1. 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

2. Scientific discovery Experiential discovery New generalizable knowledge Patients, populations in particular settings Improved outcomes + Locating, acquiring, and evaluating new knowledge Adapting evidence and redesigning practices Executing changes Developing and using measurements Established generalizable scientific knowledge Patients, populations in particular settings Desirable outcomes +

3. 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”

4. Scientific discovery Experiential discovery New generalizable knowledge Patients, populations in particular settings Improved outcomes + Locating, acquiring, and evaluating new knowledge Adapting evidence and redesigning practices Executing changes Developing and using measurements Established generalizable scientific knowledge Patients, populations in particular settings Desirable outcomes +

5. 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

6. 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

7. Experiential learning: the action cycle The generic cycle (informal): Experience  Question  Conceptualize  Retry (Dewey, Piaget, Lewin, Schon, Kolb, et al)

8. Experiential learning: the wholeness rule You need all the cycle’s elements No reflection (Q and C)  stagnation No experience (E and R)  pedantry

9. Experiential learning: extending the action cycle The generic cycle (informal learning): Experience  Question  Conceptualize  Retry The extended cycle (formal learning): Plan  Do (E)  Study (Q+C)  Act (R)

10. The experiential learning action cycle: what’s missing? Scientific and experiential discovery: Plan  Do  Study  Publish Experiential learning: Plan  Do  Study  Act Answer: No “Publish” step (Tom Nolan)

11. Quality improvement: the need for extended action cycles A new generic cycle: Plan  Do  Study  Act/Disseminate For experiential learning: Plan  Do  Study  Act/Teach/Coach For experiential discovery: Plan  Do  Study  Act/Publish/Discuss

12. 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

13. 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)

14. 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

15. 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