Welcome to the base-camp of Improvement Methodology !
‘There is nothing so practical as a good theory.’
– Kurt Lewin
The word Improvement Science is a declaration of the maturity of field and an independence from its ‘translational’ adolescence . The development of any discipline is dependent on its ability to clearly demarcate its boundaries. To provide an architecture of its knowledge. We suggest a few guidelines below, with a hope they will be enriched by others: they may appear bland at first , but are amenable to interesting reconfigurations in the future.
Improvement Method/PDSA/ Skills or How do we know that change is an improvement?* What have we achieved ? What have we learnt? The ‘technique and experience of Improvement’
Improvement Policy/Strategy or What are we trying to accomplish?* And what changes can we make in order to improve, spread or sustain *?
Improvement Practice/ Systemor Why should we improve ? When can we improve? **What are the opportunities and capabilities required? What attitudes are helpful? Who should be involved ? What methods and models are appropriate ? What are the necessary resources to suceed? Both Policy and Practice are managerial or programmatic in emphasis and are interested in the ‘context of improvement’ and largely view it as ‘technology’.
Improvement Science/ Studies or What is the body of knowledge that assures competence in improvement? How do we learn from improvement?How does improvement work ? What is its history, sociology and pedagogy? eg. Who is a Improvement Professional or Expert ? Are the results significant and are they generalisable? What is the ideal format for a public discourse about its claims? It is required to answer the question ” What is it that you are doing ?’ In a broad sense, its focus is on the ‘institution of improvement’: Structure ,Sucess/Progress and Justification.
Improvement Research or Does improvement work? How well does it work , compared to what and at what cost? Does improvement policy , practice and theory work? Again how well? It deals with the ‘evaluation of improvement ‘
Improvement Theory/Methodology or What is improvement? Why and how does it work? What is the nature of its method? Can it be analysed into its components? What is improvement policy, practice , theory or research ? How and why do they work ? How can they work better? It is concerned with the ‘content or nature of improvement ‘.
How do we learn from improvement? What is the source and nature of improvement knowledge? What are the limits of its knowledge and methods? Is it a science and if so, what kind of science? Is it a unitary science or is it a bundle of sciences? How does it relate to others methods?
Does Improvement Research work ? Why and how does it work ? What assumptions does improvement research make about Improvement Method? How can it work better?
What assumptions does Improvement Method make about the scientific nature of the practice domain ? What assumptions does improvement research make about the scientific nature of the practice domain?
What is the moral responsibility of the improvement agent ?
The concerns of Improvement Theory are not empirical questions, but are nevertheless important. This excercise is a second order inquiry and cannot be answered from within medicine or improvement . Improvement research methodologically retains the traditional comparative method; and is thus efficient in verfying reliability but not validity of improvement . Improvement Theory does not negate the need for Improvement Research, but merely supervenes it.
It is current practice the world over to use the words Improvement science and Improvement Theory interchangeably.I believe it would be worthwhile to make a distinction. The domain of Improvement Theory as distinct from Improvement Science is justified as it allows us to ask fundamental questions which would otherwise not be possible : for e.g because of the empirical nature of Improvement Method it is not possible, without begging the question , to ask within Improvement Method: What is ‘this thing called improvement ? Is it physical i.e. exists in spaceand time or mental i.e. exists in time alone or is it abstract i.e. it exists neither in space or time. Can it be broken down into components ? Is it descriptive or normative? Is it discovered by an individual or constructed socially ? Further , conceptually at what point in time does change become improvement? I am aware that in a logical positivist tradition of science these questions would be metaphysical speculation and would thus be meaningless, ‘nonsense’ or without cognitive significance . It is possible that Improvement would turn out to be a science- sui- generis. Nevertheless I would like to believe it would , at the least, be a post-positivistic science.
Similarly, absence of a well defined domain of Improvement Theory has allowed Improvement Research, with its mechanistic underpinning of a RCT, to question the effectiveness of Improvement Methods, without due consideration of conceptual complexity and situational uniqueness of certain improvement interventions . Improvement Theory evaluates Improvement Research but Improvement Research, because of its definitional fixation on ‘evidence ‘ and clarity of initial condtions, is illequipped to evaluate Improvement Theory?
In this introductory brief I have merely raised demarcating questions in order to show that Improvement Theory is not the same as improvement method, strategy, system, science or research . The purpose of this blog is to inquire whether this hierachical question framework can be fruitfully translated into similar hierachical, telescopic definition framework ? And eventually, whether and how such a meta-theoretical analysis would contribute to healthcare improvement. The idea being , that a simplified version would be useful as a entry point for beginners in the field, as well as a motivation for researchers .
One could summarise the categories under these two headings :
Method : Tools , Policy and System.
Methodology : Science, Research and Theory. The quality of Improvement.
I have a more immediate reason for adopting this schema : While the importance of strategy and practice to theory is not in question , visitors to this blog are unlikely to find much commentary on them . Those interested in applied aspects can find excellent resources in the links collected under the heading ‘improvemnt Fraternity’ on the right hand side column of these pages.
Key Words: Improvement Method, Improvement Science, Improvement Theory,Improvement Research, Method, Methodology, Demarcation, Post-Positivist Science.
*The improvement model from Improvement Guide: A Practical Approach to Improving Organizational Performanceby Tom Nolan et al. Please visit Apiweb.org
** Don Berwick’s premises for identifying: Ripeness for Improvement. Please visit IHI.org.
Note: The contents of this blog are not peer-reviewed. They are offered as broad brush strokes of an ‘Agenda for Scholarship’.