# Presentation: 025567

## An integrated model for improvement: Implications for study design

- Frank Davidoff, MD, MACP
- Editor Emeritus, *Annals of Internal Medicine*
- Executive Editor, Institute for Healthcare Improvement

## Slide 2

## The three kinds of learning that drive improvement

- Scientific discovery: learning about “what is”
- Experiential discovery: learning about “what 	works” (i.e., learning about learning)
- Experiential learning: learning “how to”

## Slide 4

## Experiential learning: what it looks like

_**Setting**_: real-world, local, contextual 	variables not controlled
_**Product**_: know-how, competence, 	“knowing-in-practice”
_**Reflexiveness**_: learning changes the 	thing learned, i.e., performance – 	instability
_**Originality**_: learning what’s already known

## Scientific and experiential discovery: what they look like

_**Setting**_: artificial, protocol-driven, 	contextual variables controlled
_**Product**_: abstract, conceptual knowledge
_**Reflexiveness**_: discovery doesn’t change 	the thing discovered – stability
_**Originality**_: discovering what’s not yet 	known or understood

## Experiential learning: the action cycle

_**The generic cycle (informal):**_
**E**xperience  **Q**uestion  **C**onceptualize  **R**etry
- 				(Dewey, Piaget, Lewin, Schon, Kolb, et al)

## Experiential learning: the wholeness rule

_**You need all the cycle’s elements**_
- 	No reflection (Q and C)  stagnation
- 	No experience (E and R)  pedantry

## Experiential learning: extending the action cycle

_**The generic cycle (informal learning):**_
**E**xperience  **Q**uestion  **C**onceptualize  **R**etry
_**The extended cycle (formal learning):**_
**P**lan  **D**o (**E**)  **S**tudy** (Q+C**)  **A**ct (**R**)

## The experiential learning action cycle: what’s missing?

- _Scientific and experiential discovery_:
- 		**P**lan  **D**o  **S**tudy  **P**ublish
- _Experiential learning_:
- 		**P**lan  **D**o  **S**tudy  **A**ct
- _Answer: No “Publish” step_
- 						(Tom Nolan)

## Quality improvement: the need for extended action cycles

- _A new generic cycle:_
- 	**P**lan  **D**o  **S**tudy  **A**ct**/D**isseminate
- _For experiential learning:_
- 	**P**lan  **D**o  **S**tudy  **A**ct/**T**each/**C**oach
- _For experiential discovery:_
- 	**P**lan  **D**o  **S**tudy  **A**ct/**P**ublish/**D**iscuss

## Failure to publish: the consequences

- Trouble establishing repeatability
- Prevents public scrutiny, accountability
- Reduces opportunity to clarify thinking
- Slows spread of known improvements
- Inhibits discovery of innovations
- Ethical issue: fails to give back to public
- Limits influence of publication on QI

## Publication shapes scientific discovery

- Peer review
- Requirement for authors’ control of data
- Requirement for authors’ control of 	decision to publish
- Publication guidelines
- General: Uniform Requirements for Manuscripts (ICMJE)
- By design and content (CONSORT)

## Can publication shape improvement?

- BMJ/QSHC 1999 publication guidelines
- For less formal “QI case reports”
- New proposed publication guidelines
- For more organized, formal QI projects: experiential discovery
- Adopts IMRaD format: generic flow of all thinking in discovery
- Not suitable for story telling, reviews, etc.
- Potential impact on planning QI, funding decisions, editorial process

## Summary: An integrated model of QI

- Science-based care is complex
- Improvement must be layered on, built in
- Integrated model: 3 kinds of learning
- The key role of experiential learning

- Experiential discovery: link to generalizable knowledge
- Publication guidelines: help shape QI