HomeSeptember 2015A Proven Framework For Change

A Proven Framework For Change

Dr. Peter Lachman says the framework for change used on the RCPI Quality and Leadership Diploma can be used to introduce improvement in the Irish health services.

Dr. Peter Lachman
Dr. Peter Lachman

The aim of healthcare should be to ensure that the person who needs care receives the right treatment the first and every time, wherever he or she is treated, and without delay. One could say that that is impossible without added resources, as the healthcare system in Ireland is overburdened with an ageing population, insufficient resources to meet the demand and the political challenges to deliver the requires change. This is no different to other healthcare systems. I contend that if we apply what we know, by using methods that work, then we can move to the ideal and apply available resources more effectively and efficiently.

To achieve reliability one needs vision, leadership committed to the vision, and a theory, method and measurement system for change. In this article I will introduce a framework for change that we use on the RCPI Quality and Leadership Diploma.

To achieve reliability one needs vision, leadership committed to the vision, and a theory, method and measurement system for change.

The theories of continual quality improvement emanate from a long line of theorists and have been introduced in healthcare only in the last 20 years. Based on the teaching of Deming, Shewhart and Juran, these theories provide the framework for change. On the RCPI diploma we have elected to teach the theories of Deming and use some of the methods that have evolved from that theory.

Deming published two books which underpin continual improvement[1][2]. Deming’s theories represent a synthesis of the leading sociological, psychological and change management research over the last century. He viewed change through four lenses and called this Profound (or Improvement) Knowledge. Within the healthcare system one can use these lenses to introduce improvement.

  • The first lens is the need to understand Systems. Clinical Microsystems are the key components of healthcare and when we understand how they work and interact, and then we can develop the processes for improvement. The interaction of the Clinical Microsystems and their relationship to the wider system is essential to implement lasting change. Microsystem theory as developed in Dartmouth[3] examines how clinical teams can make a difference with ownership of the improvement needed. The larger and smaller systems within the service all have the same dynamic interactions that can either promote or hinder improvement.
  • The second lens is that of Psychology as systems are made up of people and processes. One needs to understand the belief systems that exist, which determine attitudes and behaviour; i.e. the culture that dictates how people work. This is complex as one requires engagement and buy-in for change. Too often good ideas and initiatives developed in the centre, fail when the people in the clinical Microsystems are not engaged in the process and do not own the proposed change, no matter how logical it is.
  • Systems and people produce Variation and Deming contended that to achieve maximum performance one requires a deep understanding of the variation within the system; be it common causee. a manifestation of the system’s processes or a special cause which needs to be studied. Often we react to normal variation without any understanding that it is what one would expect from a stable system. Use of Shewhart or statistical control charts allows this to be studied with confidence.
  • Finally one needs Knowledge of a method for change be it the Model for Improvement, Lean, or Six Sigma. These all have the same ethos; that testing and measurement are integral parts of a quality improvement programme.

One needs to understand the belief systems that exist, which determine attitudes and behaviour; i.e. the culture that dictates how people work.

An example is the wait times in ED. One could say the problem is the lack of beds but if one studies variation over time, while there is increasing demand the system may be in a more steady state than one realises, with occasional special causes resulting in a decrease or increase in demand. The solution to this challenge lies in working with the complex interaction of different systems i.e. hospitals, care homes, primary care and the different clinical Microsystems within the hospitals. All of these are influenced by the belief systems of the staff, patients and managers. We have had four hospital teams on the RCPI Diploma use these improvement lenses to start help them understand their ED congestion and then develop an improvement project using improvement methodologies (details from RCPI).

Deming said “it’s no use trying to do your best, first you must know what to do and then do your best.” The system of Profound Knowledge, when added to subject matter knowledge of clinicians and managers, offers a framework for improvement and allows you to know what to do. The theory of change is then applied and can be chosen depending on the needs of the problem.

In the next article I will look at concepts that could be used to improve the flow of patients in the healthcare system.

Dr Peter Lachman is the Quality Improvement Lead Faculty for RCPI and the National Quality Improvement Programme (HSE/RCPI). In 2005-2006, Peter became a Fellow of Quality Improvement at the Institute for Healthcare Improvement in Cambridge, Massachusetts. His current position is Deputy Medical Director (Patient Safety), Great Ormond Street Hospital for Children NHS Foundation Trust. He is also a Consultant Paediatrician at the Royal Free Hospital Hampstead NHS Foundation. His current interests are in patient safety and designing services that are safe and person friendly at the same time.



  • [1] Deming, W. Edwards (1993). The New Economics for Industry, Government, and Education. Boston, Ma: MIT Press.
  • [2] Deming, W. Edwards (2000). Out of the crisis (1. MIT Press ed.). Cambridge, Mass.: MIT Press.
  • [3]