Improvements to Health Services in High-income Countries
Improvements to Health Services in High-income Countries
Patients and citizens want more and better healthcare, and want to pay less for it. One way rapidly to respond to these demands is to spread proven or promising improvements in treatments or service delivery models. However, there is little research from high-income countries about effective ways to spread these improvements. In international health there is more experience and knowledge of scale-up, more variety in research approaches used to study the subject, and fewer resources and infrastructure for scaling-up improvements across a nation. This paper draws on reviews of research and experience in international health to contribute to conceptual and empirical knowledge as well as to practical strategies. It describes and illustrates three approaches: hierarchical control, participatory adaptation and facilitated evolution. It presents lessons from international health which could be of use to those studying, choosing, planning and progressing strategies to increase the uptake of proven or promising interventions to health services in high-income countries.
Many studies have show variations in the quality of health services and the potential for improvement. There is evidence of the high cost of quality under-performance, both in suffering and in financial terms. There is also growing evidence of interventions and changes which can be effective in some situations for improving quality. One approach has been to find such effective changes, specify their elements and enable and encourage others to copy the change, using 'spread' or 'scale-up' strategies. This is distinct from 'diffusion', which refers less to an intentional strategy and more to how innovations become adopted, although knowledge of innovation diffusion can contribute to understanding successful intentional spread.
Quality breakthrough collaboratives are one example of an intentional spread strategy, but the results of individual projects taking part in collaboratives are variable, as are the results from spread programmes of other types. Many questions remain about the cost effectiveness of collaboratives and of similar strategies, and about whether one approach is as effective for preventing, for example, central line infection as it would be for other changes such as spreading a 'medical home model' or 'computer physician order entry'.
Overall, the intentional spread of an improvement change found to be effective in one place to other places has not been as successful as was hoped. This paper proposes that some explanations and solutions for this can be found from international studies of the 'scale-up' of practices and projects.
In this paper 'international health' refers to knowledge about health services, systems and population health in middle and lower income countries, as opposed to knowledge about these subjects in higher income countries such as Northern America, Europe and Australasia, although this distinction is increasingly problematic. There is an extensive experience of trying to improve health and healthcare in low-income countries, and examples of scale-up strategies, often lead by non-governmental organizations and church agencies (NGOs). Researchers in international health have developed research and evaluation methods, and debated many of the conceptual and epistemological issues which are beginning to be confronted by quality improvement (QI) researchers when considering ways to document and evaluate complex social interventions and large-scale social programmes.
The aim of this paper is to contribute both to research and to practical action for strategies and methods to speed and spread the use of effective treatments and service models. The paper draws on the author's research and experience in international health to identify three distinct approaches which are illustrated in different examples. The research is a systematic review of strategies for strengthening health systems, a review carried out by the author for an IHI/VHA conference on the subject, and the author's evaluations of and experience with international health projects since 1994. The lessons from this field could be of use to those studying, choosing, planning and progressing strategies to increase the uptake of proven or promising interventions to health services in high-income countries, such as researchers, policy advisors, managers and QI specialists.
Abstract and Introduction
Abstract
Patients and citizens want more and better healthcare, and want to pay less for it. One way rapidly to respond to these demands is to spread proven or promising improvements in treatments or service delivery models. However, there is little research from high-income countries about effective ways to spread these improvements. In international health there is more experience and knowledge of scale-up, more variety in research approaches used to study the subject, and fewer resources and infrastructure for scaling-up improvements across a nation. This paper draws on reviews of research and experience in international health to contribute to conceptual and empirical knowledge as well as to practical strategies. It describes and illustrates three approaches: hierarchical control, participatory adaptation and facilitated evolution. It presents lessons from international health which could be of use to those studying, choosing, planning and progressing strategies to increase the uptake of proven or promising interventions to health services in high-income countries.
Introduction
Many studies have show variations in the quality of health services and the potential for improvement. There is evidence of the high cost of quality under-performance, both in suffering and in financial terms. There is also growing evidence of interventions and changes which can be effective in some situations for improving quality. One approach has been to find such effective changes, specify their elements and enable and encourage others to copy the change, using 'spread' or 'scale-up' strategies. This is distinct from 'diffusion', which refers less to an intentional strategy and more to how innovations become adopted, although knowledge of innovation diffusion can contribute to understanding successful intentional spread.
Quality breakthrough collaboratives are one example of an intentional spread strategy, but the results of individual projects taking part in collaboratives are variable, as are the results from spread programmes of other types. Many questions remain about the cost effectiveness of collaboratives and of similar strategies, and about whether one approach is as effective for preventing, for example, central line infection as it would be for other changes such as spreading a 'medical home model' or 'computer physician order entry'.
Overall, the intentional spread of an improvement change found to be effective in one place to other places has not been as successful as was hoped. This paper proposes that some explanations and solutions for this can be found from international studies of the 'scale-up' of practices and projects.
International Health Experience and Research
In this paper 'international health' refers to knowledge about health services, systems and population health in middle and lower income countries, as opposed to knowledge about these subjects in higher income countries such as Northern America, Europe and Australasia, although this distinction is increasingly problematic. There is an extensive experience of trying to improve health and healthcare in low-income countries, and examples of scale-up strategies, often lead by non-governmental organizations and church agencies (NGOs). Researchers in international health have developed research and evaluation methods, and debated many of the conceptual and epistemological issues which are beginning to be confronted by quality improvement (QI) researchers when considering ways to document and evaluate complex social interventions and large-scale social programmes.
The aim of this paper is to contribute both to research and to practical action for strategies and methods to speed and spread the use of effective treatments and service models. The paper draws on the author's research and experience in international health to identify three distinct approaches which are illustrated in different examples. The research is a systematic review of strategies for strengthening health systems, a review carried out by the author for an IHI/VHA conference on the subject, and the author's evaluations of and experience with international health projects since 1994. The lessons from this field could be of use to those studying, choosing, planning and progressing strategies to increase the uptake of proven or promising interventions to health services in high-income countries, such as researchers, policy advisors, managers and QI specialists.
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