Why It Matters
"Dosages” of the science of improvement should vary depending on an individual's role in an organization’s quality journey and how much improvement knowledge they need to be effective.
Photo by Mufid Majnun | Unsplash
When two patients with the same diagnosis (e.g., hypertension) are prescribed the same medicine (e.g., irbesartan), it is highly likely that they will be prescribed different doses. The usual dose of irbesartan for high blood pressure is between 150 mg to 300 mg, taken once a day. Why is there a range? Because the dose will be related to the needs of the patient. To manage their blood pressure, some patients will require 150 mg, while others may require 200 mg. Some will take 300 mg.
Similarly, "dosages” of the science of improvement (SOI) should vary depending on an individual's role in an organization’s quality journey and how much improvement knowledge they need to be effective. Not everyone needs to have the same dose of the SOI, for example, sending all staff to a 4-day quality improvement (QI) workshop. Therefore, it is incumbent on the leaders of an organization to have a serious dialogue about the dose of the SOI necessary for various parts of the organization. The dose, for example, that board members and senior leaders need will be different from what middle managers and supervisors need. The dose of the SOI for those delivering care will be different from what supervisors receive, and both doses will be different from the deeper dose those expected to coach and advise improvement teams should receive.
The Institute for Healthcare Improvement (IHI) helps determine the proper dose of the SOI needed by different groups within an organization. Note that the dosing approach is not a statistical formula that tells you how many staff “need to be trained.” Instead, it is a process that is tailor-made to the organization interested in building capacity and capability for QI.
Capacity refers to:
- The ability to receive, hold or absorb
- The maximum or optimum amount that can be absorbed
- The ability to learn or retain information
- A measure of volume; the maximum amount that can be held
Building capacity refers to filling people with the knowledge, methods, and skills of the SOI. It can be considered an initial step in creating the potential for an organization to improve. But building capacity by itself provides no assurance that improvement thinking and behaviors will be part of the very fabric of daily life within the organization.
Capability refers to:
- The power or ability to generate an outcome
- The ability to execute a specified course of action
- Knowledge, skill, ability, or characteristics associated with desirable performance on a job, such as problem solving, analytical thinking, or leadership
- Motives, beliefs, and values of individuals towards work
If capacity is focused on filling people with the appropriate knowledge (i.e., giving them potential) then capability is releasing this potential energy and turning it into kinetic energy. This means giving people with knowledge and skills of the SOI: 1) protected time to apply the knowledge they have gained; 2) access to structures and processes that support quality initiatives; and 3) opportunities to be part of a learning organization that values ongoing learning and growth.
Improvement leaders must analyze the number of individuals at various levels who need to be dosed and estimate the amount of SOI knowledge and skills they require to be effective participants in their organization’s QI journey. The results of this analysis will differ from organization to organization depending on:
- Number of employees
- Complexity
- Stage in the organization’s quality journey (i.e., just beginning, evolving, or mature)
- Leadership commitment to make quality the central driver of their business strategy
IHI has helped many organizations design and apply a dosing strategy. The capacity and capability journey requires an ongoing strategic and tactical commitment to prepare the organization for the future. It requires vision, a QI strategy, and the commitment of leadership to provide the structures, processes, and cultural context to make the vision a reality.
Figure 1 shows the starting point for a dosing strategy. Different shades of blue indicate the intensity of the SOI dose required for each group within an organization. The next step is to analyze the various groups of employees, use self-assessment tools to determine what individuals in each group know and do not know about the SOI, and finally co-design a strategy for administering the respective doses.
For example, some individuals may require a light dose that can be satisfied by administering the modules in the IHI Open School on the SOI. Others may require half-day doses, a day-long workshop, or more in-depth workshops such as the IHI Improvement Coach Professional Development Program or the 10-month Improvement Advisor Professional Development Program. Each organization must customize the approach to fit their organization’s needs. Figure 2 shows how IHI designed one of the first dosing strategies with the Kaiser Permanente Quality Institute in 2009. Figure 3 presents the dosing strategy developed with East London NHS Foundation Trust and Figure 4 presents the dosing design developed with the QI team at Barts Health NHS Trust.
Figure 1. Science of improvement dosing for selected groups within an organization (Source: Institute for Healthcare Improvement)
Figure 2. Improvement Institute dosing at Kaiser Permanente (Source: Kaiser Permanente)
Figure 3. Improvement dosing at East London NHS Foundation Trust (Source: East London NHS Foundation Trust)
Figure 4. Improvement Training dosing at Barts Health NHS Trust (Source: Barts Health NHS Trust)
Building capacity and capability for improvement is not difficult. But it does require the will to resist accepting the status quo as the organization’s operating philosophy. It also involves generating new ideas for improvement and execution skills to move the entire organization to a new level of desired performance. This journey begins with determining the appropriate dose of the SOI required in various parts of an organization.
Robert Lloyd, PhD, is IHI Vice President, Improvement Science & Methods, and a Senior Improvement Advisor.
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