getting any other kind of education. When you finish [your requirements], you get a certificate or a degree, but the point of the education is not the certificate or degree. The point is to change how you think, to change your approach to problem solving and to go make a difference in the world.

Editor’s note: This interview has been edited for length and clarity.

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