Improving the Way IHI Drives Healthcare Improvement

David M. Williams, PhD, began his career as a paramedic, then went on to become an expert in improvement science. A longtime faculty member of the Institute for Healthcare Improvement, he recently joined IHI full time as the executive director co-leading the improvement capability focus area. Integrated Healthcare Executive talked to him about his new role and about the drive to improve healthcare delivery.

The terms “quality improvement” and “process improvement” get used a lot. How can we be sure we’re all talking about the same thing?

There are wide variations of people’s understanding. In a lot of health systems, you have folks who are very clear on it; they really understand and appreciate what process improvement is and what quality improvement is, and the focus on systems and trying to improve systems to produce better results. But you still have a large number who put a lot of their emphasis in thinking about assurance and compliance and inspecting versus improving. One thing I’m having to do consistently is define what quality improvement is. I’ll say, “Keep in your mind, this is what we’re doing. If you find yourself gravitating toward inspection or if you find yourself wanting to try to identify who is the problem versus what is wrong in the process and the system, then we’re talking about different things.”

Do you have to do the same for the Triple Aim—consistently define what it is?

I find there’s a lot of opportunity for people to appreciate what the Triple Aim actually is. And many folks who are working on it are not working on the full breadth of what the Triple Aim is trying to accomplish.

For example, when we talk about patient experience, there are a number of places that have only picked up on patient satisfaction. If you read what patient experience really involves, it’s actually a pretty extensive amount of work. Part of it is having satisfaction at the end. But it also involves pursuing the six quality-chasm aims from the IOM report—producing safe care and equitable care, patient-centered care, etc.—so it’s a lot about designing and improving the quality of the entire experience so that, when you measure it at the back end, patients respond and say, “Yes, I’m satisfied.”

Another common one is in the per-capita cost. There are a number of folks who are trying to, let’s say, reduce unwarranted charges. So they’re trying to avoid a patient having a procedure or going to an ER when they shouldn’t. And that’s part of the puzzle. But if you look at the true definition, the intent is to try to reduce the overall per-capita cost in the population that’s served. So that may mean trying to figure out how to improve the quality and reliability of how services are delivered so they don’t cost as much, or figuring out how to eliminate waste or rework. So it’s not just trying to reduce charges. It’s actually trying to improve the entire efficiency and effectiveness of the system.

What is improvement capability—the focus area you’re now co-leading—in the context of IHI?

Within IHI there are a series of focus areas, including the Triple Aim for populations; quality, cost and value; person/family-centered care; and patient safety. And at the heart of all of that work is the focus area of improvement capability. That includes building capabilities through designing learning and development programs, and teaching those programs to help people learn about improvement science. It also involves continuing to explore and evolve our improvement capability method. So we’re continuing to study improvement science and learning about the tools and embedding the tools in both our improvement programs and our work. And the third piece is our results-oriented work, where we’re partnering with organizations to apply improvement science to solving problems, whether that’s in patient experience or improving patient safety or enhancing the quality of different patient care areas.

You’ve said that coming into your role with “fresh eyes” may help you identify new areas of opportunity. What might those be?

There are some definite opportunities as we think about the different training programs we offer folks. They were originally created for independent purposes. And now we’re starting to look at how to design a professional development pathway or trajectory, so there’s some kind of path.

We also want to continue to appreciate how learning occurs for the audience and to continue improving our ability to deliver content in a virtual environment. We have programs that are
virtually and asynchronously delivered, like the IHI Open School, where you can go and sign up at any time and there’s content that’s just there. We’re currently working with the HarvardX group at Harvard University to develop a massive open online course (MOOC) that’s a little bit more synchronous. It’s based on courselike structure and timing, but it’s all delivered virtually, with a high production experience.

Are you working on improvement capabilities in areas beyond healthcare?

Yes. Some of it stems from work the executive director of the Triple Aim and I have been doing with the Early Years Collaborative in Scotland. That’s a huge program that’s working to improve the outcomes of children from conception through 8 years old. And it’s not just looking at healthcare. It’s looking at education and family attachment and social and environmental factors. And so one thing we’re starting to explore is, if a lot of our work in patient care is pushed into the community, how do we learn and build improvement capability in the community?

What do you see as the biggest challenges to making real strides in improving healthcare?

One of the biggest challenges is timing it so that payment policy matches what we’re trying to accomplish. There are a number of spots where people were ahead of where payment was. And there was that challenge of “I don’t want to change too early because, to be honest, I’m paid for doing it this way.” So how do I keep focused on knowing that it needs to change, knowing that’s the right thing to do, and believing that it will at some point, but also recognizing that if I change too early I may lose money in the process?

What advice do you have to offer for healthcare leaders who are guiding improvement efforts?

What’s important for healthcare entities to recognize is that you can’t do it by yourself. You can’t do it just as a health system, as a hospice, as a nonprofit or FQHC or as an ambulance service. The patient moves through a continuum of service providers, and you have to work together with all of those folks to try to flip the delivery model. I think that’s exciting.

Take-Home Points

• To improve processes, look at system issues, not individual performance.
• Focus on the quality of patients’ experience, not just satisfaction. It’s an outcome but not the goal.
• Look for systemwide efficiencies, like reducing waste and rework, to improve per-capita cost.