Improvement Studies: The two cultures.

Improvement Science has arrived in practice.But its theory and pedagogy lag behind. It works in practice , but does it work in theory. This ontological anxiety spills over into epistemology and pedagogy. We need to identify two categories of pedagogy: The pedagogy of those who strive to create  academic space , who wish to integrate improvement into clinical curriculum, who redefine professionalism in terms of improvement behavior,  who teache students and do research . These ‘upstream- drivers’ are at heart essentialist. They believe in institution building and nurture expertice.They work within a historical frame and see progress as being cumulative.They view improvement as a ‘normal science’.

The other category is the pedagogy for facilitators, led by minimalist who are interested in the practical organization and achievement of the field. For them, improvement is a science , because it is successful in practice. They see no problem in it as a field and often view it as a ‘good enough’ science.These ‘downstream- drivers’ are constructionists. Their enthusiasm is not for the field but for what it can do in their endeavors. There is a need for tools and rules , but not for definitions or mastery. They believe more in collaboration than institutions. They have a futuristic outlook and they see progress as a paradigm shift.They continue to view improvement as a ‘revolutionary science’.

What does this have to offer curriculum development?  When we speak of designing improvement science curriculum it is important to keep in mind  the categories that motivate such initiatives : Individuals consciously or unconsciously subscribe to these different schools of thought. It would be fruitful if the pedagogical tools match the mental models. A constructivist may be involved with curriculum initiatives but would do well to base their initiatives on constructivist tools.

The current standard bearer of the constructivist camp is the ‘forum’. They constitute the ‘royal wedding ‘model of theory building. The invitation is for applied work. The earliest greek version of heros, best captured in the Homerian classics, are the doers: If you are knighted you are invited. What is in small print is : ‘No theory is required’. Forums are useful but here I am using them to mirror the nature of  field of improvement science. The constructivists though promoters of collaboration and openness  may  actually be more hierarchical. They are highly prone to mythopoesis. If you go to mathematics or cardiology conference, it wouldn’t be considered awkward, if the youngest person can challenge the most senior one and the speaker would be expected to answer. The ‘sage on stage’ format is itself contradictory to the philosophy of improvement. A ‘guide at your side’ format would encourage critical thinking .  To become a science , improvement must be self critical , otherwise it should only remain as Improvement Management. Management is inherently hierarchical, science by its nature democratic.

The above statements should not be seen as a blatant denunciation of ‘forums’. They do serve the need of participants to gain new knowledge, ideas , guidance and to network with like minded individuals. They are artifacts of a revolutionary science that ‘ raises consciousness’ and invites people to the edge. But today when we call improvement a science , it is as a normal science.

It may not be fair or even useful to pigeon hole researchers into categories but they do reflect different modes of learning : essentialist tend to operate in a ‘acquisitive mode’ while the constructivist support ‘efficiency or prudence mode’. The former value structure  both infra and supra, and endeavor towards substantiation of the ‘structure- outcome’ relationship, while the later are content with ‘process-outcome ‘ relationship. We must not loose sight that improvement thinking is common to both but their emphasis differ: the former on curiosity , the later on opportunity. The former are ‘dam builders’, the latter are ‘bridge builders’. The former recognize the importance of ‘facticity’, the latter acknowledge only ‘facts’. The essentialist prescribe a ‘ grammar of inference’ , the constructivist a ‘grammar of translation’. While there is no value judgement intended, we may consider a thought experiment: imagine an ‘international forum’ in 2014- to mark the 25th year of a mainstream publication about improvement- is organized in a developing country. What would be the additional difficulty for participants from the developed world. To what extent would participants in the developing world benefit. The answer to the first question is merely a little bit of social inconvenience. To answer the second question we need to critically look at another artefact : the campaign.

Most people value the campaign for its outcomes. Twelve hospitals outside the USA participated and of this three were in India. The campaign is often characterized as a social movement, by virtue of the fact it goes beyond asking what and how: the questions the participants asked and answered for the five interventions- to that extent it was a quality assurance or accountability maneuver- to larger questions of ‘what form’ and ‘what reasons’ which are more explicitly social. The campaign was a success but  what  fascinated me more was its potential form as a recruitment mechanism. The campaign along with the ‘crisis literature ‘ from the IOM had tremendous rhetorical value. The campaign was a success but would have still retained its value, even if it failed its target or whatever the intervention bundles consisted off. Thus contrary to what is generally perceived, any disagreement about an intervention for eg rapid response teams, is not a challenge to improvement science,  as has been made out to be by some scholars, but merely a part of the dialectics of  evidence generation.

The question of ‘form’ of the intervention brings us close to design. We can recognize the value of form in this example: consider an initiative to reduce water-borne disease in an community in a developing country: we could reach out to all the households and campaign for sanitation and boiling of drinking water . Such initiatives are about doing the right thing right. A distinct alternative ‘form ‘ of intervention is to ensure adequate chlorination of the water source to the whole community. The two types of intervention have practical implications for ease of implementation.

Knowledge by itself is not a barrier. Knowledge for improvement is no exception. What has been lacking is the question of its form and reasons. For example , the textbooks of medicine used in the developing world are written in the west, yet the practice varies in its form- its emphasis on research and the systems in which practice occurs . These are determined by political economy. Until the campaign, there were limited mechanisms for participation: traditional ‘mortality reviews ‘ or Clinico- Pathological Conference’; Clinical Audits with implicit or Explicit criteria, ISO 9000 implementations , Accreditation regimes. all of lacked mechanism to close the loop. The system was not considered a component of care. The campaign offered a ‘radical design’ and had symphonic form. It was bold and vibrant, almost like the middle and late symphonies of Beethoven, with the ‘ bang at the door’ attitude , it took idea of improvement directly to the heart of care or to the bedside.  It brought clinical reason and relevance to improvement.

Today as we celebrate IHI open school complete its recruitment of 100, 000 members , we must recognize that it couldn’t have happened without the campaign. However, with respect to developing countries the campaign had its deficiencies : it did not essentialise improvement. Most organizations merely added the data collection work to the nurses and waited for the results.If at all there was any problem solving , there is a high probability they treated all causes as ‘special causes’. By an large, improvement remains what Feynman called a tribal science. Not surprisingly , Dr Berwick did not make any mention of the international participants in his speech at the close of the campaign .  Its is not clear if there were more or less participants from India in the 500K campaign. It had no cultural impact and was a lost  opportunity. The campaign deserves replication in the developing world  provided we learn from the deficiencies. Adding a small essentialist agenda would dramatically reduce the ‘social opportunity loss’.

Even in the west , before the campaign there was limited participation of clinicians in improvement. Today,the control chart is  in the doctors bag and the nurses cart. But in the mid nineties when I attended courses at IHI, there were only a handful of physicians among the participants and even in the faculty. I probably must have been the youngest physician to attend the program. It is the campaign that also raised the awareness of improvement as a science as it directly engaged with evidence based practice and precipitated a epistemic crisis in medicine:  implementation science waving the flag of foundationaliam , improvement science  that of foundherentism.

Epistemologies change with time. From the static view of the athenians to the revisionist of modern day. Similarly, epistemologies also differ with position. when batalden, berwick and james discovered improvement in the mid eighties, they were all in some form of leadership positions . Their strategic stance was a given.Would the contours of the field  been the same, if the field was dicovered by a third year medical resident or the nursing head of  ICU unit. What would have been the contours of the field if the resident or nurse worked in the developing world? When Deming first chose to enunciate his views to japanese executives, it was based on his experience in USA after the war. Would Deming have taken the same decision if he were addressing a room full of surgeons . Very unlikely.

Epistemology is not limited to what is true and what we do, but may be concerned with who benefits from that knowledge or action, who decides what is true or what you ought to do. We need to pay greater attention to the social structure of improvement knowledge, if we want to avoid the ‘blind mule bias’. We have to deliberately ask whether the current shape of the science systematically excludes anyone. We need not merely ‘ stock taking ‘ but also ‘ soul searching’. Besides looking at our ‘spreadsheets’ we need to listen at the ‘fireside’. Scholars in improvement must demonstate the same ’emotional honesty’ that physicians and nurses do while caring for patients.

The ideal of continuous improvement is susceptible a infinite regress. if change is all pervading , then the change also implies to the methods of change and they to further change of methods , thus leading to a never-ending regress. This regress can only be stemmed by greater clarification of the objective of change: balance the voice of the process with the voice of the customer or systemness.

The domain of Improvement science is often defined by the co ordinates of two questions : are we doing the right thing and are we doing it the right way. But these questions do not determine the culture of improvement . they require additional questions : are we doing things in the right form ? Are we doing it for the right reasons? While the essentialists and constructivists share the domain- defining questions they differ in the culture- defining questions. They constitute two cultures in improvement science.

In reality there are no essentialists or constructionists. The purpose of this caricature is not choose between these modes but to balance them in individuals, organization and initiatives. In the name of innovation , there may be over enthusiasm for efficiency  , that may even be attractive to funders, but a essentialist counterweight could fruitful in the long run. Archimedes asked not only for ‘lever long enough’ but also for a ‘place to stand’.

Of the 100,000 registered with IHI open school, 9000 are faculty. It is role of the faculty that this post reflects upon. What are their likely ambitions. Would they become Academics or Facilitators. I hope there will be equal numbers in both.

This post is not a excercise in name calling. Both the essentialists and constructionists are well intentioned , but see the world differently. They seek the same truth, find different meaning , create different cultures.

The solution we envision for integrating the two cultures is called the socialization of quality. In this framework we explore the theoretical fundamentals of the Capability for improvement. Capabilities are broader than process, decision , resource, competency or capacity based improvement approaches. We also elaborate a dialectic understanding of quality as a social movement.

To be continued.

For a discussion of institutions and collaboration view Clay Shirky’s TED talk here Institutions versus Collaboration.

This entry was posted in Theory. Bookmark the permalink.

Leave a Reply