Two kinds of knowledge to achieve better care.

In this issue of JGIM, Deyo et al. present the results of a 1-year effort by 22 organizations to improve the care of patients with back pain.1 Sponsored by the Institute for Healthcare Improvement (IHI), this “Breakthrough Series” collaborative sought to diminish the gap between what is known about best care for back pain and what is delivered to most patients in practice. Experts in the field coached the participants on the “principles of scientific back care”: highlighting the role of primary care, identifying patients at risk for systemic disease and neurologic impairment, focusing (and decreasing) the use of radiography, minimizing bed rest, and encouraging exercise to prevent recurrences. Experts in change management and improvement taught about “rapid change,” including 1) strategies to break down the overall goal of improving back pain care into smaller, more specific aims (such as achieving appropriate triage, establishing a cost-effective evaluation strategy, and shortening the time to return to work); 2) an interdisciplinary approach to intervene at multiple points in the process of care; and 3) a series of small pilots to test and establish new practices. This combination of professional knowledge (the “evidence” in evidence-based medicine) and knowledge for improvement (a structured approach to achieving change for better care) is a powerful foundation for improving health care.2 Experience has taught us that knowledge of the literature, while essential, may be insufficient to making best care happen day to day.3,4 Similarly, performance measurement and feedback are critical to improvement, but they may not be enough to achieve better results.5,6 Why? In part because individual clinicians work within a system of care. To be applied consistently, knowledge of best care must be embedded in that system. To achieve change, feedback about what is being accomplished must be used to help the system as a whole learn to improve. The operative question is not “How am I doing?” but “How are we doing?” The next question is “How can we do better?” The cases described by Deyo and his colleagues are good examples. The organizations adopted interventions that included information and feedback to physicians, but also included system-based actions: new patient education materials, easy availability of physical therapy consultation, modified standards for back films, and changes in medical record forms. Table 2 in their article lists potential strategies for improvement throughout the process of back pain care: before the office visit, at the time of care, and afterward to accelerate a return to usual activities. Note that this approach focuses on the process from the patient's (not the provider's) point of view, starting before and continuing after the office visit. Making change in a system, even a small one, is not an easy task. Fortunately, much is known about making change successfully and in a way that is durable. Knowledge for improvement draws on literature from a variety of fields (anthropology, diffusion science, outcomes measurement, organizational behavior, psychology, statistical process control, and others) to give us a structured approach to change. The most successful organizations in the back pain collaborative used these methods to implement six or more interventions in only a year. One must note that the organizations in this group were highly motivated to make a change in how they cared for patients with back pain. They volunteered to be part of the collaborative and paid a substantial fee to participate. The Deyo article represents a cohort study that must be combined with other evidence to draw generalizable lessons about improving care. For this group, the authors observed several elements they felt to be associated with success: confidence about the scientific evidence for the change, establishing specific goals, quick tests of change, monitoring the results, and involving both clinicians and administrators. These observations are consistent with prior reports describing the characteristics of effective improvement efforts: 1) involvement and collaboration of the providers whose practice is affected, 2) support for change at multiple levels of the organization, 3) specific changes that are understandable and easy to control, 4) organized systems to support and reinforce the proposed change, and 5) ongoing measurement and feedback.4,7,8 Collaborative learning across organizations is a popular and potentially powerful way to disseminate knowledge and skill about improving care. In addition to the work described by Deyo et al., IHI has used this approach to help health care organizations improve care for patients approaching the end of life, reduce adverse drug events and medical errors, improve outcomes and reduce costs in adult cardiac surgery, safely reduce Cesarean section rates, and reduce costs and improve outcomes in adult intensive care.9–11 Other examples of multi-site collaborative learning include a 57-clinic, two-HMO effort to improve adult preventive services12 and a five-hospital consortium to reduce mortality after coronary artery bypass graft surgery.13 Another way to spread knowledge and skill in improving care is to include it as part of the core education of health professionals. While this approach has a longer time horizon, it has the potential for enormous impact. How different (and faster) our efforts to improve will be when health professionals in practice are able to analyze the processes of care, interpret data on outcomes, generate hypotheses about the relation between variation in process and variation in outcomes, and, based on this evidence, design and test interventions for improvement. The President's Commission on Consumer Protection and Quality in the Health Care Industry recognized this need, calling for “a health care workforce that is strongly dedicated to caring for patients, knowledgeable and well trained, committed to continuous quality improvement and cooperative work.”14 The Accrediting Council for Graduate Medical Education now includes “practice-based learning and improvement” and “systems-based practice” as two of its six areas of core competency for all physicians.15 Deyo and colleagues began with an interdisciplinary planning group that included experts in back pain (professional knowledge) and experts in making change (knowledge for improvement). They generated specific recommendations for improving the care of patients with back pain, shared these with teams from participating organizations, and then coached them as they worked to apply the lessons to their local environments. Their work takes us a step further in learning how to improve care. It also has implications for educators, who must find ways for young physicians and other health professionals to finish their training with both the professional knowledge and the knowledge for improvement they need for modern, evidence-based, continually improving clinical practice.