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"In my opinion, culture change is the real 'secret sauce' of improvement science."
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Why Compliance with Quality Measures Is Not Enough

By Nana Twum-Danso | Friday, September 10, 2021
Why Compliance with Quality Measures Is Not Enough
Photo by Charles Deluvio | Unsplash

Big challenges are nothing new for Nana Twum-Danso, MD, MPH, FACPM. She led a successful Institute for Healthcare Improvement (IHI) nationwide initiative to reduce morbidity and mortality in children under five in Ghana called Project Fives Alive! and served as IHI’s Executive Director for the Africa Region. She later took her expertise to the Bill & Melinda Gates Foundation and The Rockefeller Foundation. Now that Twum-Danso is back at IHI as Senior Vice President, Global, she is leading IHI’s efforts to improve health and health care for greater numbers of people around the world. As IHI celebrates its 30th anniversary, she describes in the following interview the power of spreading improvement science far and wide.

What has excited you most about the growth of IHI’s global reach?

One of the things that excited me most about coming back to IHI was the expansion we’ve had in our global work in the almost 10 years since I left. IHI has been working in more than 40 countries around the world. And the breadth of the work that we’re doing has also increased. We’re working in clinical care, public health, housing, education, and other social determinants of health. That’s exciting!

The number of people and the operations we have to support the work around the world has also expanded. When I was at IHI before, we had a few people working in a handful of countries. We’re now light years ahead of that. We have a robust human resources system and operational support that is very important to get the work done.

Where do you see opportunities for improvement?

There are three ways to look at this. The first would be in our customized services we provide to specific institutions. We could potentially consolidate and go deeper with a few institutions in a few countries and have greater impact. The work of improving health systems is a multi-year, multi-layered piece of work. To do it and have great outcomes and great impact, you need time, people, and resources.

The second opportunity for improvement is our large-scale educational offerings, especially the work we do to build capability in improvement science. IHI has been offering virtual educational training for some time, but the COVID-19 pandemic has forced us to think more creatively, more systematically about all our educational offerings, and the extent to which we can make them available online, either synchronously or asynchronously. We should also be thinking creatively about how we make improvement science more accessible around the world.

I don’t just mean using a virtual platform when I talk about access. We must also pay attention to the content of the work, the context, the language, and even the format in which the work is delivered. In many parts of the world, especially poorer parts of the world, people may not have laptops. This is certainly true at the student level, but even professionals may not have laptops. More and more people, however, have smartphones. A lot of serious work is happening on smartphones with bigger screens and more powerful computer processing. So, can IHI make our educational content more mobile-friendly and more accessible to people in a wider range of contexts? I expect we'll be doing more in this space in the next few years.

The third opportunity is around the people. The operational support we provide our people globally has gotten better over the past 10 years, but there is room for improvement. About 20 to 25 percent of our people work outside the US, but the majority of IHI is US-based, and I think the tendency is to design for the majority. We need to design for all our staff. We need to be more inclusive in the way we design our operations, our human resource management, and our technology support. Figuring this out is a very important part of my job.

How has improvement science influenced you as a leader?

A lot of who I am now is a reflection of my time at IHI. Learning improvement science, practicing it, teaching it, and coaching others to do it in the intense way I did while I was at IHI the first time around absolutely transformed me as a professional.

I often say to people that I have three major milestones in my professional career that influence how I look at the world, how I define problems, and how I come up with solutions. The first is medicine. I trained as a doctor. Second is my public health training. The third lens is improvement science, which I didn’t know about until I first joined IHI. Having an improvement lens changed me in so many ways. A lot of it is mindset, right? It’s also about the way you approach people to start an improvement conversation, the psychology of change, the way people learn, the way organizations change over time, systems thinking, building teams and nurturing them towards achieving ambitious shared aims. All of that, I learned at IHI.

Some of the seminal texts and thinkers that influenced me at IHI probably influenced me more after I left because I continued to teach quality improvement to leaders, managers, and frontline health personnel so I had to go back and re-read them. Deming’s work has been completely foundational. The Improvement Guide has been so important because I teach from it all the time. Good to Great, the Jim Collins classic, also greatly influenced my thinking.

How did your time away change your perspective on IHI?

It enrichened my view of IHI. When I was at IHI before, I took so much for granted in terms of using an improvement lens. In hindsight, that’s understandable since I was surrounded by people who had been trained in improvement science and essentially breathed and lived it daily. Being away from IHI showed me that people come from so many different disciplines that shape how they define a problem and how they come up with solutions and test them. Even the concept of testing and learning before you do something at scale is not a common concept in the world of work. People love to come up with a solution and implement it right away [without testing it]. Context matters. Testing the change and seeing its effects in different contexts before implementing at scale can make the difference between success and failure.

Being away from IHI really made me see the importance of the improvement science lens. And I think IHI has an opportunity to demystify improvement science. It goes beyond the tools.

In my opinion, culture change is the real “secret sauce” of improvement science. It enables an organization to go from a certain type of performance to sustainable transformational results. And this organizational culture change includes what we do with data. Do we collect the right type of data? Do we look at it on a regular basis? Who looks at it? Who acts on it? Who are the managers? Do the managers facilitate change? Or do the managers simply tell people what to do? Do we empower people at different levels of the organization to lead at their level and only bubble up problems to the next level after they’ve tried to solve it without leadership involvement? Do the leaders practice what they preach? Or do they lead through edicts and slogans? All these things influence how staff behave every day. This ultimately contributes to organizational performance.

Organizational culture change is not an easy sell, and it’s not easy to communicate. Improvement is a journey, and it starts with us. We, as change agents at IHI, need to understand it well and teach it well, and support people as they practice those skills, make mistakes, and correct the mistakes. We need to be on the journey with those who want to learn with us.

IHI has always tried to partner with others to build sustainable improvement capability wherever we work. Is there a story you can share that helps illustrate why this is so important?

I have so many stories I can tell. One that comes to mind right away is in the context of a maternal mortality reduction program. It was a national program working with a Ministry of Health in a Caribbean country. The institution was very hierarchical and focused on quality assurance, protocols, procedures, and checklists. They were collecting mountains of data every day, every week, and plotting them on a red, yellow, and green dashboard.

Most of the indicators related to maternal survival were achieving 90 percent compliance or more, so the indicator was always green on the dashboard. But maternal survival wasn’t changing. So, part of the improvement capability building we were doing involved teaching them how to ask the right questions: Why do you think we’re still getting the same maternal mortality rate over the past couple of years despite such high compliance? What else can we be doing? Facilitating this kind of conversation helps get to the root causes and provides an opportunity to teach about the root cause analysis tool and what it can help you achieve.

The other way to look at [a situation like this] is a Pareto chart. Using this tool means asking other kinds of questions: What are the most common reasons why pregnant women are dying in this jurisdiction? What can we do to address those top two or three reasons? Are there issues around access to care? Around the quality of care when people arrive [at the hospital]? Are people arriving too late [to get the care they need]? Are some of our processes in the hospital failing us?  Let’s do a deep dive on those factors.

At IHI, we encourage people to go beyond quality assurance and beyond quality control to embrace improvement in an intuitive way. And this is no criticism of quality assurance. I think it's important as a foundation, but we need to do more exploring when quality assurance is not achieving the improvement that we expect. What else can we do? What data do we have to guide us? What are the tools?

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

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