Past Program

Jul 10 - Jul 15, 2016

Better Health Care: How do we learn about improvement?


Achieving the best health care outcomes is constrained by systems' ability to reliably deliver evidence-based care, every time, to the people who need it. Systems include not only the design of care models and care delivery processes, but also supporting structures and the human interactions in between. These human interactions at every level put improving healthcare squarely in the arena of complex, adaptive systems.

The field of improvement has evolved to address the complex, systemic nature of health care challenges, particularly through the use of adaptive, iterative testing and implementation of changes which empower teams to use data in real-time to test changes which address systems issues and lead to improved outcomes. These teams engage all the key stakeholders involved in the outcome of interest, and can include various cadres of healthcare workers as well as patients, families and communities. For several decades the application of modern improvement methods has evolved from working to improve simple processes in facilities, for example to reduce waiting times, to clinical improvements like reducing the incidence of hospital acquired infections, to more significant improvements in healthcare, like decreases in mortality, and achieving such results at scale.

Given the adaptive, iterative nature of improvement, the method of learning about the improvement should not undermine these very features which make improvement activities successful. For the most part, improvement methods have relied on time series charts, with or without statistical process control. Other designs include: stepped wedge trials, time series analyses with or without control groups and case reports. The use of randomized controlled trials, the gold standard for clinical research, has been limited in the field of improvement, with the fixed conceptualization of the improvement intervention, donor constraints and ethical issues regarding randomization, particularly for those in low- and middle-income country settings, often cited. Nuanced review of these methods and matching them to the aim of the inquiry is needed, as well as efforts to develop the epistemology of the field of improvement.


Bruce Agins
Medical Director, AIDS Institute/New York State Department of Health, New York, N.Y., USA
Joshua Bardfield
Danika Barry
Danika Barry, Healthcare Improvement Fellow, USAID ASSIST Project and Quality & Performance Institute (QPI) at University Research Company, LLC, USA
Maina Boucar
Director, USAID ASSIST Project for Francophone Africa, Niger
Viktor Boguslavskyi
Regional Director - East Africa, Europe & Eurasia, USAID ASSIST Project, USA
Bruno Bouchet
Director, Health Systems Strengthening division, FHI 360, USA
Rhea Bright
Technical Advisor, Office of Health Systems, U.S. Agency for International Development (USAID), USA
Danielle Charlet
Technical Advisor, University Research Company, LLC, Canada
Vijay Chattu
Faculty, University of the West Indies- Trinidad & Tobago and Lead Assessor, NABH, India
Astou Coly
Senior Improvement Advisor, USAID ASSIST Project, USA
Mahesh Devnani
Associate Professor of Hospital Administration and Joint Medical Superintendent, Post Graduate Institute of Medical Education and Research (PGIMER), India
Nancy Dixon
Nancy Drazner Zionts
Chief Operating Officer and Chief Program Officer, Jewish Healthcare Foundation, USA
Amel Farrag Hammad
Senior Quality Consultant, Ministry of Health and Population, Egypt
Katherine Fatta
Improvement Advisor for Knowledge Management, University Research Co., LLC (URC) & Center for Human Services (CHS), USA
Karen Wolk Feinstein
Founding and Current President and Chief Executive Officer, Jewish Healthcare Foundation, USA
Ezequiel Garcia Elorrio
Director Health Care Quality and Patient Safety, Institute for Clinical Effectiveness and Health Policy, Argentina
Donald Goldmann
Chief Medical and Scientific Officer, Institute for Healthcare Improvement (IHI)
Cecil Haverkamp
Country Director, University Research Co., LLC, Botswana
James Heiby
Medical Officer and Contracting Officer's Technical Representative, USAID Health Care Improvement Project, Washington, DC
Jorge Hermida
Director of HCI Programs-Latin American Region, University Research Co., LLC, USA
Lisa Hirschhorn
Associate Professor of Medicine, Harvard Medical School and Director Implementation and Improvement Science, Ariadne Labs, USA
Clifford Hughes
President, International Society for Quality in Health Care and Senior Advisor, Patient Safety at Guy's & St Thomas' Trust, Ireland
Usman Iqbal
Assistant Professor and Digital Health Consultant, Taipei Medical University, Taiwan
Donna Jacobs
Public Health Professional, USAID ASSIST Project, South Africa
Rachel Jean-Baptiste
Oxford Epidemiology Services, USA
Ashish K. Jha
Director, Harvard Global Health Institute and the K.T. Li Professor of Health Policy, Harvard T.H. Chan School of Public Health as well as Professor of Medicine at Harvard Medical School, USA
Mary Kawonga
Medical Specialist, Community Health, Gauteng Provincial Health Department & University of Witwatersrand School of Public Health, South Africa
Edward Kelley
Director, Service Delivery and Safety, World Health Organization, Switzerland
Peter Lachman
CEO, International Society for Quality in Healthcare, Ireland
Teresa Li
Assistant Director, Family and Elderly Health Services, Department of Health of the Hong Kong SAR Government, China
Nigel Livesley
Project Director, ASSIST India, USAID ASSIST Project/URC, USA
Deneil Logiudice
Quality Improvement Consultant, The Billions Institute, LLC, USA
Charles Maina
Monitoring & Evaluation Advisor, University Research Co., LLC, Kenya
Nancy Marquez
Knowledge Management Director, USAID ASSIST Project/URC, USA
Michael Marx
Professor for International Public Health, Institute of Public Health, University of Heidelberg, Germany
Nana Mensah-Abrampah
Technical Officer, Service Delivery and Safety Department, World Health Organization (WHO), Switzerland
Brian Mittman
Senior Scientist, Kaiser Permanente Department of Research and Evaluation and Senior Implementation Scientist, US Department of Veterans Affairs' Quality Enhancement Research Initiative (QUERI), USA
Mohamed Mohamed
Director Health Quality Assurance, Ministry of Health, Tanzania
Andrew Muhire
Sector M&E and Report Lead Specialist, Ministry of Health, Rwanda
Bejoy Nambiar
Research Associate, Institute for Global Health, UCL, India
Houleymata N'Diaye
Chief of Party, USAID ASSIST Mali
James Nganga Ndirangu
James Ndirangu, PhD, Regional Advisor, USAID ASSIST Project, South Africa
Katie O'Connor
Public Health Analyst, Health Resources and Service Administration (HRSA), USA
John Ovretveit
Director of Research and Professor of Health Care Innovation Implementation and Evaluation, Medical Management Centre, The Karolinska Institute, Sweden
Gareth Parry
Senior Scientist, Institute for Healthcare Improvement, United Kingdom
Mihajlo Rabrenovic
Associate Professor, School of Business Studies, Belgrade, Serbia
Rohit Ramaswamy
Clinical Associate Professor, Gillings School of Global Public Health, University of North Carolina, USA
Julie Reed
Deputy Director and Academic Lead, The National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Northwest London (NWL), United Kingdom
Amy Jacqueline Reid
Director, Institute for Healthcare Improvement (IHI)
Alexander Rowe
Medical Epidemiologist with the Malaria Branch of the U.S. Centers for Disease Control and Prevention (CDC), USA
Sylvia Sax
International Public Health Consultant, Researcher and Lecturer, Institute of Public Health, University of Heidelberg, Germany
Lisa Simpson
President and Chief Executive Officer, AcademyHealth, USA
Kelly Suzan
Executive Leadership Team, Neighborhood Health Center (NHC), USA
Abraham Wandersman
Professor of Psychology, University of South Carolina-Columbia, USA
Nengliang Yao
Assistant Professor of Public Health Sciences, University of Virginia, USA & Founding Chair, Global Health and Healthcare Interest Group, AcademyHealth, USA
Roman Yorick




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Key Questions

A key question being asked by those in the field is how we know whether the results achieved can be attributed to the intervention conducted. This question underlies one line of inquiry, however, there are many others which would contribute to our learning about improvement. For each, the choice of methods depends on the aim of the inquiry. For example, increasing knowledge on the contextual factors which underlie the "how" or "why" a successful result was achieved is a very different line of inquiry, requiring different methods, than asking to what degree a result is attributable to an improvement intervention. These are legitimate and welcome questions, as it indicates the field has evolved and grown, and it now poses the next challenge in the evolution of the science of improvement.

Outcomes and Impact

The value of such a result will be to help in the design, implementation and evaluation of improvement to increase the validity of the conclusions and the attribution of the results to the activities implemented. This in turn allows us to understand which activities under which conditions are most effective at achieving sustained results in health outcomes.


See what participants are saying about the session:

Sylvia Sax & Michael Marx from the Institute of Public Health at Heidelberg University, Germany


Don Goldmann, chief medical and scientific officer at the Institute for Healthcare Improvement (IHI) 


Ed Kelley, Director of Service Delivery and Safety at the WHO


Rashad Massoud, Senior Vice President, Quality & Performance Institute, and Director, USAID Health Care Improvement Project


Rhea Bright, Technical Advisor, Office of Health Systems, USAID


Andrew Muhire, M&E and Report Lead Specialist, Ministry of Health, Rwanda


Nancy Dixon, Health Care Researcher and Consultant