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Making Sense of Multiple Frameworks: How to Enable Whole System Quality

Why It Matters

Two IHI experts offer guidance on how IHI frameworks on safety and the psychology of change support whole system quality.


As health care organizations strive to deliver ambitious quality strategies in complex systems, the work to build a culture that enables change and learning has never been more important.  

The recent IHI white paper, Whole System Quality: A Unified Approach to Building Responsive, Resilient Health Care Systems, provides a more holistic approach to quality management that enables organizations to close the gap between the quality that customers are currently receiving and the quality that they could be receiving. Based on the Juran Trilogy, the whole system quality (WSQ) approach provides guidance for integrating quality planning, quality control, and quality improvement activities across multiple levels of the system.

Two pre-requisites are needed for the integrated WSQ operating system to be successfully deployed:

  • A well-aligned quality strategy that provides a clear line of sight to customer needs, a vision of a future state of quality, and a commitment to methods and resources that ensure quality; and
  • A learning culture that supports an organization-wide pursuit of quality through leadership and management practices that facilitate knowledge exchange and foster a culture of learning.

Throughout the years, IHI has emphasized the crucial underlying importance of culture in enabling and promoting change in complex systems. IHI thus developed multiple implementation frameworks to support organizations in achieving the environmental conditions that enable and support change in the pursuit of quality. Two such frameworks — A Framework for Safe, Reliable, and Effective Care and the Psychology of Change Framework — provide detailed guidance on how to build the culture and behaviors that enable the level of improvement and quality envisioned in whole system quality. Both frameworks present supplemental guidance to organizations seeking to implement the WSQ approach.

The Framework for Safe, Reliable, and Effective Care provides a roadmap for building a culture to support WSQ that is centered on the needs and what matters to patients and the health care workforce. The framework has two foundational domains — the culture that supports improvement, and the learning system required to effect rapid change —  and includes interrelated components: leadership, psychological safety, accountability, teamwork and communication, negotiation, and transparency. A key element of the culture domain is the role of leaders in setting direction and modeling behaviors of the desired culture. The framework describes specific ways in which leaders can build an environment of psychological safety, including guidance on mutual accountability and conflict resolution — both essential for a safe work environment — and the fundamental requirement for transparency among the workforce and with patients.

Grounded in a social theory of learning, the IHI Psychology of Change Framework is well-suited to support the ambitious change that is envisioned in WSQ. The framework places a renewed focus on the human side of change, which can increase the likelihood that efforts to improve health and health care will succeed in the short term and can be scaled and sustained over time. Health care improvers worldwide still struggle with the adaptive side of change — understanding and unleashing the power and motivation of people to advance and sustain improvement. This framework provides practical guidance and methods to activate people’s agency to commit to change through five interrelated domains of practice: unleash intrinsic motivation, co-design people-driven change, co-produce in authentic relationship, distribute power, and adapt in action. In addition to the transformation required in individual and interpersonal changes in thinking, feeling, and acting, the framework recognizes that these people-focused changes need to be accompanied by system-level changes in structures, processes, and conditions that are at the heart of the WSQ approach.

Pierre Barker, MD, MBChB, is IHI's Chief Scientific Officer. Frank Federico, RPh, is an IHI Vice President.

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