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**QUALITY IMPROVEMENT AND PATIENT SAFETY IN HEALTHCARE\ **Health care services are universal requirements by the population for healthy population. The provision of healthcare services has to bone in such a ways the safety of the recipients is given a top priority. Quality improvement and patients...

**QUALITY IMPROVEMENT AND PATIENT SAFETY IN HEALTHCARE\ **Health care services are universal requirements by the population for healthy population. The provision of healthcare services has to bone in such a ways the safety of the recipients is given a top priority. Quality improvement and patients safety in healthcare refers to the systematic and continuous efforts to enhance the effectiveness, efficiency, and safety of healthcare services delivered to patients. It involves a range of activities aimed at preventing errors, reducing harm, and improving patient outcomes. "Every system is perfectly designed to get the results it gets". The improvement in patient outcomes is dependent upon improving the systems that exist to provide healthcare. Quality Improvement uses a range of techniques and methods translated from other industries to improve the quality of patient care whilst driving down costs. Mastery of quality and patient safety sciences and practices should be part of initial preparation and lifelong education of all healthcare professionals, including managers and executives. A common problem encountered in the healthcare system is that managers see a clinical problem that they don\'t understand. Doctors see a "system problem" and hope that managers will sort it out. For the quality of care to improve, it is imperative that clinicians understand and engage with Quality Improvement as part of their daily work to guarantee patients safety. There is no single universal definition of quality. The Institute of Medicine has described quality in healthcare as being safe, effective, patient centered, timely, efficient, and equitable: *safety, experience of care, and effectiveness of care*. QI is a broad term that describes the systematic use of a range of tools and techniques to improve patient care and associated healthcare processes continuously. QI is sometimes described as 'the combined and unceasing efforts of everyone---healthcare professionals, patients and their families, researchers, payers, planners and educators---to make the changes that will lead to better patient outcomes (health), better system performance (care) and better professional development (learning). Quality improvement is the framework used to systematically improve care and to standardize processes and structure to reduce variation, achieve predictable results, and improve outcomes for patients, healthcare systems, and organizations. **DATA** **INTRODUCTION**: Effectiveness and efficiency of organizations are a product of the quality of actions taken on a regular basis in the course the business. Actions rely on the policies of the organization. Making decision requires knowledge of the environment of business based on information available to the decision makers. Manager at all levels and the subordinates carry out duties on a daily basis to further the course of the organization. The day to day successful operation of any system depends on available information that guide decision making. The information depends on the quality of data available to the operators of the system. Data may be denoted by different words which among others include: facts, figures, statistics, evidence, input, etc. they refer to a collection of individual facts, statistics or figures useful for a particular purpose which could be an analysis or a survey. It therefore relates to evidences that have translated into a form that is efficient for processing. They might include weight, age, temperatures, distances, individual prices, residence, feelings, thinking, opinion etc. Data generally represent a raw form of knowledge which do not carry significance or purpose. Data have to be interpreted to have a meaning. Although data and information are frequently used interchangeably, they have different meanings. **DATA VS INFORMATION\ **Data refers to the individual pieces of facts, number, figure or graphs; the idea contained in the organized and interpreted facts is information. Data may be seen as the bricks while information is seen as the house representing the bricks when laid out in an organized manner. Temperature reading over a period of time for a particular location may be seen as data. These temperature readings would be meaningless to anyone. An analysis of these temperature readings could be used to determine seasonal temperature pattern or climate trend. Data may appear simple and meaningless or even useless, but when analyzed, organized and interpreted it gives information. Data are facts that can be processed to get information; while Information is processed data that has meaning. **DIFFERENCES BETWEEN DATA AND INFORMATION\ **Data are a collection of facts while information put those facts into perspective. 1. Data are raw and not organized while information is organized. 2. Data are individual and sometimes unrelated; Information provides a complete picture of how the data fit. 3. Data in isolation is meaningless but when analyzed and interpreted, it becomes meaningful information. 4. Data do not depend on information; Information depends on data. 5. Data typically come in the form of numbers, graphs, statistics; Information are presented through words, language, thoughts and ideas. 6. Data are not sufficient for decision making while decision making can be based on information. **TYPES OF DATA\ **Data are broadly categorized into two, viz: Quantitative and qualitative data. **Quantitative Data**: These are data provided in numerical forms such as weight, height cost of items, volumes etc.\ **Qualitative Data**: These are data that are descriptive in nature such as name, sex, attitude, colour of eyes, opinion, feelings etc **SOURCES OF DATA\ **Sources of data are classified under primary, secondary and tertiary. These are based on the originality of the material and the proximity of the source or origin. **Primary Sources**: These are records of events or evidences as they are first described or actually happened without any interpretation or commentary. **Secondary Sources**: This offers an analysis of the primary sources by explaining or describing them. They often summarize, interpret, reorganize or otherwise provide added value to the primary sources eg articles that review or interpret research works. **Tertiary Sources**: This refers to sources that index, abstract, organize compile or digest other sources. Tertiary sources are usually not credited to a particular author. Examples of tertiary sources include dictionaries, , encyclopedias, indexing and abstracting sources, directories, fact books, handbooks, textbooks etc. some of these may also be secondary sources **USING DATA TO TELL A STORY\ **Use data to tell a story of the academic activities/achievements of the students of the class from the admission exercise through first semester of year one till date. These include: a. Performance at the admission exercise b. Attendance c. Class participation d. Performance at class test e. Report from clinical practice setting f. Performance at the semester examination g. Progression in the course **THE BASIC ELEMENTS OF A RUN CHART\ **Run chart is also referred to as run-sequence, trend chart or time series plot. It is a graph (line chart of data) that display observed data values in a time order (running record of process overtime). It graphically depicts the process performance or data values. Often the data displayed are used to represent observation over a period of time and to: a. Study the trend or pattern over a specific period of time b. Monitor the effects of an intervention (implementation of a solution) to measure the effect. c. Viewing data overtime gives a more accurate conclusion rather than just summary statistics. It can be used to identify shifts and trends. Run Chart **KEY COMPONENTS OF A RUN CHART** **Time-Series**: The specific time period of the output (Hours, Days, Weeks, Month Year) plotted on the horizontal (X) axis. **Output**: Data obtained from the measurement following completion of the measurement process. This is plotted on the vertical (Y) axis. **Data Points**: Output value (result) plotted on the chart. **Median Line**: The line on the graph that shows the averages of all the output measure. **STEPS TO CREATE A RUN CHART** 1. Determine the data to be measured 2. Obtain required data in a time sequence: minimum of 10 -- 15 data points are required. 3. Plot a graph in a time sequence in the x-axis and the measuring variables on the y-xis. 4. Plot the data value in a time order. 5. Compute the mean/median and apply the value to draw a horizontal line on the graph. 6. Analyze the graph (analyze trends and patterns to detect special cause variation in the process). **The run chart helps with:** 1. Monitoring of data overtime to detect trends, shifts and cycles. 2. Comparison of measure before and after the implementation of solution to measure impact. 3. Focusing attention on vital changes, not normal variations. 4. Tracking useful information for predicting trends. 5. To depict the effects or result of the process graphically. **FOUR RULES FOR INTERPRETING RUN CHART\ **The run is a five or more consecutive points in one direction either up all down. The following are the run chart decision rule to avoid inaccurate analysis and initiate appropriate improvement action. **Shift**: The shift indicates a dramatic change in the process. When a run chart exhibits seven of eight points successively, up or down the median line is a shift. It indicates that a trend is clearly present in the data and needs processing. It does not consider the points that fall on the median line as they are not towards or against the shift.  **Runs** -- Too many or too few runs displayed on the chart. In other words, one or more consecutive points are all lying on the same side of the line. The points on the line are ignored. https://sixsigmastudyguide.com/wp-content/uploads/2020/12/r1.png **Clustering**: Too few runs or groups of points in one or more areas of the plot. It is an indication of measurement or sampling problems  **Trend**: Seven or more consecutive points are increasing or decreasing. The rule of thumb is when a run chart exhibits seven or eight points successively up or down, then a trend is clearly present in the data and need process improvement. This rule applies when the consecutive points are above, below or crossing the median. https://sixsigmastudyguide.com/wp-content/uploads/2020/12/r4.png **Mixtures**: This implies that there are too many runs in a chart with absence of points near the median line.  **Astronomical Point**: This occurs when there is one value that is very different from the other data values on the chart. This value is an outlier is highly unlikely to occur again. Run Chart **COUNTING RUNS\ **The run is a series of point in a row on one side of the median ie one or more consecutive points are all lying on the same side of the median line. Some points can fall exactly on the line which do not define the side such runs belong to. We ignore if the value is exactly on the median line. Interpreting the run chart requires investigation. When two or more consecutive points are the same, you ignore one of the points when counting. This is because like values do not make or break a trend. **ADVANTAGES OF USING THE RUN CHART FOR DATA ANALYSIS** 1. It is easy to plot. 2. It does not require to many calculations or software to analyze. 3. It is easy to interpret the results. 4. Minimum knowledge of statistics re required to produce and interpret the chart **WHEN TO USE RUN CHART** 1. When it is necessary to visually depict how the process is running. 2. When it becomes necessary to effectively track and report improvement. 3. To identify process variation and guide objective action. 4. To display output that allows visualization for stability or instability. **IDENTIFYING SIGNALS OF IMPROVEMENT\ **The run chart is a powerful and useful for tracking information and predicting trends or patterns. It can determine whether a process has a common cause or special cause variation. The results enable you chose the most appropriate ways to manage performance. Improving performance is about closing gaps between the current level of performance and the target. The seven performance indicators that can be used to monitor improvements are: **Performance is Unpredictable and Chaotic**: This means performance fluctuates widely with high level of variability over time. This indicates that the process is out of control. **Performance is Worsening**: Indicators of performance can be based on intended or unintended results (outcomes). This can be a downward shift or trend as the patient satisfaction or profit. It can also be an upward shift or trend as the case with expenditure. We can identify at what point the worsening in performance began, we may be able to identify the why and take successful action. **Performance is Stable and not Changing**: Performance values are always expected to change to some extent. If this becomes consistent with the same range, it signals that nothing is changing. This is sometimes good when we are already at the target level but not good when we expect improvement following implementation of a change improvement Performance is Improving but too Slow for the Target: This call for intervention. Determine the reason for the slow progression despite efforts and take action. Sometime over ambitious target may cause this. **Performance is Improving Enough at a Rate that the Target Will Likely be met**: This is a good signal showing your strategies are working. We watch for extraneous variables in this case to keep on track. Keep reviewing your implementation and monitor results. **Performance has Reached Target**: This is the best signal from your performance measures showing that strategies and performance measures have worked. **Performance has Exceeded the Target**: This may sometimes result from potential waste of resources and time that could have invested in other KPIs calling for additional resources. **LOOKING AHEAD: IMPLEMENTATION AND SPREAD\ **Safety of care embraces the quality of care and the mechanism adopted in achieving it. The main dimensions are: **Safe**: Harm must be avoided when providing care that is intended to help patients.\ **Timely**: Care givers must reduce waits and sometimes, harmful delay.\ **Effective**: Services must be provided based on evidences that provide clear benefits.\ **Efficiency**: This involves providing the needed services and meeting the set targets based on the available resources. Avoiding waste is the key. The spread encourages that the coverage of performance improvement meet the majority or all of the target population. **QUALITY IMPROVEMENT FRAMEWORK\ **Quality Improvement (QI) strategy is an approach to change that provides a framework and tools to plan, organize and then to monitor, sustain and spread the changes that data show are improvements. The quality of healthcare can be measured by observing its structure, process and outcomes. The QI Project can include small samples, frequent changes in intervention, and adoption of new strategies that appear to be effective. Each of these measures assesses: **Structure**: Accessibility, availability and quality of resources such as health insurance, bed capacity of hospitals, and number of key personnel with advanced training.\ **Process**: The delivery of healthcare services by clinicians and providers\ **Outcome**: This indicates the final result of healthcare that can be influenced by environmental and behavioral factors. These include patients satisfaction, mortality and improved health status. **QUALITY IMPROVEMENT STRTEGIES AND TOOLS\ **Establish a QI policy and structure 1. Use proven QI strategies and tools 2. Use measurements and data to guide and drive improvement **Total Quality Management (TQI)**: This may also be referred to as Continuous Quality Improvement (CQI) incorporates the view that the entire organization must be committed to quality and improvement to achieve the best result. It involves organizational management, team work, defined processes, system thinking and change to create an environment of improvement. **Person-Centred**: There has to be an established partnership between the care providers and the service users to ensure the care users preferences and needs are respected.\ **Care Equity**: This involves providing services/care without having to vary quality because of a service user's characteristics. Next up: Implementation Making change stick **SUSTAIN CHANGE\ **This refers to how we can successfully sustain the new ways of carrying out the work that show improvements. - Ensure the change is ready to be implemented and sustained. - Allow time for experimentation as it provides freedom to work out the odds of the new process. - Build support among the teams and help them understand and experience how the new method is better. - Communicate the benefits of the improved process - As part of new standard approach to work, get staff to be consistently involved in the work which features the new innovations. - Make the new way of doing thing unavoidable with the standard work process. **SUSTAINING IMPROVEMENT\ **Select measures strategically a. Balance the resources required to report the measure against the value of the result b. Collect data from a variety of sources c. Display data d. Act on available information. **SPREAD CHANGE\ **Spreading the change means getting others to know about it and eliciting adoption of the strategies of improvements. This becomes possible when: a. You can demonstrate success with data. b. Have and hold project drivers who tested the initial change and are ready to communicate, influence and train others (spread) c. Have the interest and support of key leaders d. Have plans and resources to train staff to carry out the new processes. **BEST PRACTICE FOR SPREAD\ **This embraces the use of quality improvement strategies and tools. Strategies include: a. Have a QI Team in place with identified strategies. b. Adopt the Model for improvement which include the development of strategies (Aims, Measures and Ideas) c. The second component of the QI model is the use of Plan-Do-Study-Act (PDSA) cycle. Its steps include: **Plan**: Planning an intervention\ **Do**: Testing the change on a small scale\ **Study**: Observing, measuring and analyzing the test of change\ **Act**: Using the knowledge gained to plan the next step **Lean Methodology**: It is a client-focused strategy of quality improvement that aims to improve processes by driving out "non-value-ended" activities otherwise known as waste. This can be used to engage employees, manage work flow and improve processes, clinical quality and reliability. **SCIENCE OF IMPROVEMENT\ **The science of improvement is traced to W. Edward Deming who postulated that by adhering to certain principles of management, organizations can increase quality and at the same time reduce cost. It looks at working with individuals, teams or organizations, systems, state, regions and countries to improve quality, including, safety, equity and value in health and healthcare. It is the act of getting better or improving on the current level towards a set standard. This term applies to situations whether good or bad but getting better. The patient is at the centre of healthcare activities in the healthcare system. Quality improvement strategies are directed generally at satisfactory outcomes in client/patient care intervention meant to guarantee continuous improvement. The science of improvement is simply finding out how to improve and make changes in the most effective ways. It deals with a systematic examination of methods and factors that best work to facilitate quality improvement. The improvement science deploys rapid tests of change to guide the development, revision and continued fine-tuning of new tools, processes, work roles and relationships. This strategy is designed to accelerates learning by-doing The science of improvement is an applied science that includes the following and how they are applied to improve the performances in every facet of life including that of healthcare. 1. The interaction of systems thinking. 2. Understanding variation. 3. The theory of knowledge. 4. The psychology of change The proper application of this science requires the integration of a set of improvement methods and tools with knowledge of subject matter to develop, test, implement, spread and scale up changes that lead to improvement. Elements of the Science of Improvement Improvement science deploy rapid tests of change to guide the development, revision and continued fine-tuning of new tools, processes, work roles and relationships. The process is designed to accelerate learning-by-doing. Deming proposed four elements he referred to as the system of profound knowledge. This system provides an outside view (lens -- framework for quality planning) that serves as a map of theory to understand the organization and the context we work. He was of the opinion that it is the interaction of these elements with each other and with subject matter knowledge that produces the insight leading to improvement. The elements are: 1. Appreciation for a System 2. Understanding Variation 3. Theory of Knowledge 4. Knowledge of Psychology **The Deming Cycle** consist s of a logical sequence of four repetitive steps for continuous improvement and learning: PLAN, DO, CHECK (STUDY), and ACTS **SYSTEM OF PROFOUND KNOWLEDGE\ **A profound knowledge (having or show great understanding) is when a person takes in everything happening around them and continues to learn and work to find ways to improve it. Deming theory of Profound Knowledge is a management philosophy grounded in system theory. It is based on the principle that each organization is composed of a system of interrelated processes and people that makes up system's components. He developed his system of profound Knowledge to describe the work of organizations. The system of profound knowledge is made up of four components through which the world is looked at simultaneously. These components which are inter-related, function as lenses through which we see. The four components are: **Appreciation for a System**: This focus on the ways parts of the process interrelate and create a system with a specific aim. A business is a system whose parts interact and affect each other called unintended consequences. If we learn about the systems, we can better avoid these unintended consequences and optimize the whole system. **Understanding Variation**: This relates to knowledge about variation. One of the goals of quality is to reduce variation. We must be able to distinguish common cause variation (variations from the system) and special cause (variations from outside the system). Managers who do not understand variation frequently increase variation by their actions. **Theory of Knowledge**: There is no knowledge without theory. It recognizes the need for theory to make predictions and incorporate the scientific method in improvement. **Knowledge of Psychology**: To understand how interpersonal and social structures impact performance of a system or process. Leaders should therefore know how people learn, how people relate to change and what motivates people. The principle of Deming's theory is to create a constant purpose towards improvement. His theories are based on the simple concept of continual improvement which helps to increase quality while decreasing costs (Total Quality Management). The principles include: 1. Plan for quality in the long term. 2. Resist reacting with short-term solutions. 3. Don't just do the same thing batter, find better things to do. 4. Predict and prepare for future challenges. 5. Always have the goal of getting better. This theory is capable of helping individuals transform within their organizations which in turn improve outcomes in quality improvement efforts and also capable of creating a better leadership culture. Deming believed that: 1. Profound knowledge comes from outside the system and it is only useful if invited with firm desire to learn and improve. 2. A system only understands itself with help from outside the system as prior experiences bias objectivity required for critical analysis. 3. An objective self-examination is difficult without input from an impartial analysis from outside the organization. 4. Insiders can rarely serve as hostile critics without for of the system's reaction. **BENEFITS OF IMPROVEMENT SCIENCE\ ** 1. Continuous improvement is assured. 2. Data-Driven decision making 3. Collaborative learning communities 4. Focus on the right problems 5. Tested interventions 6. Adaptability 7. Sustainable change 8. Empowering workers. **PRINCIPLES OF CONTINOUS IMPROVEMENT** 1. Stop fixing and start improving 2. Best practices are the ones you already have. 3. Changing behaviour in more important than changing process 4. If you aren't falling, you aren't trying. **UNDERSTANDING VARIATION\ **Data variation also known as data variability, spread or dispersion refers to how wide a spread of data is. This allows data users a way to describe how much data set data sets vary. This allows analyst and users of statistics to compare different set of data. A change or slight difference in condition, amount or level, typically within certain limitsAbility to understand and manage data is key to understanding variation and managing confusions. Variations in treatment do occur. It is important to understand the reasoning behind alternative approaches to diagnosis and treatment. This will help tract the sources of the different approaches, justify the changed approach and use appropriate tools to reduce alternative approaches when appropriate. There are so many examples of random variation in healthcare which include: 1. For individual physiological makeup, patients would react to differently to identical courses of treatment. 2. Different courses of treatments are prescribed by different providers to nearly identical patients when both treatments could be equally effective. 3. A preference for one diagnostic method over another by clinicians. There are also some unjustified variations in healthcare such as: 1. Ignoring preferred pre-established treatment guidelines for unexplained reasons. 2. Prescription of therapies not in line with established guidelines or medically established best practice. 3. Prescription of medications without following an appropriate diagnostic method to determine whether such treatment is necessary. At times, warranted variation in healthcare may be done when there is a deviation from standard treatment or method of diagnosis. The reason for these departure are based on science or out of respect for patient's preferences. 1. Ignoring standard prescription guidelines because of known adverse reaction to such by the patient in the past. 2. Increasing or decreasing the schedule of treatment over a few weeks to accommodate patients work schedule. 3. Preference for a certain diagnostic method by the patient. **HOW TO REDUCE CLINICAL VARIATION\ **Every healthcare system seeks to reduce variation via: 1. Determine the part of your healthcare team that contributes to the changed approach. This can track down potential treatment and diagnostic inconsistencies. 2. Determine who is most likely responsible for the variation to decide how to reduce unwanted clinical variation. 3. Controlling variation can improve positive outcomes and reduce costs. It can also reduce legal liabilities and improve hospital's reputation. **PSYCHOLOGY OF CHANGE\ **Change is defined as a cause to be different or to transform. According to Dewing, Psychology of Change is defined as the science of the mind and human behaviour especially as a function of awareness, feelings or motivation. It is a cause to be different or transform. Summarily, the Psychology of Change is the science and art of human behaviour as it relates to transformation. The framework for advances and maintain improvement together with the people who are directly or indirectly affected by it. This include: Healthcare workers, patients and families, community members, policy makers ets. The inherent value of each of these persons is recognized by the framework It also recognizes ways of identifying how each person affected by the improvement can also contribute importantly to it. It also recognizes that people act according to their unique identities while conforming with predictable human behaviours. **Components of Change Framework\ **These include: 1. Power: Ability to act with purpose 2. Courage: Emotional resources to choose to act in the face of challenges 3. The Psychology of Change Framework. This has five domains which are not sequential as discussed but are interrelated. **Unleash Intrinsic Motivation**- Tapping into sources of intrinsic motivation galvanizes into peoples individual and collective commitment to act. **Co-Design People-Driven Change**: The most affected by change have the greatest interest in designing it in ways that are meaningful and workable to them. **Co-Produce in Authentic Relationship**: Change is co-produce when people inquire, listen see, and commit to one another. **Distribute Power**: People can contribute their unique assets to bring about change when power is shared. **Adapt in Action**: Acting can be a motivational experience for people to learn and redo to be effective. **APPRECIATION OF SYSTEM\ **Appreciation is a feeling of expression of admiration, approval or gratitude. A system on the other hand is a network of interdependent components that work together to accomplish the goal of the system. The aim is usually a gain for everybody and not that one part of the system gain at the expense of the other. According to Deming, a system is characterized by a set of interaction among the people who work there, the tools, methods, and materials they have at their disposal and the process through which these people and resources join to accomplish its work. Taking a systems approach results in management viewing the organization in terms of many internal and external interrelated connections and interactions, as opposed to discrete and independent departments or processes governed by various chains of command. When all the connections and interactions are working together to accomplish a shared aim, a business can achieve tremendous results---from improving the quality of its products and services, to raising the entire esprit de corps of a company. A system view of the organization views the flow of the processes to create products and services. The interactions between various processes are respected.  W. Edwards Deming view of an organization as a system A system view helps create a long term focus. Rather than seeing incidents as isolated (and often looking for the person to blame for a bad result) a system view allows managers to focus on the systemic drivers of results. *The aim proposed here for any organization is for everybody to gain -- stockholders, employees, suppliers, customers, community, the environment -- over the long term.* Dr. Deming continually increased the percentage of problems attributable to the system instead of to special causes (outside of the system) such as blaming a person for a mistake. Problems are most times inevitable but the most effective way to improve and avoid them is to improve the system. **THEORY OF KNOWLEDGE\ ** "The greatest obstacle to discovery is not ignorance -- it is the illusion of knowledge." -- Daniel J. Boorstin. Understanding the theory of knowledge within the context of the Deming's System for Managing helps us more effectively and consistently learn and improve the processes and systems we work with. Areas of knowledge to explore are: 1. What do we know that isn't so? 2. How can we avoid the mistakes we are in danger of making in our thinking? 3. How can we improve the learning process? These are some of the questions that led Dr. Deming to include the "theory of knowledge" in the System of Profound Knowledge. That is core to a theory of knowledge. [**Confirmation bias**](https://curiouscat.com/management/dictionary/confirmationbias):  is one such important concept; it means that we tend to key onto evidence that supports our beliefs and ignore evidence that undermines our beliefs. **Experiments, Prediction and Learning:** To the extent possible it is best to gather evidence based on experiments to support your theories. The model used within the Deming System for Managing to gain evidence and insight is the [Plan-Do-Study-Act (PDSA) cycle](https://curiouscat.com/management/dictionary/pdsa). The PDSA cycle is a process to improve based on an understanding of the theory of knowledge. People learn better when they predict. This forces us to think ahead about the outcomes and causes us to examine more deeply the system, question or theory we have in mind. Also we learn about our understanding of the management beliefs we hold as we examine the results of our predictions. **Variation:** People believe there is much less variation in systems and processes than there is. This underestimation of variation causes people to believe normal variation is not normal, which in turn causes them to search for special causes for the variation. Doing so is a very low yield strategy for improvement. **Psychology and the theory of knowledge:** As stated previously the four components of SoPK are interrelated. **Operational Definition**: There is no true value of any characteristic, state, or condition that is defined in terms of measurement or observation. The "value" is in the context for a given operational definition. Understanding that a value must be interpreted via context, leads us to question any data that doesn't provide the operational definition for how the data was created. And this leads to better understanding. Otherwise, without having the operational definition we are likely to draw incorrect conclusions from data. **In more detail the **[four elements](http://asqhdandl.org/uploads/3/4/6/3/34636479/2013_profound.pdf)**:** *[Appreciation of a System: A business is a system. Action in one part of the system will have effects in the other parts. We often call these "unintended consequences." By learning about systems we can better avoid these unintended consequences and optimize the whole system.]* *[Knowledge of Variation: One goal of quality is to reduce variation. Managers who do not understand variation frequently increase variation by their actions. Critical to this is understanding the two types of variation --- Common cause which is variation from the system and Special cause which variation from outside the system]* *[Theory of Knowledge: There is no knowledge without theory. Understanding the difference between theory and experience prevents shallow change. Theory requires prediction, not just explanation. While you can never prove that a theory is right, there must exist the possibility of proving it wrong by testing its predictions.]* *[Understanding of Psychology: To understand the interaction between work systems and people, leaders must seek to answer questions such as: How do people learn? How do people relate to change? What motivates people?]* *[[Deming's theory of profound knowledge]](http://www.berrywood.com/wp-content/uploads/2011/08/demingpaper.pdf) is a management philosophy grounded in systems theory. It is based on the principle that each organization is composed of a system of interrelated processes and people which make up system's components. The success of all workers within the system is dependent on management's capability to orchestrate the delicate balance of each component for optimization of the entire system.* *Deming believed profound knowledge generally comes from outside the system and is only useful if it is invited and received with an eagerness to learn and improve. A system cannot understand itself without help from outside the system, because prior experiences will bias objectivity, preventing critical analysis of the organization. Critical self-examination is difficult without impartial analysis from outside the organization. Also, insiders can rarely serve as hostile critics who speak frankly without fear of reprisals.* **MODEL OF IMPROVEMENT\ **The model for improvement is very versatile and has been widely adopted in healthcare settings for improvement purposes. It is based upon three fundamental questions that frame the improvement efforts: (i) ***What are we trying to accomplish**?* The aim of the improvement programme is defined with as much clarity as possible. (ii) ***How will we know that a change is an improvement**?* Improvement is defined and measured in relation to a clear baseline or current state, for which specific metrics can be chosen. (iii) ***What changes can we make that will result in improvement**?* Ideas for change based upon a clear understanding of the problem can be tested in a controlled fashion. Well-chosen measures are simple and unambiguous, and should be easy to use. A characteristic set of measures might include a measure of process, a measure of outcome, and a countermeasure (to look for unintended consequences). Answers to three fundamental questions are essential for guiding improvement work An improvement project that can be: **Process-**focused related to saving time, money or improving quality of a service or system, or. **Outcome-**focused on improving health status, behavior, attitude, and/or knowledge. **People** who will test the interventions or changes. A family of measures, including impact and process measures. A few of the measures should have the potential of being tracked at least monthly. Interventions to be tested that are grounded in science. **Time**, usually 6 to 16 months, to allow for multiple tests of interventions. Model for improvement An external file that holds a picture, illustration, etc. Object name is gr1.jpg