Meta-Effectiveness: A Meta-Theory of Improvement.

Capability for Improvement  is dependent on the opportunity-ie the rationale and right to engage with the system. It is the awareness of the ‘freedoms’ and ‘unfreedoms’ that  support or prevent the participation of individuals in changing the system. Thus system engagement is considered prior to systems improvement in any bottom up or side-to side approaches to transformation. Capabilities thus broadly refers to both ‘knowledge resources’ and ‘participation resources’ that serve as the ‘necessary and sufficient ‘ conditions that ensure that  ‘changes’ result  in, ‘improvements’ that individuals value for themselves, across a chain of effects:  ‘Commonly understood and agreed ends’ and a ‘thouroughly inclusive common good’. After  all traditionally, hospitals have been collective and co-operative projects.

The capability approach thus qualifies improvement with a social dimension: improvement as an ethos and  quality as a public good. A good example of such an aspiration is IHI’s triple aim . Don Berwick’s schema of a ‘chain of effects’ is a description of the determinants of  a ‘global’[ not in the geographical  sense] and thus adds clarity to locus [ geographically] for improvement. It however assumes a focus , which we have found useful to be made explicit. This allows us to emphasis the agents of improvement besides the domains of the system. Thus capability is a feature of individuals, systems and communities. The focus of improvement in addition demands consideration of the personal quality and global quality, which are not prominent in current literature of improvement science. Obviously one cannot have a science devoid of a moral agent, nor can we have different sciences for different countries.

Traditionally, quality was focused on the patient-clinician interaction and the clinicians were the sole agents of quality. This continues to be so and probably   eighty to ninety per cent of quality is still determined in this relationship and by individual performance. Thus the resistance of clinicians to quality improvement is a natural phenomenon. It is only when we look at the reliability, we realise how ‘problematic’ care is. In an individual patient – clinician interaction, personal and interpersonal quality seem apparently sufficient, under ideal conditions. This kind of quality may be called as Proximal [ meaning near the centre ] and clinical [meaning at the bedside] quality respectively. The demeanor of the clinician and the decision making capacity of the clinicians are the respective substrates of the ‘craft’ of improvement. Here, improvement is a ‘ systolic action’ and the effect is one component of the micro-effectiveness- effort , decision and resource dependent. Some of the features of this paradigm are:

1. Quality is defined negatively- by what is not quality. Reliability rather than opportunity is an accurate description of the ‘Problem’.
2. Improvement  does not have an explicit method and breakthroughs occur outside the system.
3. The system is viewed mechanistically and not as complex interdependence.
4. Systolic action, without diastolic action is always asymptotic.
5. Quality could not be analysed prospectively.
6. Clinical value and social value were not linked.
7. Unquality was often due to decision failure, due to complex nature of medical knowledge.
8. A decision based approach  is founded on an epistemology of ‘Prolific Knowledge” that values encyclopaedic knowledge , extensive experience. Quality was an individual attribute that expresses itself  merely as a habit.[ an idea that has been with us from the time of Aristotle].

When physicians consider quality of their care of individual patients, it is often an optimistic viewpoint, as they track qualiity from a decision perspective. Thus it is common for them to say: What I am doing is quality? Similarly, patients rate most of their physicians high. Even if  we disregard the difference between good and great , we still have a problem. Quality is not intelligible, to the participants  in their daily work. Reliability provides a mechanism for explicating problems of care, as ‘systems failure ‘.

While quality evolved in bits and pieces for quite some time , it acquired status of a discipline from the work of Donabedian. His work referred to as quality assurance began an era of prospective analysis of quality but all work continued be viewed as systolic action moving linearly from structure process to outcome. However, it provided an explicit theory of systolic action.

In the QA era, while systolic action  is prospective , improvement is retrospective: it still remained a ‘do-and – chase’ model. It is correction not prevention. Analysis occurred in the aggregate but it held the system as constant and optimized the parts. The era is characterized  by ‘ doing the right thing right’. Systolic action is a functional view of effectiveness. It still lacked a explicit theory of improvement and thus failed to close the gap, thus Improvement still remained a craft  .

While the QA era brought into vogue extensive evaluation and measurement , it still remained within the decision- based approach and thus performance was single loop performance and its focus and locus were limited and disjointed.

The current paradigm of improvement science began in the mid eighties and is still in flux. The biggest idea is a foundation on design. In Design the functional flow [forward and dependent on feedback] and systemic flow [ is backward thinking and requires feed-forward] are in opposite directions. The idea of design is pre-systemic  or meta-systemic. The method of improvement  is both instrumental and constitutive. The action on the system is thus diastolic . Improvement is more precisely double- loop performance , systolic and diastolic action together resulting in meta-effectiveness . Functional effectiveness continues as in the traditional model.  But design thinking includes decision making [systolic action based on deductive reasoning ] and system making [ diastolic action based on abductive reasoning]. But with meta-effectiveness , the craft of improvement becomes the science of improvement.

With this focus in mind we can, borrowing from the field of economics , characterize meta-effectiveness as micro and macro effectiveness. This dichotomy can be bridged and thus retain don berwick’s ideal of mereology, if based on Process Thinking. I believe such a frame work also  allows a fairer distribution of intellectual effort and thus proportionate development of both domains. For e.g a clear distinction between ‘outcomes research’ [ macroeffectiveness] and outcomes management [ microeffectiveness] or also redress the current bias in improvement science, where much of the focus is in  hospital and acute care arena and not as much on chronic  care or public healthcare. Regardless of whether the locus is the microsystem or the community as a whole , the focus is intra- organizational.[ whether  solo practices,hospital or public health]. This centrality of intra- organizational quality, allows us drag ‘ transferable knowledge’ from as far as the personal and global domains.

I end with a summary classification of the components of Meta-Effectiveness :

Functional Effectiveness along  with Meta- Effectiveness make Care complete. Meta -Effectiveness differs from Evaluation as includes Opportunity , Change and Systemness, across the chain of effects,resulting in Social and Clinical Value.

Keywords: Capability for Improvement, Systolic Action, Diastolic action , Chain of Effects , Locus of Improvement , Focus of Improvement , Inter- Organizational Quality, Personal Quality, Proximal Quality, Functional effectiveness, Meta-System , Meta -Effectiveness, Micro-Effectiveness, Macro-Effectiveness, Single and Double -Loop performance, Abductive Reasoning,Linear Thinking, Logical Demonstration,  Experimentation, Social Value, Clinical value.