Improvement as Freedom : Learning from Development.

This entry was earlier posted as ‘System as Praxis’ but has been revised and expanded under the present title, to emphasize the ‘opportunistic’ nature and the ‘liberalizing moment’ in improvement.

A Prolegomena to a Metaphysics of Improvement:

‘Quality is the will to change ‘

-Don Berwick.

This article is not an invitation to improvement science. It is aimed at someone who already possesses the knowledge and skills of improvement science and now faces the challenge of effecting or facilitating improvement at his workplace .

There are several entry points to improvement science: being part of a team, preparation for accreditation, audit studies, participation in campaigns, ISO management review meetings etc. but theses are not the norm in developing countries. It is not uncommon for someone working in developing countries to find himself alone in his effort to introduce improvement thinking in his work place. Such circumstances not only lack the incentives to do so, but may even deny the intellectual space to articulate such ideas.

How does such a person understand and respond to the immediate reality in front of her? How can she efficiently invest her cognitive resources in pursuit of her aims ? In such a predicament a model that highlights the sources of improvement and the limits of improvement would be useful. Thus I felt the need to explicitly conceptualise the idea of opportunity as well as to limit the aim of improvement to systemness. Change is central to improvement and remains so in this model.

It is possible that even for people working within well established communities of practice, a model that captures the micro-level motivations of improvement would help them to systematize their improvement efforts and integrate systems and people. It is not a replacement of the models of improvement but an additional tool for framing the improvement practice at the shallow end. A professional driven, bottom up approach that promotes democratization of inquiry.

Before proceeding to the model , let us take stock of the situation. There are two kinds of situations in which improvement thrives : a] the actual space b] the actualising space . The actual space is one that privileges change .It guarantees a team. It is driven by economic incentives and strategic organisational targets . On the other hand, the actualising space lacks these superstructures and is largely motivated by the potential that is achievable. In this space any question of what we are trying to achieve often quickly degenerates into issues of structural deficiencies such as lack of proper medical records , incomplete documentation , inadequate staff, lack of improvement training or lack of time for improvement . When we analyse the distribution of these spaces under the rubric of economic diparities , the actualising spaces are polarised toward developing countries. There is a clear case of injustice here. The poverty of opportunity cries out for attention. The difference is in the nature of freedom – actualising spaces lack positive freedom. Isaih Berlin made the distinction between Negative and Positive freedom. Amartya Sen adds his famous insight with the emphasis on ‘Capabilities’ : the difference is that between the a person fasting and one who is starving. Both may be equal in their deprivation of nutrition but the former retains freedom. The significance of Amartya’s counsel is in the what he refers to as ‘comphrehensive evaluation’: evaluation of not only the outcomes but also the opportunity. Even though the two spaces are not mutually exclusive , the model proposed here is targeted towards the developing countries. The underlying thesis is two fold : Improvement knowldege is not enough, but requires a change in ‘work-view’ – freedom to engage with the system is prior to change and secondly in situations that are resource poor and weakly incentivised competition prevails, professional or middle management leadership have greater chance of rooting improvement ! A system of common ethics than of strategy.

The concept of a system of practice in the quality assurance literature is a static one . It remained a tool for reductive analysis of practice: While the relation between structure , process and outcome was seen as the source of scientific knowledge in the understanding of practice , it did not capture the dynamic characteristics of the system . It wasn’t required as the purpose was primarily analytical. Accordingly, the concept of process was performative and not transformative . Under this paradigm the structure , process and outcome model of Donabedian served well. In this blog segment, I wish to propose that given the dynamic view of systems , a new model for understanding practice may be conceived: System as Praxis . Improvement as discovery.

OCS model2

The word praxis is not used as synonymous with practice . It is used in the technical sense of ‘a practice that results in its own transformation’. Under this conceptualisation of praxis the ‘system’ is not a structural catalyst but a learning process: it is knowing -in – action. Thus the fundamental issue is not doing well but doing better overtime . The second assumption under praxis is the focus on predictive action and not merely corrective action. In a way, praxis is the routine practice of innovation. The third assumption as a corollary is that practice precedes theory. The fourth assumption is the recovery of the individual , both from the ‘blind aggregation of the collective ‘ and ‘the sterilization of/by the system’. Learning and improvement at the individual patient – professional level also deserves legitimate space in the improvement story.

Opportunity is also a multifactorial concept. It refers to the understanding of the system in multiple ways : experience and empirical analysis , expert opinion , evidence or exemplary practice. Engagement with systems is logically and epistemologically prior to participation in improvement. Opportunity is a critical preference for the ‘new’. It is a rational or epistemic opportunity[not fortuitous], born out of a continous interrogation of experience, of an individual [reflective] or group [deliberative]. The ability to see the problem as a problem and to take responsibility for solving it ,is not only a description of opportunity but also accountability.It is a cultural resource : the chorus of the voice of the patient, process and professional. It is the reason for action. Change is the basis of improvement but rationality [ critique, evaluation , reflection] and freedom [ opportunity ] are the starting points of improvement. The third assumption of opportunity is capability : it assumes the individual or group has the choice and knowledge to act on the system. While a individual may have both these necessary conditions, it is only with collective will, that the need to change is translated into a opportunity to improve. It is the commitment to action. The freedom of the ‘collective’ will. Fourthly, it is the inverse measure of the risk of change : It is inversely proportional to quality- what Joseph Juran referred to as ‘ the gold is in the mine’. It minimizes the threshold for experimentation. Finally, it is creative : the mindful harvesting of the ‘presence’ , within communities of learning. It is the imaginative definition of the scope of improvement .Opportunity allows in improvement a plurality of means as well as a plurality of goals.The bottomline is that opportunity is not a given , but is earned: it is not merely potential but aspirational. Opportunity is the process and freedom to meet the change hypothesis, half-way. The change hypothesis is the ‘solution’ awaiting testing.

The concept of improvement is the synthesis of two different moments either serially or in parallel. There is a ‘space of reasons ‘ and a ‘space of causes’. Opportunity resides in the former space and change in the later. There is at all times a asymmetry between the system and the individual which needs to redressed. What is the point of intersection between system , decision and care ? What is the point intersection between accountability and learning ? Mere assessment of process would not be helpful.We must include assessment of opportunity . The most prior , fundamental and ethically empowering question is to ask : ‘ What more can I do for this patient , now?’ . This question is regulative of the improvement mileu. Only by asking this question can we shift from ‘moving in ignorance to acting in knowledge ‘.

Systemness is the degree of anticipation in the system. The anticipation is not merely collective but common e.g. between patient and provider; between system and professionals. Traditionally meeting the need , conformance to requirements , exceeding expectations have been definitions of quality. These definitions are merely performative or narrowly evaluative and are based on change- effect analysis, with emphasis on products or outcomes. They are still important in a field that deals with life and death but systemness allows in addition, a experiential dimension or the relationship between individuals and system. It is the system- in- use for the provider and system-in- sight for the patient. It is dependent upon both capabilities [people and process] and freedom [ instrumental and substantive].It is indicative that, one can have effectiveness without systemness, eg by luck , by adding resources and technology or greater effort ; but not systemness without effectiveness. To assure systemness , the system must be a critical and creative praxis; it is founded on opportunity and a readiness or capability to change. The idea which Don Berwick elegantly encapsulated in the quote above , with a probable reference to the Jamesian emphasis on the ‘will’. For the time being I would like to believe that systemness can be adequately measured only indirectly:

A. Unity: completeness,consistency, cohesiveness , willingness to work together for the benefit of the patient.

B. Flow: timeliness, shared plans,continuity and predictability.

C. Choice : customization, responsiveness, scope for patient participation .

D. Care : demonstration of responsibility for others , attentiveness to patient’s needs.

E. Stability and Simplicity .

Non of these are automatic consequences of the system ie effectiveness, but are meta-systemic variables. While a system has a sense of finality , systemness is an open- ended concept. Systemness is the horizontal [unity, completeness, choice] and longitudinal [flow ,consistency, predictability] simultaneous cummulation of small-scale changes. All of them are qualitative assessments which could serve as demarcation criteria for improvement . The word improvement presupposes success or effectiveness and thus we need a theoretical criteria that goes beyond the pragmatic concept of ‘meeting a need’ or ‘achievement of project goals’. Just as karl Poppers notion between science and non-science or Georges Canguilhem notions of the normal and the pathological.

Based on these assumptions , there are three alternative scenarios available, depending on the nature of evaluation:

a) Assessment of systems without assessment of effects or System as Practice approach.

b) Assessment of effects without assessment of systems or Practice as Systems approach.

c)Assessment of both outcomes as well as the processes used achieve them or System as Praxis Approach.

In positing systemness as a goal rather than a ideal, two things are achieved. Both systems and people are visible and secondly systems are not merely of instrumental value but constitutive to improvement. It is only if we have the concept and criteria of systemness, can we legitimately talk of systemic opportunity and systemic change. In this characterisation of praxis , the components of statistical thinking , psychology and epistemology can be made to bear upon systems thinking. The object of care is not the system but the person.

Finally, change is a transformative process, which includes reflection, participation and action, rather than a mechanistic model of inputs – outputs-feedback, i.e. the efficiency engineering definition of process as a series of interrelated activities. It determines the possibility of success and rate of improvement. Change is the acronym for a method for testing the ‘change hypothesis’.

My intention in this note is to tease out the concept of systemness from that of effectiveness. While both are similar , systemness is immediate , immanent and present. It is prospective for both individual and group.By the time you talk about effectiveness, for that individual patient it is already history. Systemness differs from system with regards to perspective : the system is from the point of view of the provider , while systemness is that of the patient or user of the system. It is the effective system in use. It is the study of impact and interaction.It is the demand of the individual and the collective. At a global level ,this understanding presupposes the approximation of system design and performance ; of outcomes and process; of stability and change. It also requires the disaggregation of what we normally refer to as ‘process’ into opportunity and change. They are similar to the processes of scientific discovery and scientific justification in science in general. On the other hand , systemness is also a process but a self reflexive one: how well the process works.

The OCS model can be used to theoretical demonstrate the following precepts of Improvement Science:

a. Improvement is a prerequisite for Quality.                                                                                 b. Improvement as a fly wheel:  multiplier of  effectiveness.                                                          c. Improvement can be independent of elaborate structure and resource.                               d. Improvement consists of Effectiveness and Learning.                                                               e. Improvement is synonymous with sustainability.

Adapted from the ‘Rapid Results’ literature: Improvement Bootstrap.

Thus the OCS model is in a way a truncated version of Donabedian structure -process- outcome schema, as the structure and outcome a partially bracketed , but process is elevated to the status of a syncategory. All this is possible only because the foundation of praxis allows feed forward. But justifying praxis as a learning process cannot ignore the tradition of feedback and thus the important question of how systemness impacts opportunity and change still needs to be answered. How can we measure opportunity.How can we manage opportunity. How can we design opportunity. I look forward to your comments.


Note: This entry is inspired by Amartya Sen’s book ” Development as Freedom’

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